1
AACN BLUEPRINT GUIDE- Updated on 1/27/2024
SOURCE: “BARRON’S ADULT CCRN EXAM PREMIUM BOOK”
*ANYTHING IN HIGHLIGHTER BLUE WAS A TEST QUESTION*
I. CLINICAL JUDGMENT (80%)
A. Cardiovascular (17%)
1. Acute coronary syndrome:
a. NSTEMI: troponin positive, ST depression, T inversion, unrelenting chest pain
b. STEMI: troponin positive, ST elevation in 2+ contiguous leads, unrelenting chest pain
c. Unstable angina: Chest pain at rest, unpredictable, NTG may help. Troponin negative, ST
depression, or T inversion.
*Tx: ECG, ASA, Anticoagulant (heparin), Antiplatelet (plavix, integrillin), beta blocker, pain
meds (morphine, nitro), obtain labs. PCI within 90 min. Fibrinolytics within 30 min.
*Absolute contraindications for fibrinolytic: brain bleed, AVMs, brain cancer, stroke within the
last 3 months (but last 3 hours okay), aortic dissection, active bleeding or closed head/facial
trauma.
*Inferior MI: second-degree heart block type 1, third-degree heart block, sick sinus syndrome,
sinus bradycardia
*Anterior MI: second-degree heart block type 2 or RBBB
2. Acute peripheral vascular insufficiency:
a. Arterial/venous occlusion:
PAD s/s Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia, cool to touch. Normal
ABI is >0.90.
*do not elevate limb- put bed in reverse trendenlenberg
*Tx: tPa, heparin, ASA, plavix, and vasodilators
b. Carotid artery stenosis:
CAD s/s are a TIA, stroke, visual disturbances
*Dx: angiography, US carotid, CTA, MRA
, 2
*Tx: carotid endarterectomy, stenting, aspirin, statins
c. Endarterectomy:
Post-procedure check CMS, BP, monitor for bleeding, and hypoperfusion syndrome (headache
ipsilateral to procedure side, focal motor seizures, and/or intracerebral hemorrhage)
d. Fem-Pop bypass:
For patients with PAD. Monitor vitals, do CMS checks, give pain meds, antibiotics, and
anticoagulants, and assess the surgical site.
3. Acute pulmonary edema
Pulmonary edema is a buildup of fluid in your lungs. The main cause of pulmonary edema is
congestive heart failure.
*s/s: Difficulty breathing (dyspnea) or extreme shortness of breath that worsens with activity or
when lying down. A feeling of suffocating or drowning that worsens when lying down. A cough
that produces frothy sputum that may have blood in it. Palpitations.
4. Aortic aneurysm:
Caused by arteriosclerosis, HTN, smoking, obesity, Marfan’s syndrome.
*s/s: abdominal: pulsations in the abdomen, abdominal or lower back pain, n/v, shock
Thoracic: sudden tearing, ripping pain in chest that radiates to the shoulders, neck, and back,
cough, hoarseness, dysphagia, dyspnea, dizziness, widening of the mediastinum on CXR.
* If aneurysm <5cm- just watch and treat HTN with beta blockers
* If aneurysm >6 cm or if it’s a thoracic aneurysm that is causing symptoms- surgical repair!!!!!
and labetalol drip
5. Aortic dissection:
Blood passes through the inner lining between the layers of the aorta. The tear is spiral. It can
occur suddenly or gradually. This occurs in the ascending aorta or aortic arch and is life-
threatening and requires STAT surgery. Type A dissection think “A trip to the OR”
6. Aortic rupture:
A sternotomy is performed and the patient is put on a heart-lung machine. They’ll place a fabric
graft to replace a damaged ascending aorta. Aortic rupture is most often lethal.
7. Cardiac surgery:
, 3
a. CABG: Hemodilution with isotonic crystalloids, hypothermia is induced, anticoagulation with
large heparin doses, potassium stops the heart during diastole.
