NLE Cardiovascular Nursing — Inflammatory, Valvular and Vascular DisordersRevision Notes

Exam Tips

• NLE FAVORITE: 'A patient with IE is ordered IV antibiotics. What is the PRIORITY nursing action BEFORE administration?' — Answer: Obtain blood cultures from two different sites.
• NLE FAVORITE: 'Beck's Triad' — always equals hypotension + muffled heart sounds + JVD = Cardiac Tamponade = Pericardiocentesis.
• If the question describes a patient who feels BETTER when leaning forward, think PERICARDITIS.
• Teach high-risk patients (prosthetic valves, rheumatic heart disease history) about antibiotic prophylaxis before dental procedures to prevent IE.
• For myocarditis: priority nursing diagnosis is Decreased Cardiac Output — monitor for dysrhythmias and signs of heart failure.

Key Points

• Infective endocarditis (IE) is bacterial infection of the endocardium and heart valves — Streptococcus and Staphylococcus species are the most common causative organisms.
• Vegetations are clumps of fibrin, platelets, and microbes that form on damaged valves — they can break off and embolize to the brain (stroke), lungs (PE), spleen, or kidneys.
• PRIORITY NURSING ACTION in IE: Obtain at least two sets of blood cultures from different sites BEFORE starting IV antibiotics — this is a classic NLE question.
• IE treatment = prolonged IV antibiotics for 4–6 weeks based on culture sensitivity; surgery if valve is severely damaged.
• Classic peripheral signs of IE: Janeway lesions (painless macules on palms/soles), Osler's nodes (PAINFUL nodules on fingertips — mnemonic: Osler = Ouch!), splinter hemorrhages under nails, Roth spots (retinal hemorrhages), petechiae.
• Risk factors for IE: prosthetic heart valves, structural heart disease, history of rheumatic fever, and IV drug use (which preferentially affects the RIGHT-sided tricuspid valve).
• Pericarditis: inflammation of the pericardium causing sharp, pleuritic chest pain that WORSENS lying flat and on inspiration and IMPROVES sitting up and leaning forward.
• Pericardial friction rub is the hallmark auscultatory finding of pericarditis — a scratching, leathery sound.
• Cardiac tamponade is a LIFE-THREATENING complication of pericarditis — treat immediately with pericardiocentesis.
• Beck's Triad = the three classic signs of cardiac tamponade: Hypotension, Muffled heart sounds, and Jugular venous distention (JVD).
• Pulsus paradoxus (exaggerated drop in BP during inspiration >10 mmHg) is a key assessment finding in cardiac tamponade.
• Myocarditis: inflammation of the myocardium, most commonly viral; can progress to dilated cardiomyopathy, heart failure, and fatal dysrhythmias.

Definitions

Section Title

Inflammatory Disorders of the Heart

Common Mistakes

• Confusing Janeway lesions (PAINLESS) with Osler's nodes (PAINFUL) — remember: Osler = Ouch on your fingertips; Janeway = Just painless macules on palms.
• Starting antibiotics BEFORE drawing blood cultures — this is incorrect; cultures must be drawn first to identify the organism.
• Forgetting that IV drug users get RIGHT-sided (tricuspid) endocarditis, not left-sided.
• Confusing pericarditis chest pain with MI chest pain — pericarditis pain is POSITIONAL (worse lying, better leaning forward); MI pain is not positional.
• Missing the priority of pericardiocentesis for tamponade — students sometimes choose 'position the patient' as the top answer, but needle aspiration is the definitive treatment.

Exam Tips

• NLE FAVORITE: 'Angina + Syncope + Exertional Dyspnea' in a middle-aged patient = Aortic Stenosis.
• Widened pulse pressure + diastolic murmur = Aortic Regurgitation.
• ALWAYS teach patients with mechanical prosthetic valves about lifelong warfarin AND antibiotic prophylaxis before dental procedures.
• Preventing rheumatic heart disease = treating strep throat with penicillin for the FULL course — patient teaching priority in Philippine public health context.
• If the NLE asks about INR for a patient with a prosthetic valve, therapeutic INR is usually 2.5–3.5 (slightly higher than DVT/PE management).

