- Beck's triad
- Hypotension + JVD + muffled heart sounds = cardiac tamponade.
- PCCN
- Progressive Care Certified Nurse; AACN certification for nurses caring for acutely ill, moderately stable adults at elevated risk of instability.
- Certifying body
- AACN Certification Corporation (American Association of Critical-Care Nurses); ABSNC-accredited.
- PCCN total items
- 150 multiple-choice (125 scored + 25 unscored pretest).
- PCCN time limit
- 3 hours.
- PCCN passing score
- Criterion-referenced cut score set by modified Angoff; no fixed percentage.
- PCCN delivery
- PSI computer-based; testing center or Live Remote Proctoring.
- PCCN patient population
- Adults only.
- Clinical Judgment weight
- 80% of the exam (body-system clinical content).
- Professional Caring & Ethical Practice weight
- 20% (Synergy Model competencies).
- Largest single domain
- Cardiovascular (20%).
- Second-largest domain
- Multisystem (15%).
- Direct Care eligibility (2-yr)
- 1,750 hours in 2 years, 875 in the most recent year.
- Knowledge Professional eligibility
- 1,040 hours in 2 years, 260 in the most recent year.
- PCCN renewal
- Every 3 years; 100 Synergy CERPs (Cat A/B/C) or renewal by exam, plus practice hours.
- PCCN vs CCRN
- PCCN = progressive/step-down/telemetry (moderately stable); CCRN = ICU (critically ill).
- Synergy Model premise
- Optimal outcomes when nurse competencies match patient characteristics.
- Resiliency
- Patient's capacity to bounce back after an insult.
- Vulnerability
- Susceptibility to stressors affecting outcomes.
- Stability
- Ability to maintain steady-state equilibrium.
- Complexity
- Entanglement of two or more systems (body/family/therapies).
- Resource Availability
- Resources the patient/family/community brings.
- Predictability
- Expecting a certain course of illness.
- Clinical Judgment (competency)
- Clinical reasoning + decision-making + critical thinking + global grasp.
- Advocacy/Moral Agency
- Acting on patient's behalf; resolving ethical concerns.
- Caring Practices
- Compassionate, therapeutic, vigilant environment.
- Collaboration
- Working with the interdisciplinary team toward shared goals.
- Systems Thinking
- Managing system/environmental resources.
- Response to Diversity
- Incorporating differences into care.
- Facilitation of Learning
- Educating patients/families/staff.
- Clinical Inquiry
- Evidence-based questioning/evaluation of practice.
- Benner's competent stage
- 3rd stage; the level PCCN certifies.
- Autonomy
- Patient's right to self-determination.
- Beneficence
- Acting to benefit the patient.
- Nonmaleficence
- Do no harm.
- Justice
- Fair, equitable care.
- Fidelity/Veracity
- Faithfulness/truthfulness.
- ANA Code of Ethics
- Foundational ethical framework AACN bases certification on.
- Informed consent
- Provider obtains; nurse witnesses/verifies understanding.
- Advance directive
- Document stating care wishes if patient can't decide.
- DPOA for health care
- Surrogate decision-maker designation.
- Moral distress
- Knowing the right action but being constrained from taking it.
- SBAR
- Situation, Background, Assessment, Recommendation (structured communication).
- Two patient identifiers
- Required before any care/medication.
- ACS
- Acute coronary syndrome spectrum: unstable angina, NSTEMI, STEMI.
- STEMI ECG
- ST elevation ≥1 mm in ≥2 contiguous leads (or new LBBB).
- NSTEMI
- Elevated troponin without persistent ST elevation.
- Unstable angina
- Ischemic chest pain with normal troponin.
- Inferior MI leads
- II, III, aVF (right coronary artery).
- Anterior MI leads
- V1–V4 (LAD).
- Lateral MI leads
- I, aVL, V5–V6 (circumflex).
- RV infarct caution
- Preload-dependent; avoid nitroglycerin (causes hypotension).
- Door-to-balloon
- Goal ≤90 min for primary PCI in STEMI.
- Door-to-needle
- Fibrinolytics within 30 min if PCI unavailable.