* Post-op monitor for: tamponade, pericarditis, bleeding, atelectasis/PNA (have them do the
incentive spirometer!), pain, renal failure, infection, and electrolyte problems.
*Chest tubes should not have dependent loops. Do not milk CT unless clots appear. Mediastinal
CT remove serosanguinous fluid whereas Pleural CT removes air, blood, or serous fluid in the
pleural space. Do not clamp unless changing chambers. If output >100 ml for 2 hours, anticipate
giving blood and correcting volume status.
b. Valve replacement or repair: mechanical valves last longer but need permanent anticoagulation
b/c high risk of thrombosis whereas biological valves wear down faster but will need short term
anticoagulation and long term antiplatelet.
*Post-op: avoid drop in preload- will result in hypotension. Anticipate conduction disturbances
(temp or permanent pacing may be needed).
8. Cardiac tamponade:
Caused by cardiac surgery, pericarditis, pericardial effusion, and trauma.
* s/s- restlessness and agitation, hypotension, JVD, equalization of CVP, pulmonary artery
diastolic pressure, and PAOP, muffled heart sounds, enlarging cardiac silhouette and
mediastinum on CXR, narrowed pulse pressure, pulses paradoxus
NEEDLE ASPIRATION IS THE TREATMENT
9. Cardiac trauma:
The aortic valve is most anterior in the chest and therefore most at risk for a rupture due to
trauma. Myocardial contusion (bruise) is worse than pericarditis, and can lead to dysrhythmias,
ST elevation at the area of injury, dyspnea, pain with inspiration, and death can occur in 48 hours.
10. Cardiac catheterization:
PCI with stent or balloon without a stent. Can be performed for implanting pacemakers, AICDs,
or cardiac ablation therapy.
*Complications: stent thrombosis, retroperitoneal bleed, stroke, TIA, arrhythmias, renal failure,
false aneurysms
11. Cardiogenic shock:
, 4
LOW cardiac output, HIGH preload and afterload. Caused by AMI, chronic HF, CMP,
tamponade, papillary muscle rupture, and dysrhythmias.
*Compensatory stage: tachycardia, tachypnea, crackles, resp alkalosis, anxiety, JVD, S3 S4, cool
skin, low UOP, narrow pulse pressure, BP normal or lower than baseline
*Progressive stage: Low BP, worsening tachycardia, tachypnea, oliguria, met acidosis, worsening
crackles, skin is clammy and mottled, worsening anxiety.
*Tx: reperfusion if STEMI, emergent surgery if due to ruptured papillary muscle or VSD.
Mechanical support like IABP.
*How to enhance the pump (the heart): positive inotropes like dobutamine, dopamine, levo,
milrinone! AVOID negative inotropes. Give vasodilators.
*How to decrease demand on pump: preload and afterload reducers, optimize oxygenation,
ventilator, IABP or VAD.
*IABP- balloon inflation during diastole perfuses coronary arteries (increases diastolic
augmentation pressure) and balloon deflation decreases afterload. Balloon inflation and deflation
are determined by the trigger (R wave on ECG or upstroke on A-line)
12. Cardiomyopathies:
a. Dilated: systolic dysfunction (problem ejecting). Thin floppy dilated heart. MVR common
cause. s/s similar to systolic HF.
b. Hypertrophic: diastolic dysfunction (problem filling and relaxing). Thickened heart muscle. s/s
similar to diastolic HF.
c. Idiopathic: unknown cause
d. Restrictive: heart muscle scars and/or stiffens which is hard to fill with blood
13. Dysrhythmias:
Shockable rhythms- VF, pulseless VT, and torsades
14. Heart failure:
High intracardiac pressures and decreased cardiac output. Acute decompensated heart failure is
an abrupt onset of symptoms severe enough to send you to the hospital.
*HFrEF, or systolic HF, has an EF <40%; HFpEF, or diastolic HF, has an EF >50%.