Key Points

• Rheumatic fever is an autoimmune reaction triggered by untreated GROUP A BETA-HEMOLYTIC STREPTOCOCCAL pharyngitis (strep throat).
• Antibodies against streptococcus cross-react with heart valves (molecular mimicry), joints, skin, and brain — this is why completing penicillin for strep throat is critical.
• Repeated episodes of rheumatic fever lead to RHEUMATIC HEART DISEASE — chronic scarring of valves, most commonly the MITRAL VALVE.
• Rheumatic heart disease is a significant cause of valvular disease in the Philippines and other developing countries — it is a preventable disease if strep throat is properly treated.
• PREVENTION of rheumatic heart disease = prompt antibiotic (penicillin) treatment of streptococcal pharyngitis.
• Valvular disorders occur in two ways: STENOSIS (narrowing, obstruction of forward flow) or REGURGITATION/INSUFFICIENCY (incompetent closure, backflow).
• Mitral stenosis: obstructs flow from left atrium to left ventricle → blood backs up into lungs → dyspnea, pulmonary edema → predisposes to atrial fibrillation.
• Mitral regurgitation: backflow into left atrium during systole → holosystolic murmur → left-sided volume overload.
• Aortic stenosis: classic triad = ANGINA + SYNCOPE + EXERTIONAL DYSPNEA; harsh systolic ejection murmur at the right upper sternal border; this triad indicates severe, life-threatening disease.
• Aortic regurgitation: backflow into left ventricle during diastole → WIDENED PULSE PRESSURE → bounding pulses (Corrigan's/water-hammer pulse) → diastolic murmur.
• Medical management: diuretics (relieve congestion), rate control agents, anticoagulation (if atrial fibrillation is present).
• Surgical management: valve repair or replacement for severe, symptomatic valvular disease.
• CRITICAL TEACHING POINT: Patients with MECHANICAL PROSTHETIC VALVES require LIFELONG WARFARIN anticoagulation to prevent thromboembolism. Bioprosthetic (tissue) valve patients generally do NOT require lifelong anticoagulation.

Definitions

Section Title

Rheumatic Fever and Valvular Heart Disease

Common Mistakes

• Forgetting that aortic stenosis has a TRIAD — angina, syncope, exertional dyspnea — any one of these alone should make you suspect severe AS.
• Confusing mechanical vs. bioprosthetic valve anticoagulation requirements: MECHANICAL = lifelong warfarin; BIOPROSTHETIC (tissue) = generally no lifelong anticoagulation needed.
• Missing that mitral stenosis leads to ATRIAL FIBRILLATION due to left atrial enlargement from backed-up blood.
• Forgetting that rheumatic fever targets the MITRAL VALVE most frequently in developing countries like the Philippines.

Exam Tips

• NLE FAVORITE: 'A hypertensive patient asks why they must take their medication even when they feel well.' Answer centers on HTN being asymptomatic and that stopping medication can cause rebound crisis and end-organ damage.
• For proper BP technique, remember: right arm, at heart level, rested for 5 minutes, correct cuff size, no talking.
• If the question mentions pheochromocytoma or Cushing's syndrome with high BP, think SECONDARY hypertension — treat the underlying cause.
• ACE inhibitor cough is a COMMON side effect — if it occurs, switch to an ARB (same renal protection, no cough).
• Hypertensive crisis NLE keyword: 'BP of 200/120' + 'severe headache, blurred vision, confusion' = hypertensive emergency = controlled IV antihypertensive + ICU.

Key Points

• Hypertension is the SILENT KILLER — often completely asymptomatic until life-threatening end-organ damage occurs (stroke, MI, renal failure, retinopathy).
• ACC/AHA classification: Normal <120/80; Elevated 120–129/<80; Stage 1 HTN 130–139/80–89 mmHg; Stage 2 HTN ≥140/90 mmHg.
• Philippine DOH/JNC7 still commonly uses the older threshold of ≥140/90 mmHg as the diagnosis of hypertension — BE ALERT to which framework the NLE question uses.
• Primary (essential) hypertension = 90–95% of all cases; no single identifiable cause; linked to genetics, obesity, high sodium, sedentary lifestyle.
• Secondary hypertension = caused by an identifiable underlying condition (renal artery stenosis, pheochromocytoma, Cushing's syndrome, primary aldosteronism).
• Hypertensive URGENCY: BP >180/120 mmHg WITHOUT acute target-organ damage — can be managed with oral medications over hours.
• Hypertensive EMERGENCY (Crisis): BP >180/120 mmHg WITH acute target-organ damage (stroke, MI, acute kidney injury, hypertensive encephalopathy) — REQUIRES IV medications and controlled BP reduction in the ICU.
• CRITICAL: Lower BP gradually — do NOT drop it too rapidly as this can cause ischemic stroke, MI, or renal failure from loss of autoregulation.
• Antihypertensives: (1) Diuretics — hydrochlorothiazide; monitor K+. (2) ACE Inhibitors — enalapril; watch for dry cough, hyperkalemia, angioedema. (3) ARBs — losartan; similar to ACE-I but NO cough. (4) CCBs — amlodipine; causes peripheral edema and headache. (5) Beta-blockers — metoprolol; reduces HR; NEVER stop abruptly (rebound hypertension/ischemia).
• ACE inhibitors and ARBs are PREFERRED for patients with diabetes or chronic kidney disease because they provide renal protection (reduce proteinuria).
• Correct BP measurement technique: proper cuff size, arm at HEART LEVEL, patient seated and rested for 5 minutes, no caffeine or smoking 30 minutes before.
• Lifestyle modifications (non-pharmacologic): sodium restriction (<2g/day), weight loss, aerobic exercise, limit alcohol, STOP SMOKING, DASH diet.
• DOH PhilPEN (Philippine Package of Essential NCD Interventions) program manages hypertension at barangay health centers and primary care — nurses at the community level are key screeners.
• Priority NANDA nursing diagnoses: Risk for Decreased Cardiac Output; Ineffective Health Maintenance related to non-adherence; Deficient Knowledge about disease and treatment.

