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43 terms

NCLEX HF, ICP

NCLEX review, heart failure and intra-cranial pressure
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Which type of HF is most urgent?
Left-sided, because this impacts breathing
Left-sided HF
signs of pulmonary congestion
Left-sided HF
dyspnea
Left-sided HF
tachypnea
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
hepatomegaly
Right-sided HF
splenomegaly
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
headache
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
vomiting
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