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NCLEX review, heart failure and intra-cranial pressure

Which type of HF is most urgent?

Left-sided, because this impacts breathing

Left-sided HF

signs of pulmonary congestion

Left-sided HF


Left-sided HF


Left-sided HF

crackles in the lungs

Left-sided HF

dry, hacking cough

Left-sided HF

paroxysmal nocturnal dyspnea

Left-sided HF

increased BP (from fluid volume excess) or decreased BP (from pump failure)

Right-sided HF

dependent edema (legs and sacrum)

Right-sided HF

jugular venous distention

Right-sided HF

abdominal distention

Right-sided HF


Right-sided HF


Right-sided HF

anorexia and nausea

Right-sided HF

weight gain

Right-sided HF

nocturnal diuresis

Right-sided HF

swelling of the fingers and hands

Right-sided HF

increased BP (from fluid volume excess) or decreased BP (from pump failure)

Right-sided HF

signs are evident in the systemic circulation

Left-sided HF

signs are evident in the pulmonary system

acute pulmonary edema s/s

severe dyspnea and orthopnea; pallor; tachycardia; expectoration of large amounts of blood-tinged, frothy sputum; wheezing and crackles on auscultation; bubbling respirations; acute anxiety, apprehension, and restlessness; profuse sweating; cold, clammy skin; cyanosis; nasal flaring; use of accessory breathing muscles; tachypneia; hypocapnia, evidenced by muscle cramps, weakness, dizziness, and paresthesias

increased ICP

altered LOC (most sensitive and earliest indication)

increased ICP


increased ICP

abnormal respirations (i.e. Cheyne-Stokes, neurogenic hyperventilation, apneustic, ataxic, cluster)

increased ICP

rise in BP w/ widening pulse pressure (late)

increased ICP

slowing of pulse (late)

increased ICP

elevated temperature

increased ICP


increased ICP

pupil changes

increased ICP

increased systolic BP, widened pulse pressure, slowed HR (late)

increased ICP

change in motor function from weakness to hemiplegia (late)

increased ICP

positive Babinski's reflex (late)

increased ICP

decorticate or decerebrate posturing (late)

increased ICP

seizures (late)

pulse pressure

the difference between the systolic and diastolic pressures; normal pulse pressure is 30-40mmHg

Babinski's reflex

dorsiflexion of the ankle and great toe w/ fanning of the other toes when firmly stroking the lateral aspect of the sole of the foot; abnormal after infancy

decorticate posturing

rigid flexion of arms and legs (wrists curled up tightly under the chin, toward the cortex)

decerebrate posturing

rigid extension and pronation of arms and legs (arms straight at sides, wrists curled away from the sides of the body)

ICP interventions to prevent increase

elevate HOB 30-40 deg as prescribed; avoid Trendelenburg's position; prevent flexion of the neck and hips; monitor respiratory status and prevent hypoxia; avoid the admin of morphine sulfate to prevent the occurrence of hypoxia; maintain mechanical ventilation as prescribed - maintaining the PaCO2 at 30-35mmHg will result in vasoconstriction of the cerebral blood vessels, decreased blood flow, and therefore decreased ICP; maintain body temp and prevent shivering, which can raise ICP; decrease environmental stimuli; monitor elyte levels and acid-base balance; monitor I/O; limit fluid intake to 1200mL/day; instruct client to avoid straining activities, such as coughing, sneezing, Valsalva's maneuver; give meds as ordered; surgical intervention

meds given to decrease ICP

anticonvulsants to prevent seizures; antipyretics and muscle relaxants to prevent temp elevation & shivering (dantrolene sodium); BP meds to maintain cerebral perfusion at a normal level; corticosteroids to decrease cerebral edema; IV fluids to control blood volume (being careful to avoid fluid overload, which increases ICP); mannitol to draw fluid from the brain cells into the vascular system

Valsalva's maneuver

increases pressure in central veins, cranium; happens when pt holds breath and "bears down"; stimulates a vagal response; used to increase safety while inserting central lines (keeps air out of vasculature)

Immediate management of acute HF episode

place client in High Fowler's position, w/ legs in dependent position, to reduce pulmonary congestion and relieve edema; administer O2 in high concentrations by mask or cannula to improve gas exchange and pulmonary function; prepare for intubation/ventilator support if required; monitor lung sounds for crackles and decreased breath sounds; suction fluids as needed to maintain patent airway; assess LOC; provide reassurance to client; monitor VS closely, noting tachycardia or pulsus alternans; monitor for hypotension r/t decreased tissue perfusion or for HTN resulting from anxiety or history of HTN; monitor HR and monitor for dysrhythmias by using a cardiac monitor

pulsus alternans

a weak pulse alternating with a strong one

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