Cardiovascular
13%of exam
Respiratory
12%of exam
Endo, Heme, GI, Renal
21%of exam
Neuro, MSK, Behavioral
18%of exam
Multisystem
16%of exam
Professional Caring & Ethics
20%of exam
Quick Facts
- Credential
- CCRN (Adult)
- Items
- 150 (125 scored)
- Time
- 3 hours
- Pass
- 83 of 125
- Format
- Multiple choice
- Fee
- $255 or $370
- Framework
- Judgment 80%, Caring 20%
- Body
- AACN Certification
- Valid
- 3 years
Shockable Rhythms
Shock VF and pulseless VT
VF: defibrillatePulseless VT: defibrillateAsystole/PEA: no shock
Cardiogenic vs Hypovolemic
Cardiogenic
- High PAWP
- Low cardiac index
- Needs inotropes
Hypovolemic
- Low PAWP
- Low CVP
- Needs fluids
Pump vs volume
Shock Type Picker
- Low CVP, high SVR→Hypovolemic(Give fluids)
- High PAWP, low output→Cardiogenic(Inotropes)
- Low SVR, warm skin→Distributive(Pressors + source)
- Equal diastolic pressures→Tamponade(Drain pericardium)
- Fluid-refractory, high lactate→Septic shock(Norepinephrine)
Hemodynamic Normals
- CVP
- 2-6 mmHg, preload
- PAWP
- 8-12 mmHg, left preload
- CO
- 4-8 L/min
- CI
- 2.5-4; shock under 2.2
- SVR
- 800-1200; afterload
- MAP
- 70-100; target over 65
- SvO2
- 60-80% oxygen delivery
- PA pressure
- Systolic 15-25 mmHg
MAP Formula
MAP = (SBP + 2 DBP) / 3
Two-thirds diastoleTarget over 65
Mobitz I vs Mobitz II
Mobitz I
- PR progressively lengthens
- Then dropped beat
- Usually benign
Mobitz II
- PR stays constant
- Sudden dropped beat
- May need pacing
Gradual vs sudden
Vasopressor Picker
- Septic shock→Norepinephrine(First-line)
- Refractory septic shock→Add vasopressin(Fixed dose)
- Cardiogenic, low output→Dobutamine(Inotrope)
- Anaphylaxis→Epinephrine(IM first)
- Symptomatic bradycardia→Atropine(Then pace)
- Reduce afterload→Nitroprusside(Arterial dilator)
Shock Profiles
- Hypovolemic
- Low preload, high SVR
- Cardiogenic
- High PAWP, low output
- Distributive
- Low SVR, warm skin
- Obstructive
- Tamponade, PE, tension pneumo
- Septic
- Distributive; give norepinephrine
- Anaphylactic
- Distributive; epinephrine first
- Neurogenic
- Low SVR with bradycardia
Norepinephrine vs Dobutamine
Norepinephrine
- Vasopressor
- Raises SVR/MAP
- Septic shock
Dobutamine
- Inotrope
- Raises cardiac output
- Low-output states
Squeeze vs pump
Dysrhythmia Response
- Pulseless VF or VT→Defibrillate(Unsynchronized shock)
- Asystole or PEA→CPR and epinephrine(No shock)
- Unstable tachycardia→Synchronized cardioversion
- Torsades de pointes→Magnesium
- Symptomatic bradycardia→Atropine, then pace
Dysrhythmias & ECG
- Atrial fib
- Irregular, no P waves
- Atrial flutter
- Sawtooth flutter waves
- SVT
- Narrow, fast, regular
- V-tach
- Wide QRS over 100
- V-fib
- Chaotic; defibrillate immediately
- Torsades
- Polymorphic VT; give magnesium
- Asystole / PEA
- Non-shockable; CPR and epinephrine
- 1st-degree block
- PR over 0.20 seconds
- Mobitz I
- PR lengthens, drops beat
- Mobitz II
- Constant PR, sudden drop
- 3rd-degree block
- AV dissociation; may pace
Vasoactive Drips
- Norepinephrine
- Alpha vasopressor; septic first-line
- Epinephrine
- Alpha and beta; arrest
- Vasopressin
- Non-adrenergic; septic add-on