Definitions

Section Title

Hypertension

Common Mistakes

• Telling hypertensive patients they can stop medications once BP normalizes — WRONG; hypertension requires lifelong management and medication must be continued.
• Reducing BP too rapidly in a hypertensive emergency — controlled reduction over hours to days is the goal to prevent ischemic complications.
• Forgetting to never stop beta-blockers abruptly — this causes dangerous rebound hypertension and can precipitate angina or MI.
• Not differentiating between hypertensive URGENCY (no organ damage) and EMERGENCY (with organ damage) — management differs significantly.
• Using the wrong cuff size — too small a cuff gives falsely HIGH readings; too large gives falsely LOW readings.

Exam Tips

• NLE FAVORITE: 'Arterial = Dangle; Venous = Elevate' — this single rule answers many positioning questions.
• Ulcer location is key: TOE or FOOT pressure point ulcer = ARTERIAL (PAD); MEDIAL MALLEOLUS shallow moist ulcer = VENOUS.
• Raynaud's: white → blue → red — cold causes pallor (white) → stasis causes cyanosis (blue) → reperfusion causes rubor (red).
• Buerger's NLE question: young male smoker with foot/leg ischemia → answer will always involve SMOKING CESSATION as priority.
• NEVER apply compression stockings to a patient with suspected arterial disease — always assess pulses first.

Key Points

• Peripheral Arterial Disease (PAD) = atherosclerotic narrowing of peripheral arteries → reduced limb blood flow → ischemia.
• HALLMARK of PAD: INTERMITTENT CLAUDICATION — cramping leg pain with walking/exercise that is RELIEVED BY REST (because rest reduces oxygen demand).
• Arterial insufficiency assessment findings: pain WORSENS with elevation (less arterial flow with gravity away from limb), IMPROVES when legs are DEPENDENT; diminished or absent peripheral pulses; cool, pale, shiny, hairless skin; brittle nails; 'punched-out' PAINFUL ulcers on toes or pressure points; prolonged capillary refill.
• MNEMONIC for arterial care: ARTERIAL = DANGLE the legs (dependent position promotes arterial flow by gravity).
• Nursing management for PAD: encourage WALKING (builds collateral circulation); keep legs DEPENDENT; meticulous FOOT CARE; avoid crossing legs, tight clothing, or prolonged cold exposure; STOP SMOKING (smoking is the most important modifiable risk factor in PAD).
• Medications for PAD: antiplatelet agents (aspirin, clopidogrel), cilostazol (improves walking distance), statins.
• Chronic Venous Insufficiency (CVI) is the OPPOSITE of arterial disease — caused by incompetent venous valves and venous hypertension.
• Venous insufficiency findings: pain IMPROVES with ELEVATION; pitting edema; brownish (hemosiderin) discoloration of skin around ankles; SHALLOW, MOIST ulcers at the MEDIAL MALLEOLUS; varicose veins.
• MNEMONIC: VENOUS = ELEVATE the legs + use COMPRESSION STOCKINGS + encourage AMBULATION.
• CRITICAL COMPARISON: ARTERIAL = Dangle, painful punched-out toe ulcers, absent pulses, cool pale skin. VENOUS = Elevate, medial malleolus shallow moist ulcers, edema, brownish discoloration.
• Buerger's Disease (Thromboangiitis Obliterans): inflammatory occlusive disease of SMALL and MEDIUM arteries and veins of extremities; strongly associated with TOBACCO USE in young men; key intervention = COMPLETE SMOKING CESSATION — halts disease progression and prevents amputation.
• Raynaud's Phenomenon: episodic vasospasm of digital arteries triggered by cold or stress; classic color sequence = WHITE (pallor) → BLUE (cyanosis) → RED (rubor) in fingers; management = keep warm, avoid cold/nicotine, calcium channel blockers (nifedipine) for severe cases.