- Troponin
- Most specific cardiac biomarker for MI.
- DAPT
- Dual antiplatelet therapy: aspirin + P2Y12 inhibitor (ticagrelor/clopidogrel).
- Pericarditis
- Pleuritic chest pain relieved by sitting forward; friction rub; diffuse ST elevation + PR depression.
- Myocarditis
- Inflammation (often viral) → HF, dysrhythmias, ↑troponin without occlusion.
- Endocarditis signs
- Janeway lesions, Osler nodes, splinter hemorrhages, Roth spots; new murmur + fever.
- Aortic dissection
- Tearing chest/back pain, BP differential between arms; lower HR/BP first (beta-blocker before vasodilator).
- Pulsus paradoxus
- SBP drop >10 mmHg on inspiration (tamponade).
- Tamponade treatment
- Pericardiocentesis.
- Cardiogenic shock
- Pump failure; cold/clammy, hypotension, pulmonary congestion, rising lactate.
- Inotropes for cardiogenic shock
- Dobutamine, milrinone.
- Dilated cardiomyopathy
- Enlarged weak ventricle, ↓EF, systolic HF.
- Hypertrophic cardiomyopathy
- Thick septum, outflow obstruction; sudden death risk; avoid dehydration/excess preload reduction.
- Restrictive cardiomyopathy
- Stiff ventricle, diastolic dysfunction.
- Takotsubo
- Stress cardiomyopathy; apical ballooning; mimics STEMI with clean coronaries; reversible.
- Atrial fibrillation
- Irregularly irregular, no P waves; stroke + RVR risk.
- CHA2DS2-VASc
- Stroke risk score guiding AF anticoagulation.
- SVT treatment
- Vagal maneuvers, then adenosine.
- Adenosine administration
- Rapid IV push + fast flush; transient asystole expected.
- VT (pulseless)/VF
- Defibrillate.
- Torsades de pointes
- Polymorphic VT with prolonged QT; treat IV magnesium.
- Complete (3rd-degree) heart block
- AV dissociation; needs pacing.
- Symptomatic bradycardia
- Atropine, then transcutaneous pacing.
- Acute decompensated HF
- Dyspnea, crackles, pink frothy sputum, ↑BNP, S3.
- HF acute treatment
- Upright position, O2/NIV, IV loop diuretic, nitroglycerin.
- Left-sided HF
- Pulmonary congestion (crackles, dyspnea).
- Right-sided HF
- Systemic congestion (JVD, edema, hepatomegaly).
- BNP
- Elevated in heart failure.
- HF daily weight alert
- Report >2–3 lb/day or >5 lb/week gain.
- GDMT for HF
- ACE-I/ARB/ARNI, beta-blocker, MRA, SGLT2 inhibitor, diuretic.
- Hypertensive urgency
- Severe BP without end-organ damage; oral lowering.
- Hypertensive emergency
- Severe BP WITH end-organ damage; IV titratable agents.
- HTN emergency BP goal
- Lower ~10–20% in first hour, then gradually.
- IV antihypertensives
- Nicardipine, clevidipine, labetalol, nitroprusside.
- TAVR complication
- New conduction block (may need pacemaker), vascular bleeding, stroke.
- Aortic stenosis triad
- Syncope, Angina, Dyspnea (SAD); avoid aggressive preload/afterload reduction.
- Acute limb ischemia (6 P's)
- Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia.
- Nitroglycerin
- Vasodilator; hold if SBP <90, RV infarct, recent PDE-5 inhibitor.
- Diltiazem
- CCB for AF rate control; avoid in decompensated HF.
- Amiodarone
- Antiarrhythmic; hypotension/bradycardia; long-term lung/thyroid/liver toxicity.
- Furosemide
- Loop diuretic; monitor K+, renal function, daily weight.
- Norepinephrine
- First-line vasopressor for septic/distributive shock; maintains MAP.
- Post-cath site care
- Assess bleeding/hematoma, distal pulses, contrast nephropathy, retroperitoneal bleed.
- Contrast-induced nephropathy
- Prevent with hydration; monitor creatinine post-cath.
- Electrical alternans
- Beat-to-beat QRS amplitude variation; seen in tamponade.