- Phenylephrine
- Pure alpha vasoconstrictor
- Dopamine
- Dose-dependent adrenergic effects
- Dobutamine
- Beta inotrope; raises output
- Milrinone
- PDE-3 inodilator
- Nitroglycerin
- Venodilator; lowers preload
- Nitroprusside
- Arterial dilator; lowers afterload
ROME for ABGs
Respiratory Opposite, Metabolic Equal
Resp: pH and CO2 oppositeMetab: pH and HCO3 same
Oxygenation vs Ventilation
Oxygenation
- Low PaO2
- Raise FiO2 and PEEP
- Shunt or V/Q
Ventilation
- High PaCO2
- Raise minute ventilation
- Hypoventilation
PaO2 vs PaCO2
ABG Disorder Picker
- pH down, CO2 up→Respiratory acidosis
- pH up, CO2 down→Respiratory alkalosis
- pH down, HCO3 down→Metabolic acidosis
- pH up, HCO3 up→Metabolic alkalosis
- High anion gap→DKA, lactate, toxins
ABG Interpretation
- pH
- 7.35-7.45 normal range
- PaCO2
- 35-45 mmHg; respiratory
- HCO3
- 22-26 mEq/L; metabolic
- PaO2
- 80-100 mmHg oxygenation
- Resp acidosis
- pH down, CO2 up
- Resp alkalosis
- pH up, CO2 down
- Metabolic acidosis
- pH down, HCO3 down
- Metabolic alkalosis
- pH up, HCO3 up
- Anion gap
- High: DKA, lactate, toxins
Ventilation Modes
- Assist-Control
- Full support every breath
- SIMV
- Mandatory plus spontaneous breaths
- PSV
- Pressure support; spontaneous only
- CPAP
- Constant pressure; spontaneous
- PEEP
- End-expiratory alveolar pressure
- Tidal volume
- 6 mL/kg in ARDS
- Plateau pressure
- Keep below 30 cmH2O
- Auto-PEEP
- Air trapping; drops preload
Respiratory Emergencies
- ARDS
- Bilateral infiltrates; normal wedge
- P/F ratio
- Under 300 signals ARDS
- Berlin severe
- P/F under 100
- Oxygenation failure
- Low PaO2; raise PEEP
- Ventilation failure
- High PaCO2; raise rate
- Prone positioning
- Improves severe ARDS oxygenation
- Tension pneumo
- Tracheal shift; needle decompress
- Pulmonary embolism
- Obstructive shock; anticoagulate
DKA vs HHS
DKA
- Ketoacidosis
- pH under 7.3
- Younger, type 1
HHS
- No ketoacidosis
- Glucose over 600
- Older, type 2
Acidosis vs hyperosmolar
Endocrine Crises
- DKA
- Acidosis, ketones; watch K+
- HHS
- Very high glucose, hyperosmolar
- Thyroid storm
- Fever, tachycardia, agitation
- Myxedema coma
- Hypothermia; IV levothyroxine
- Adrenal crisis
- Refractory hypotension; hydrocortisone
- Diabetes insipidus
- Dilute urine; give desmopressin
- SIADH
- Concentrated urine; hyponatremia
CRRT vs Hemodialysis
CRRT
- Slow, continuous
- Hemodynamically unstable
- Gentle fluid shifts
Hemodialysis
- Fast clearance
- Stable patients
- Rapid fluid removal
Slow vs fast
Heme, GI & Renal
- DIC
- Clots and bleeds together
- HIT
- Platelets drop; stop heparin
- Neutropenic fever
- ANC under 500; antibiotics
- Pre-renal AKI
- Perfusion loss; fluid responsive
- Intrinsic AKI
- ATN; muddy brown casts
- Post-renal AKI
- Obstruction; relieve it
- CRRT
- Slow; for unstable patients
- Hepatorenal
- Cirrhosis; albumin and vasoconstrictor
- SBP
- Ascites PMN over 250
- Variceal bleed
- Octreotide, banding, antibiotics
Cushing Triad
Rising ICP: up BP, down pulse
Widening pulse pressureBradycardiaIrregular breathing
Brain Death vs Vegetative
Brain death
- No brainstem reflexes