Definitions

Section Title

Peripheral Vascular Disease

Common Mistakes

• Confusing the POSITION orders for arterial vs. venous disease: ARTERIAL = DANGLE (dependent); VENOUS = ELEVATE. This is a classic NLE distractor.
• Describing arterial ulcers as medial malleolus ulcers — venous ulcers are at the medial malleolus; ARTERIAL ulcers are on the TOES and pressure points.
• Forgetting that in Buerger's disease, SMOKING CESSATION is the #1 priority intervention — not medications.
• Applying compression stockings to a patient with ARTERIAL disease — this is CONTRAINDICATED as it further compromises arterial blood flow.
• Encouraging Raynaud's patients to use hot water to warm hands — recommend gradual warming, not sudden heat application.

Exam Tips

• NLE KEYWORD: 'Pulsating abdominal mass' = suspect AAA = DO NOT vigorously palpate.
• Post-AAA repair: assess peripheral pulses AND urine output — both renal perfusion and limb perfusion can be compromised.
• Aortic dissection vs. MI: 'tearing/ripping' chest pain going to the BACK = DISSECTION; 'pressure/crushing' going to the ARM/JAW = MI.
• Control of hypertension is the most important medical intervention to prevent aneurysm expansion and rupture.
• If asked about AAA management for a 6 cm asymptomatic aneurysm — answer is SURGICAL repair (either open or EVAR) because it exceeds the 5.5 cm threshold.

Key Points

• An aneurysm is a LOCALIZED, PERMANENT dilation (bulging) of an artery wall due to weakening of the vessel wall.
• Most common location: ABDOMINAL AORTA (AAA — Abdominal Aortic Aneurysm).
• Risk factors: atherosclerosis (most common cause), hypertension, smoking, and family history; predominantly affects older men.
• Types: true aneurysm (all three vessel wall layers), false aneurysm (pseudoaneurysm — only outer layer), dissecting aneurysm (tear in intima allows blood to track between layers — most dangerous).
• Most AAAs are ASYMPTOMATIC — found incidentally on imaging.
• Clinical manifestations of AAA: pulsating, expansile MASS in the ABDOMEN (periumbilical area); bruit heard on auscultation; abdominal or back pain (suggests expansion or impending rupture).
• RUPTURE of AAA = SURGICAL EMERGENCY: sudden severe TEARING/RIPPING back or abdominal pain + HYPOTENSION + HEMORRHAGIC SHOCK = life-threatening — requires IMMEDIATE surgery.
• CRITICAL NURSING ACTION: Do NOT vigorously palpate a known or suspected pulsating abdominal mass — you risk triggering rupture.
• Medical management of small, asymptomatic AAA: BP control (keep SBP <130), smoking cessation, and serial ultrasound surveillance.
• Surgical management: ELECTIVE repair for AAA ≥5.5 cm in diameter OR symptomatic AAA — either OPEN surgical repair or ENDOVASCULAR STENT GRAFT (EVAR).
• Postoperative nursing care after aneurysm repair: monitor PERIPHERAL PULSES (arterial adequacy), URINE OUTPUT (renal perfusion — kidneys receive blood from aorta), signs of bleeding/hemorrhage, neurological status.
• Aortic DISSECTION: blood enters a tear in the intima and tracks between the layers — presents with sudden, severe, TEARING or RIPPING chest pain that RADIATES TO THE BACK; pulse and BP differentials between arms; this is a different and distinct emergency from MI.

Definitions

Section Title

Aneurysm

Common Mistakes

• Palpating a pulsating abdominal mass vigorously — this is dangerous and contraindicated if aneurysm is suspected.
• Confusing aortic dissection pain with MI — dissection has TEARING pain radiating to the BACK; MI has pressure/squeezing pain radiating to the arm/jaw.
• Forgetting to monitor URINE OUTPUT after aortic aneurysm repair — the renal arteries branch from the aorta; clamping during surgery can cause acute renal failure.
• Missing the triad of AAA rupture: sudden abdominal/back pain + pulsatile mass + hypotension = surgical emergency.