- Normal ABG
- pH 7.35–7.45, PaCO2 35–45, HCO3 22–26, PaO2 80–100.
- Respiratory acidosis
- ↓pH, ↑PaCO2 (hypoventilation).
- Respiratory alkalosis
- ↑pH, ↓PaCO2 (hyperventilation).
- Metabolic acidosis
- ↓pH, ↓HCO3.
- Metabolic alkalosis
- ↑pH, ↑HCO3.
- ROME
- Respiratory Opposite, Metabolic Equal (pH vs value direction).
- ARDS
- Refractory hypoxemia + bilateral infiltrates not from cardiac failure.
- Lung-protective ventilation
- Low tidal volume ~6 mL/kg IBW, PEEP, plateau <30, permissive hypercapnia.
- Severe asthma silent chest
- Ominous sign of no air movement → impending failure.
- Asthma severe treatment
- SABA + ipratropium, systemic steroids, magnesium.
- COPD O2 target
- SpO2 88–92% (avoid over-oxygenation).
- COPD exacerbation NIV
- BiPAP first-line for hypercapnic respiratory failure.
- OSA treatment
- CPAP; risk of post-sedation respiratory depression.
- Central sleep apnea
- No respiratory effort; linked to HF, stroke, opioids.
- Tension pneumothorax
- Tracheal deviation away, hypotension, JVD → needle decompression.
- Hemothorax
- Blood in pleural space.
- Empyema
- Pus in pleural space.
- Chylothorax
- Lymph in pleural space.
- Chest tube air leak
- Continuous bubbling in water-seal chamber.
- Chest tube tidaling
- Normal fluctuation with respiration.
- PE signs
- Sudden dyspnea, pleuritic pain, tachycardia, hypoxia.
- PE diagnostic
- CT pulmonary angiography; D-dimer sensitive not specific.
- PE ECG
- S1Q3T3 with RV strain.
- Massive PE
- Obstructive shock; thrombolytics/embolectomy.
- Pulmonary fibrosis
- Restrictive scarring, chronic hypoxemia, clubbing.
- Pulmonary hypertension
- ↑PA pressure → RV strain → cor pulmonale, loud P2.
- Sarcoidosis
- Granulomatous connective tissue disorder; steroid-responsive.
- Opioid-induced respiratory depression
- Monitor capnography/SpO2; reverse with naloxone.
- Type I respiratory failure
- Hypoxemic (PaO2 <60).
- Type II respiratory failure
- Hypercapnic (PaCO2 >50 + acidosis).
- Failure to wean
- Inability to liberate from ventilator; assess RSBI, secretions, strength, nutrition.
- SBT
- Spontaneous breathing trial to assess extubation readiness.
- VAP prevention
- HOB 30–45°, oral care, sedation interruption, readiness-to-extubate.
- Pneumonia signs
- Fever, productive cough, consolidation, hypoxia, leukocytosis.
- Pneumonectomy
- No chest tube to suction; cautious fluids (one lung).
- Lobectomy
- Chest tube to re-expand remaining lobes; pulmonary hygiene.
- VATS
- Video-assisted minimally-invasive thoracic surgery.
- Venturi mask
- Delivers precise FiO2; useful in COPD.
- Non-rebreather mask
- High-concentration O2 delivery.
- HFNC
- High-flow nasal cannula; bridges before NIV/intubation.
- CPAP
- Continuous positive airway pressure (one level).
- BiPAP
- Bilevel positive airway pressure (inspiratory + expiratory).
- Rising PaCO2 in fatigued patient
- Red flag for impending respiratory failure.
- Naloxone
- Opioid reversal agent.
- Capnography (EtCO2)
- Monitors ventilation/early respiratory depression.
- Hypoglycemia (<70)
- Shakiness, diaphoresis, confusion; rule of 15, D50/glucagon if unconscious.
- DKA glucose
- >250 mg/dL with ketosis and anion-gap acidosis (pH <7.3).
- DKA breathing
- Kussmaul respirations + fruity breath.
- HHS glucose
- >600 mg/dL (often >1000), minimal ketosis, osmolality >320.
