LIVE NCLEX RN Review Session: Cor Pulmonale and Pulmonary Edema

Session Overview

• Welcome to the live NCLEX RN review session, day 20 of a 90-day series.
• Aim: Cover a wide range of nursing topics, tackle 2,000 NCLEX questions with detailed explanations.
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Cor Pulmonale (Pulmonary Heart Disease)

Definition

• Cor Pulmonale: Also known as pulmonary heart disease; strain on the right side of the heart.

Causes

• Pulmonary Diseases: Acute or chronic pulmonary vascular diseases, COPD, interstitial lung disease, cystic fibrosis.
• Blood Disorders: Polycythemia vera (thickens blood), Sickle cell disease (blocks blood vessels), Macroglobulinemia (rare cancer thickening blood).
• Structural Issues: Kyphoscoliosis (spine structure affecting chest shape), obstructive sleep apnea (OSA).
• Pulmonary Hypertension: Idiopathic increase in lung artery pressure leading to right ventricle strain.

Clinical Features

• Fatigue: Due to poor gas exchange, decreased oxygen.
• Exertional Dyspnea: Shortness of breath on exertion.
• Cough and Hemoptysis: Small vessel rupture due to increased pulmonary pressure.
• Chest Pain: Angina due to heart strain.
• Jugular Venous Distension (JVD): Blood backflow in the venous system impacts jugular veins, especially visible at 45 degrees.
• Peripheral Edema: Swelling in feet, legs, sacral area due to blood backup.
• Cyanosis: Blue discoloration (mouth, fingertips) due to low oxygen.
• Right Upper Quadrant Pain: Liver enlargement and congestion.
• Syncope: Fainting during exertion.
• Split Second Heart Sound: Due to pulmonary valve delay closure.

Diagnostic Tests

• Chest X-Ray: Right-sided heart enlargement.
• 12 Lead EKG: Tall R-waves (right ventricular hypertrophy), peaked P-waves, inverted T-waves (V1 to V4), low-voltage QRS, right bundle branch block (complete/incomplete).
• Echocardiogram: Assesses ejection fraction (normal >52-55%).
• Right Heart Catheterization: Confirms cor pulmonale, evaluates pulmonary hypertension.
• ABG (Arterial Blood Gases): Shows hypoxemia, possible acidosis.
• Pulmonary Function Tests: Identifies COPD or other lung conditions.
• V/Q Scan: Evaluates pulmonary embolism impact.
• Hematocrit and CBC: Checks blood viscosity and cell count.
• Alpha-1 Antitrypsin Level: Identifies COPD type (emphysema).
• Antinuclear Antibody (ANA): Checks for collagen vascular diseases.
• Coagulation Studies: Evaluates clotting issues.

Management

• Oxygen Therapy: Correct hypoxemia, decrease heart workload, reduce vasoconstriction.
• Targeted Pharmacological Therapies:
  • Prostacyclin Analogues: Vasodilators (Epoprostenol IV, Treprostinil IV, Iloprost inhalation).
  • Endothelin Receptor Antagonists: Vasodilator (Bosentan).
  • PDE5 Inhibitors: Relax smooth muscles (Sildenafil, Tadalafil).
  • Digoxin: Increases ventricular contractility (positive inotropic effect).
  • Anticoagulants: For pulmonary embolism prevention.
  • Diuretics: Loop diuretic like furosemide (Lasix).
  • Calcium Channel Blockers: Vasodilatory effect (Nifedipine SR, Diltiazem).
  • Bronchodilators: For COPD.
• Mechanical Ventilation: For severe hypoxemia.
• Sodium Restriction: Less than 2g per day.

Complications

• Respiratory Failure: Due to poor gas exchange.
• Dysrhythmias: Life-threatening arrhythmias due to cardiac strain.

Nursing Actions

• Assess History: Document lung disease history, hypoxemia severity.
• Monitor Symptoms and Labs: Regular checks for JVD, peripheral edema, ABG, oxygen saturation.
• Administer Medication: Follow protocols for oxygen, targeted therapies, and anticoagulants.
• Dietary Management: Limit sodium intake.

Pulmonary Edema

Definition and Causes

• Pulmonary Edema: Excess fluid in the lungs, impeding gas exchange.
• Causes: Left-sided heart failure, acute MI, cardiogenic shock, valve diseases (aortic stenosis/mitral valve disease), hypertension, fluid overload from IV transfusion, allergies, drug reactions, high altitude, trauma, near drowning.

Clinical Assessments

• Early Symptoms: Coughing, restlessness during sleep, accessory muscle use.
• Sputum: Pink frothy sputum.
• Severe Anxiety/Panic: Sense of drowning.
• Noisy Breathing: Inspiratory/expiratory wheezing, crackles.
• Cyanosis: Blue discoloration.
• Sweating: Clammy skin.
• JVD: Visible jugular veins.
• Tachycardia: Rapid heart rate.
• Tachypnea: Rapid breathing.
• Oliguria: Low urinary output due to decreased cardiac output.

Diagnostic Tests

• Chest X-Ray: Shows fluid in the lungs.
• Ejection Fraction: Less than 55%.
• Pulmonary Artery Wedge Pressure: Via Swan-Ganz catheter, pressure in left atrium.
• Blood Cultures: Detects infection before antibiotics.
• Cardiac Markers: Troponin I/T, CK-MB, Myoglobin levels.
• Complete Blood Count: Hematocrit, creatinine, electrolytes, WBC count.
• BNP Levels: Elevated signals fluid overload.
• ABG: Determines respiratory failure.
• Thoracentesis: Removes fluid from pleural space.
• Lung Ultrasound: Detects interstitial edema (B-lines/comet-tail artifact).

Management

• Oxygen Therapy: Corrects hypoxemia.
• Non-Invasive Ventilation: BiPAP or CPAP.
• Mechanical Ventilation: For non-responsive patients.
• Medications:
  • Morphine: Reduces anxiety, promotes venous pooling.
  • Vasodilators: Nitroglycerin for preload/afterload reduction.
  • Diuretics: Furosemide to reduce fluid overload.
  • Positive Inotropes: Digoxin, Dobutamine, Milrinone to enhance contractility.
• Intra-Aortic Balloon Pump: Reduces afterload, improves cardiac output.

Complications

• Dysrhythmias: Due to hypoxemia and heart strain.
• Respiratory Failure: Impaired gas exchange.
• Right-Sided Heart Failure: From pulmonary congestion.

Nursing Actions

• Monitor: Breath sounds, level of consciousness, cardiac output, ABGs.
• Administer Oxygen: Adjust based on patient needs.
• Positioning: Elevate head of bed for lung expansion.
• Medications: Administer as per orders.
• Patient Education: Medication adherence, lifestyle changes, recognizing worsening symptoms, diet modifications to reduce sodium intake.