- Apnea test positive
- Legally dead
Vegetative
- Brainstem reflexes intact
- Breathes spontaneously
- Alive, unconscious
Dead vs unconscious
Neuro & Behavioral
- CPP
- MAP minus ICP; 60-70
- ICP
- Treat over 22 mmHg
- Cushing triad
- Hypertension, bradycardia, irregular breathing
- Uncal herniation
- Blown pupil; neurosurgical emergency
- Brain death
- No brainstem reflexes; apnea
- Alteplase
- Ischemic stroke within 4.5h
- Meningitis
- Antibiotics within one hour
- Delirium
- CAM-ICU; fluctuating attention
- Restraints
- Last resort; time-limited
- Status epilepticus
- Benzodiazepine is first-line
Sepsis vs Septic Shock
Sepsis
- Infection plus SOFA rise
- Organ dysfunction
- No pressors yet
Septic shock
- Needs vasopressors
- Lactate over 2
- Higher mortality
Dysfunction vs collapse
Sepsis & Multiorgan
- Sepsis-3
- Infection plus organ dysfunction
- qSOFA
- Altered, low BP, tachypnea
- Septic shock
- Pressors plus lactate over 2
- Hour-1 bundle
- Cultures, lactate, antibiotics, fluids
- Initial fluids
- 30 mL/kg crystalloid
- First pressor
- Norepinephrine, then vasopressin
- MODS
- Two or more organs fail
- Lactate
- Trend to guide resuscitation
8 Nurse Competencies
Judgment, Advocacy, Caring, Collaboration, Systems, Inquiry, Learning, Diversity
8 nurse competencies8 patient characteristicsMatch = synergy
Synergy Model
- Core premise
- Match competence to patient need
- Resiliency
- Ability to bounce back
- Vulnerability
- Susceptibility to stressors
- Stability
- Ability to stay steady
- Complexity
- Entangled patient systems
- Predictability
- Expected illness trajectory
- Clinical judgment
- Reasoning and critical thinking
- Advocacy
- Moral agency for patient
- Systems thinking
- Navigate care resources
- Clinical inquiry
- Question and improve practice
Ethics & End-of-Life
- Autonomy
- Patient right to choose
- Beneficence
- Act for patient good
- Non-maleficence
- Avoid causing harm
- Justice
- Fair resource distribution
- Informed consent
- Capacity, disclosure, voluntariness
- Moral distress
- Blocked from right action
- Palliative care
- Symptom relief, any stage
- Goals of care
- Align treatment with values
- Surrogate
- Substituted judgment for patient
Common Traps
DKA potassium
Hold insulin if low K+ ≠ Replace potassium first
HIT platelets
Stop all heparin ≠ Never transfuse platelets
First pressor
Norepinephrine first-line ≠ Not dopamine
qSOFA role
Bedside screen only ≠ Not diagnostic criteria
IABP contraindication
Avoid in aortic insufficiency ≠ Inflates during diastole
Brain vs vegetative
Brain death is dead ≠ Vegetative is alive
ARDS wedge pressure
ARDS wedge is normal ≠ High wedge is cardiogenic
Last Minute
- 1.Pass = 83 of 125
- 2.MAP target 65 or higher
- 3.Norepinephrine first in septic shock
- 4.Shock VF and pulseless VT
- 5.ARDS tidal volume 6 mL/kg
- 6.ROME reads the ABG
- 7.DKA: replace potassium first
- 8.HIT: stop all heparin
- 9.CPP equals MAP minus ICP
- 10.Sepsis bundle within one hour
- 11.Synergy matches nurse to patient
- 12.qSOFA screens, not diagnoses
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