- DKA/HHS first treatment
- IV fluids first, then insulin infusion.
- DKA insulin + potassium
- Insulin shifts K+ into cells; don't start insulin if K+ <3.3.
- DKA dextrose timing
- Add dextrose when glucose ~200 to prevent hypoglycemia/cerebral edema.
- SIADH
- Too much ADH → water retention, concentrated urine, hyponatremia.
- SIADH treatment
- Fluid restriction; hypertonic saline if severe.
- Diabetes insipidus
- Too little ADH → polyuria, dilute urine, hypernatremia.
- DI treatment
- Fluid replacement + desmopressin (DDAVP).
- Sodium correction rule
- Correct slowly to avoid osmotic demyelination/cerebral edema.
- Thyroid storm
- Fever, tachy/AF, agitation; beta-blocker + antithyroid + cooling.
- Myxedema coma
- Hypothermia, hypotension, ↓LOC; IV levothyroxine.
- Insulin drip
- Continuous IV insulin for DKA/HHS; hourly glucose monitoring.
- Glucagon
- Reverses severe hypoglycemia if no IV access.
- Hyperglycemia complications
- Risk of DKA/HHS; treat cause + insulin.
- Anion gap
- Elevated in DKA (metabolic acidosis).
- Cerebral edema risk
- From too-rapid glucose/osmolality correction.
- Thiamine before glucose
- Prevents Wernicke encephalopathy (esp. alcohol use).
- DDAVP
- Desmopressin; synthetic ADH for diabetes insipidus.
- Serum osmolality (HHS)
- Markedly elevated (>320 mOsm/kg).
- Anemia
- ↓O2-carrying capacity; fatigue, pallor, tachycardia, dyspnea.
- Warfarin monitoring
- INR.
- Warfarin reversal
- Vitamin K, PCC/FFP.
- HIT
- Heparin-induced thrombocytopenia; platelets drop ≥50% + paradoxical clotting ~5–10 days in.
- HIT action
- Stop ALL heparin; start non-heparin anticoagulant (argatroban/bivalirudin/fondaparinux).
- HIT — avoid
- Platelet transfusions and warfarin until platelets recover.
- 4Ts score
- Pretest probability tool for HIT.
- Heparin monitoring
- aPTT or anti-Xa.
- Platelet inhibitors
- Aspirin, clopidogrel, ticagrelor; bleeding risk.
- Guillain-Barré
- Ascending paralysis post-infection; monitor vital capacity (respiratory failure risk).
- GBS treatment
- IVIG or plasmapheresis.
- Myasthenia gravis
- Fluctuating weakness; myasthenic vs cholinergic crisis.
- Multiple sclerosis
- Demyelinating autoimmune disorder.
- ALS
- Progressive motor neuron disease; respiratory monitoring.
- Lupus (SLE)
- Multisystem autoimmune disorder.
- Ischemic stroke
- ~87% of strokes; clot-caused.
- Hemorrhagic stroke
- Bleed; BP control, reverse anticoagulation.
- FAST/BE-FAST
- Stroke recognition (Balance, Eyes, Face, Arm, Speech, Time).
- NIHSS
- Standardized stroke severity scale.
- tPA/alteplase
- Thrombolytic for eligible ischemic stroke within window.
- Thrombectomy
- Mechanical clot removal for large-vessel occlusion.
- Post-tPA precautions
- Frequent neuro/BP checks, bleeding precautions, no invasive lines 24h.
- Dysphagia screen
- Before any PO intake post-stroke (aspiration risk).
- Normal ICP
- 5–15 mmHg.
- Cushing's triad
- Hypertension (widened pulse pressure) + bradycardia + irregular respirations = late ↑ICP.
- ICP management
- HOB 30°, head midline, normocapnia, osmotic therapy.
- Mannitol
- Osmotic diuretic to reduce ICP.
- Status epilepticus
- Seizure ≥5 min or recurrent without recovery; emergency.
- Status epilepticus first-line
- Benzodiazepine (lorazepam/midazolam).
- Seizure precautions
- Padded rails, suction/O2 at bedside, nothing in mouth, side-lying after.
