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Heart Failure &
Pulmonary Edema

Recognizing the decompensating cardiac patient and taking the right priority actions — fast.

NCLEX-RN

What Is Heart Failure?

Heart failure (HF) is a syndrome in which the heart cannot pump enough blood to meet the body's metabolic demands. It is not "the heart stopping" — it is the heart failing to keep up.

Where the Fluid Backs Up

LEFT-Sided HF LV LUNGS Pulmonary edema Crackles, dyspnea, pink frothy sputum RIGHT-Sided HF RV BODY Peripheral edema JVD, ascites, weight gain

Acute Pulmonary Edema

Pulmonary edema is a life-threatening emergency. Fluid floods the alveoli, so oxygen cannot cross into the blood. The patient is "drowning from the inside."

Hallmark Signs
Severe dyspnea, pink frothy sputum, crackles, anxiety, orthopnea, low \( SpO_2 \).
Patient Position
Found sitting upright, leaning forward, gasping — cannot lie flat.

The Priority Rule: ABCs First

When choosing the first action in pulmonary edema, follow Airway → Breathing → Circulation. Oxygenation and breathing problems outrank everything else.

The LMNOP Treatment Bundle

L
Lasix (furosemide): loop diuretic to remove excess fluid.
M
Morphine: reduces anxiety, preload, and work of breathing.
N
Nitroglycerin: vasodilator that decreases preload & afterload.
O
Oxygen: high-flow to correct hypoxemia.
P
Position: sit upright with legs dependent to reduce venous return.

Distinguish: Worsening vs Emergency

Chronic Worsening HFAcute Pulmonary Edema
OnsetGradual (days)Sudden (minutes-hours)
BreathingExertional dyspneaSevere dyspnea at rest
SputumNonePink, frothy
Lung soundsMild basilar cracklesDiffuse coarse crackles
PriorityAdjust meds, monitorOxygen NOW, rapid Rx

How to Choose the First Action

1
Assess airway & breathing first. Is the patient oxygenating? Check \( SpO_2 \) and respiratory effort.
2
Position upright in High Fowler's — a fast, independent nursing action.
3
Apply high-flow oxygen and prepare for possible non-invasive ventilation.
4
Then give ordered meds (diuretics, nitrates) and notify the provider.

Reading the Oxygenation Trend

100% 90% 82% Time (untreated edema) Critical: \( SpO_2 < 90\% \) Act here

Example 1: The First Move

A patient with HF develops sudden dyspnea, \( SpO_2 = 84% \), and coarse crackles. Four interventions are ordered. Which do you do first?

Example 2: Furosemide Safety

After IV furosemide, which lab must the nurse monitor most closely, and which finding is the priority?

Monitor
Serum potassium ( \( K^+ \) ). Loop diuretics waste potassium.
Priority Concern
Hypokalemia (\( K^+ < 3.5 \)) → dangerous dysrhythmias.

Example 3: Nitroglycerin Check

Before giving IV nitroglycerin for pulmonary edema, what must the nurse assess, and when is it contraindicated?

Common Mistakes

✕ Lying patient flat
Supine worsens dyspnea. Always sit them upright in High Fowler's.
✕ Giving meds before O₂
Oxygen and positioning come before diuretics or nitrates (ABCs).
✕ Pushing IV fluids
Extra fluid volume worsens overload — restrict fluids, don't add them.

Priority Action Summary

StepActionRationale
1Upright + O₂Improve gas exchange
2FurosemideRemove fluid volume
3Nitroglycerin↓ Preload & afterload
4Morphine↓ Anxiety & preload
5Monitor \( K^+ \), BP, \( SpO_2 \)Catch complications

Let's Practice

Question 1 of 5

A patient with acute pulmonary edema is short of breath with \( SpO_2 = 85% \). What should the nurse do first?

Question 2 of 5

Which finding is the classic hallmark of acute pulmonary edema?

Question 3 of 5

After giving IV furosemide, which lab value is the priority to monitor?

Question 4 of 5

Before administering IV nitroglycerin to a patient in pulmonary edema, the nurse should assess which value?

Question 5 of 5

Which finding best indicates that treatment for pulmonary edema is working?