Formulas

Exam Tips

• NLE RULE: DVT + 'what should the nurse AVOID?' = NEVER massage the leg.
• Anticoagulation antidote memory trick: 'Heparin — Protamine (both start with 'P' of Protection)'; 'Warfarin — Vitamin K (both have a K sound in them)'.
• PE suspect scenario: post-op Day 3, sudden onset dyspnea and pleuritic chest pain → PRIORITY = O2, position upright, notify physician STAT.
• INR 2.0–3.0 is the standard therapeutic range; 2.5–3.5 for MECHANICAL prosthetic valves (slightly higher because of higher clot risk).
• Warfarin teaching NLE favorite: 'A patient on warfarin asks if they should stop eating vegetables.' Answer: No — eat consistent amounts; abrupt changes in vitamin K intake (not elimination) cause INR fluctuations.

Key Points

• DVT = thrombus (blood clot) formed in a deep vein, most commonly in the deep veins of the LEGS (femoral, popliteal, iliac).
• VIRCHOW'S TRIAD = the three conditions that predispose to thrombosis: (1) VENOUS STASIS (immobility, long flight, post-surgery, bed rest), (2) ENDOTHELIAL INJURY (trauma, surgery, IV catheter), (3) HYPERCOAGULABILITY (pregnancy, cancer, oral contraceptives, genetic clotting disorders).
• Clinical manifestations of DVT: UNILATERAL leg swelling, warmth, redness, pain or tenderness in the calf; Homan's sign (calf pain with dorsiflexion) — note: no longer considered reliable/diagnostic but still commonly tested.
• DVT symptoms may be SUBTLE or ABSENT — diagnosis confirmed by Doppler ultrasound.
• Most DANGEROUS complication of DVT: PULMONARY EMBOLISM (PE) — clot dislodges and travels to pulmonary circulation → sudden dyspnea, pleuritic chest pain, tachycardia, hemoptysis, hypoxia, and potential circulatory collapse → LIFE-THREATENING.
• PRIORITY NURSING ACTION if PE is suspected: OXYGEN → Notify physician → Position (Semi-Fowler's or high Fowler's) → Prepare for emergency management (IV access, anticoagulant orders).
• PREVENTION of DVT: early ambulation post-surgery, leg exercises (ankle pumps), SEQUENTIAL COMPRESSION DEVICES (SCDs) for immobile patients, TED stockings, and prophylactic anticoagulation (enoxaparin).
• DVT TREATMENT: anticoagulation — typically IV HEPARIN or subcutaneous ENOXAPARIN bridging to WARFARIN or a direct oral anticoagulant (DOAC like rivaroxaban).
• CRITICAL NURSING ACTION: DO NOT MASSAGE the affected leg — massaging a DVT can dislodge the thrombus and cause PE.
• Nursing management for DVT: elevate the affected leg; apply warm moist compresses; maintain anticoagulation; monitor for signs of PE; bed rest during acute phase then gradual ambulation.
• HEPARIN monitoring: aPTT (activated partial thromboplastin time) — therapeutic range = 1.5 to 2.5 times the control value; antidote = PROTAMINE SULFATE.
• WARFARIN monitoring: PT/INR — therapeutic INR = 2.0 to 3.0 for most indications (2.5–3.5 for mechanical prosthetic valves); antidote = VITAMIN K (phytonadione); teach consistent dietary VITAMIN K intake (green leafy vegetables affect levels).
• WARFARIN teaching: avoid abrupt changes in vitamin K–rich foods, watch for bleeding signs (easy bruising, prolonged bleeding from cuts, blood in urine or stool), regular INR monitoring, and avoid NSAIDs/aspirin without physician guidance.

Definitions

Section Title

Deep Vein Thrombosis (DVT) and Venous Thromboembolism (VTE)

Common Mistakes

• MASSAGING the affected limb in DVT — this is the most dangerous mistake; always a CONTRAINDICATED action in NLE questions about DVT.
• Confusing aPTT (heparin monitoring) with PT/INR (warfarin monitoring) — common exam distractor.
• Forgetting the antidotes: HEPARIN → PROTAMINE SULFATE; WARFARIN → VITAMIN K.
• Not recognizing sudden dyspnea and chest pain in a post-operative patient as a PE emergency.
• Telling warfarin patients to AVOID all vitamin K foods — incorrect; they should maintain CONSISTENT intake, not eliminate vitamin K entirely.
• Applying SCDs over an ACTIVE DVT or arterial disease — SCDs are for PREVENTION, not treatment, and are contraindicated with suspected DVT.