- TBI
- Monitor for rising ICP, herniation, seizures.
- Subdural hematoma
- Venous bleed; slower onset.
- Epidural hematoma
- Arterial bleed; lucid interval then decline.
- Hepatic encephalopathy
- ↑ammonia → confusion; treat lactulose/rifaximin.
- Delirium
- Acute, fluctuating, often reversible confusion; treat the cause.
- Dementia
- Gradual, progressive, irreversible cognitive decline.
- CAM/CAM-ICU
- Delirium assessment tool.
- Delirium management
- Reorient, treat cause, minimize sedatives/restraints, sleep/mobility.
- Encephalopathy types
- Hypoxic-ischemic, metabolic, infectious, hepatic.
- Space-occupying lesion
- Tumor/hematoma/abscess causing mass effect.
- Altered mental status causes
- Infection, hypoxia, electrolytes, meds, withdrawal.
- Glasgow Coma Scale
- Eye/verbal/motor; ≤8 suggests need to protect airway.
- Cerebral perfusion
- Maintain by avoiding hypotension/hypoxia in brain injury.
- Levetiracetam
- Common antiepileptic.
- Wernicke encephalopathy
- Thiamine deficiency; give thiamine before glucose.
- Stroke BP management
- Don't over-lower in ischemic; tighter control in hemorrhagic.
- Pupillary changes
- Asymmetry/fixed dilation suggests herniation.
- Upper GI bleed
- Hematemesis/coffee-ground emesis, melena; ulcer/varices.
- Lower GI bleed
- Hematochezia (bright red); diverticular/malignancy.
- Variceal bleed
- Octreotide, urgent endoscopy + band ligation; possible balloon tamponade.
- GI bleed nursing
- Large-bore IV, fluids/blood, NPO, type & cross, monitor Hgb.
- Melena
- Black tarry stool (upper GI bleed).
- PPI
- Suppresses acid; used in upper GI ulcer bleed.
- Pancreatitis labs
- Elevated lipase and amylase.
- Cullen's sign
- Periumbilical bruising (hemorrhagic pancreatitis).
- Grey Turner's sign
- Flank bruising (hemorrhagic pancreatitis).
- Pancreatitis care
- NPO/bowel rest, fluids, pain control; watch SIRS, hypocalcemia.
- Bowel obstruction
- Distension, vomiting, abnormal bowel sounds; NG decompression.
- Ileus
- Functional bowel motility failure.
- C. difficile
- Contact precautions + soap-and-water (alcohol doesn't kill spores).
- Cirrhosis complications
- Varices, ascites, encephalopathy, coagulopathy, hepatorenal syndrome.
- Ascites
- Fluid accumulation from portal hypertension.
- Ischemic bowel
- Pain out of proportion + lactate↑; emergency.
- Refeeding syndrome
- Watch phosphate/K/Mg when restarting nutrition in malnourished.
- Bariatric surgery complications
- Anastomotic leak, dumping syndrome.
- Esophageal varices
- Dilated veins from portal hypertension; high bleed risk.
- Dumping syndrome
- Rapid gastric emptying post-GI surgery.
- Prerenal AKI
- ↓perfusion (hypovolemia, hypotension, HF); often reversible.
- Intrarenal AKI
- Direct damage (ATN, nephrotoxins, contrast).
- Postrenal AKI
- Obstruction (stones, BPH, tumor).
- Oliguria
- Urine output <0.5 mL/kg/hr.
- AKI monitoring
- BUN/creatinine, urine output, electrolytes; avoid nephrotoxins.
- CKD
- Progressive irreversible kidney damage.
- ESRD
- Requires dialysis.
- AV fistula care
- No BP/blood draws/IV in that arm; assess thrill/bruit.
- Hyperkalemia ECG
- Peaked T → widened QRS → loss of P → sine wave → arrest.
- Hyperkalemia first step
- Calcium gluconate to stabilize myocardium.
- Hyperkalemia shift therapy
- Insulin + glucose, beta-agonist, bicarbonate.
- Hyperkalemia removal
- Diuretics, GI binders, dialysis.
- Hypokalemia ECG
- U waves, flattened T waves, arrhythmias.