AACN BLUEPRINT GUIDE- Updated on 1/27/2024
SOURCE: “BARRON’S ADULT CCRN EXAM PREMIUM BOOK”
*ANYTHING IN HIGHLIGHTER BLUE WAS A TEST QUESTION*
I. CLINICAL JUDGMENT (80%)
A. Cardiovascular (17%)
1. Acute coronary syndrome:
a. NSTEMI: troponin positive, ST depression, T inversion, unrelenting chest pain
b. STEMI: troponin positive, ST elevation in 2+ contiguous leads, unrelenting chest pain
c. Unstable angina: Chest pain at rest, unpredictable, NTG may help. Troponin negative, ST
depression, or T inversion.
*Tx: ECG, ASA, Anticoagulant (heparin), Antiplatelet (plavix, integrillin), beta blocker, pain
meds (morphine, nitro), obtain labs. PCI within 90 min. Fibrinolytics within 30 min.
*Absolute contraindications for fibrinolytic: brain bleed, AVMs, brain cancer, stroke within the
last 3 months (but last 3 hours okay), aortic dissection, active bleeding or closed head/facial
trauma.
*Inferior MI: second-degree heart block type 1, third-degree heart block, sick sinus syndrome,
sinus bradycardia
*Anterior MI: second-degree heart block type 2 or RBBB
2. Acute peripheral vascular insufficiency:
a. Arterial/venous occlusion:
PAD s/s Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia, cool to touch. Normal
ABI is >0.90.
*do not elevate limb- put bed in reverse trendenlenberg
*Tx: tPa, heparin, ASA, plavix, and vasodilators
b. Carotid artery stenosis:
CAD s/s are a TIA, stroke, visual disturbances
*Dx: angiography, US carotid, CTA, MRA
, 2
*Tx: carotid endarterectomy, stenting, aspirin, statins
c. Endarterectomy:
Post-procedure check CMS, BP, monitor for bleeding, and hypoperfusion syndrome (headache
ipsilateral to procedure side, focal motor seizures, and/or intracerebral hemorrhage)
d. Fem-Pop bypass:
For patients with PAD. Monitor vitals, do CMS checks, give pain meds, antibiotics, and
anticoagulants, and assess the surgical site.
3. Acute pulmonary edema
Pulmonary edema is a buildup of fluid in your lungs. The main cause of pulmonary edema is
congestive heart failure.
*s/s: Difficulty breathing (dyspnea) or extreme shortness of breath that worsens with activity or
when lying down. A feeling of suffocating or drowning that worsens when lying down. A cough
that produces frothy sputum that may have blood in it. Palpitations.
4. Aortic aneurysm:
Caused by arteriosclerosis, HTN, smoking, obesity, Marfan’s syndrome.
*s/s: abdominal: pulsations in the abdomen, abdominal or lower back pain, n/v, shock
Thoracic: sudden tearing, ripping pain in chest that radiates to the shoulders, neck, and back,
cough, hoarseness, dysphagia, dyspnea, dizziness, widening of the mediastinum on CXR.
* If aneurysm <5cm- just watch and treat HTN with beta blockers
* If aneurysm >6 cm or if it’s a thoracic aneurysm that is causing symptoms- surgical repair!!!!!
and labetalol drip
5. Aortic dissection:
Blood passes through the inner lining between the layers of the aorta. The tear is spiral. It can
occur suddenly or gradually. This occurs in the ascending aorta or aortic arch and is life-
threatening and requires STAT surgery. Type A dissection think “A trip to the OR”
6. Aortic rupture:
A sternotomy is performed and the patient is put on a heart-lung machine. They’ll place a fabric
graft to replace a damaged ascending aorta. Aortic rupture is most often lethal.
7. Cardiac surgery:
, 3
a. CABG: Hemodilution with isotonic crystalloids, hypothermia is induced, anticoagulation with
large heparin doses, potassium stops the heart during diastole.