- K+ replacement rule
- Never IV push; check magnesium too.
- Hyponatremia
- Correct slowly (osmotic demyelination risk); seizures if severe.
- Hypernatremia
- Correct slowly (cerebral edema risk).
- Hypocalcemia
- Chvostek/Trousseau signs, tetany, prolonged QT.
- Hypercalcemia
- Stones, bones, groans, psychiatric overtones.
- Hypomagnesemia
- Torsades, refractory hypokalemia.
- Hyperphosphatemia
- Common in CKD; binds calcium.
- Uremia
- Toxin buildup in renal failure; encephalopathy, pericarditis.
- Erythropoietin
- Reduced in CKD → anemia.
- Metabolic acidosis (renal)
- Common in renal failure.
- Contrast nephropathy prevention
- Hydration; avoid nephrotoxins.
- Compartment syndrome
- ↑compartment pressure → ischemia; 6 P's; emergency fasciotomy.
- Compartment syndrome don't
- Do NOT elevate above heart or ice (worsens perfusion).
- Immobility complications
- VTE, pressure injury, pneumonia, deconditioning.
- Falls prevention
- Risk assessment, bed alarms, call-light reach, med review.
- Sepsis
- Life-threatening organ dysfunction from dysregulated infection response.
- Septic shock
- Sepsis + vasopressors for MAP ≥65 + lactate >2 despite fluids.
- qSOFA/SOFA
- Sepsis screening/severity tools.
- Sepsis Hour-1 bundle
- Lactate, cultures before antibiotics, antibiotics, 30 mL/kg fluid, vasopressors.
- Sepsis fluids
- 30 mL/kg crystalloid for hypotension or lactate ≥4.
- Sepsis first vasopressor
- Norepinephrine.
- Lactate
- Marker of tissue hypoperfusion in sepsis/shock.
- MAP goal
- ≥65 mmHg in shock.
- Hypovolemic shock
- Volume loss; tachycardia, hypotension, cool/clammy → fluids/blood.
- Anaphylactic shock
- Distributive; urticaria, angioedema, bronchospasm → epinephrine IM first.
- Epinephrine (anaphylaxis)
- First-line, IM.
- Distributive shock
- Vasodilation (septic, anaphylactic, neurogenic).
- Obstructive shock
- Mechanical (tamponade, tension PTX, massive PE).
- CLABSI prevention
- Sterile insertion, chlorhexidine, daily line review, scrub the hub.
- CAUTI prevention
- Insert only when indicated, aseptic, closed system, remove early.
- SSI prevention
- Timed prophylactic antibiotics, glucose control, normothermia.
- MRSA/VRE precautions
- Contact (gown + gloves).
- Airborne precautions
- N95 + negative-pressure room (TB, measles, varicella).
- Droplet precautions
- Surgical mask (influenza, pertussis).
- Pressure injury Stage 1
- Non-blanchable erythema, intact skin.
- Pressure injury Stage 2
- Partial-thickness loss, exposed dermis.
- Pressure injury Stage 3
- Full-thickness skin loss (fat visible).
- Pressure injury Stage 4
- Full-thickness skin + tissue loss (muscle/bone).
- Deep tissue pressure injury
- Persistent non-blanchable deep red/maroon/purple.
- Unstageable
- Base obscured by slough/eschar; depth unknown.
- Braden scale
- Pressure-injury risk assessment.
- Rhabdomyolysis
- Muscle breakdown → myoglobin → AKI; ↑CK, dark urine.
- Rhabdomyolysis treatment
- Aggressive IV fluids; monitor K+/renal/cardiac.
- Alcohol withdrawal CIWA-Ar
- Scale guiding symptom-triggered benzodiazepine treatment.
- Delirium tremens (DTs)
- 48–96h: autonomic instability, hallucinations; potentially fatal.
- Acetaminophen overdose antidote
- N-acetylcysteine.
- Palliative care
- Symptom relief at any disease stage.
- Restraints
- Last resort; ordered, monitored, time-limited, least-restrictive.
- De-escalation
- First-line response to agitation/aggression.
- Two identifiers + med reconciliation
- Core patient-safety practices at every transition.