* Post-op monitor for: tamponade, pericarditis, bleeding, atelectasis/PNA (have them do the
incentive spirometer!), pain, renal failure, infection, and electrolyte problems.
*Chest tubes should not have dependent loops. Do not milk CT unless clots appear. Mediastinal
CT remove serosanguinous fluid whereas Pleural CT removes air, blood, or serous fluid in the
pleural space. Do not clamp unless changing chambers. If output >100 ml for 2 hours, anticipate
giving blood and correcting volume status.
b. Valve replacement or repair: mechanical valves last longer but need permanent anticoagulation
b/c high risk of thrombosis whereas biological valves wear down faster but will need short term
anticoagulation and long term antiplatelet.
*Post-op: avoid drop in preload- will result in hypotension. Anticipate conduction disturbances
(temp or permanent pacing may be needed).
8. Cardiac tamponade:
Caused by cardiac surgery, pericarditis, pericardial effusion, and trauma.
* s/s- restlessness and agitation, hypotension, JVD, equalization of CVP, pulmonary artery
diastolic pressure, and PAOP, muffled heart sounds, enlarging cardiac silhouette and
mediastinum on CXR, narrowed pulse pressure, pulses paradoxus
NEEDLE ASPIRATION IS THE TREATMENT
9. Cardiac trauma:
The aortic valve is most anterior in the chest and therefore most at risk for a rupture due to
trauma. Myocardial contusion (bruise) is worse than pericarditis, and can lead to dysrhythmias,
ST elevation at the area of injury, dyspnea, pain with inspiration, and death can occur in 48 hours.
10. Cardiac catheterization:
PCI with stent or balloon without a stent. Can be performed for implanting pacemakers, AICDs,
or cardiac ablation therapy.
*Complications: stent thrombosis, retroperitoneal bleed, stroke, TIA, arrhythmias, renal failure,
false aneurysms
11. Cardiogenic shock:
, 4
LOW cardiac output, HIGH preload and afterload. Caused by AMI, chronic HF, CMP,
tamponade, papillary muscle rupture, and dysrhythmias.
*Compensatory stage: tachycardia, tachypnea, crackles, resp alkalosis, anxiety, JVD, S3 S4, cool
skin, low UOP, narrow pulse pressure, BP normal or lower than baseline
*Progressive stage: Low BP, worsening tachycardia, tachypnea, oliguria, met acidosis, worsening
crackles, skin is clammy and mottled, worsening anxiety.
*Tx: reperfusion if STEMI, emergent surgery if due to ruptured papillary muscle or VSD.
Mechanical support like IABP.
*How to enhance the pump (the heart): positive inotropes like dobutamine, dopamine, levo,
milrinone! AVOID negative inotropes. Give vasodilators.
*How to decrease demand on pump: preload and afterload reducers, optimize oxygenation,
ventilator, IABP or VAD.
*IABP- balloon inflation during diastole perfuses coronary arteries (increases diastolic
augmentation pressure) and balloon deflation decreases afterload. Balloon inflation and deflation
are determined by the trigger (R wave on ECG or upstroke on A-line)
12. Cardiomyopathies:
a. Dilated: systolic dysfunction (problem ejecting). Thin floppy dilated heart. MVR common
cause. s/s similar to systolic HF.
b. Hypertrophic: diastolic dysfunction (problem filling and relaxing). Thickened heart muscle. s/s
similar to diastolic HF.
c. Idiopathic: unknown cause
d. Restrictive: heart muscle scars and/or stiffens which is hard to fill with blood
13. Dysrhythmias:
Shockable rhythms- VF, pulseless VT, and torsades
14. Heart failure:
High intracardiac pressures and decreased cardiac output. Acute decompensated heart failure is
an abrupt onset of symptoms severe enough to send you to the hospital.
*HFrEF, or systolic HF, has an EF <40%; HFpEF, or diastolic HF, has an EF >50%.
