CCRN Pediatric Exam: Key Facts and Figures

• These are concise study notes for students
• All key facts, entities, and figures are listed

CCRN Pediatric Exam Overview

• 150 multiple-choice questions are on the CCRN Pediatric exam, with 125 scored questions
• Exam duration: 3 hours
• Answers can be changed during the exam
• Result: Pass/fail

Clinical Judgement Content (80% of Exam)

• Cardiovascular (CV): 15%
• Pulmonary: 16%
• Neurological: 12%
• Multisystem: 14%
• Endocrine: 4%
• Hematology/Immunology: 4%
• Gastrointestinal (GI): 5%
• Renal/Genitourinary (GU): 4%
• Integumentary: 2%
• Musculoskeletal: 2%
• Behavioral/Psychological: 2%

Professional Caring and Ethical Practice (20% of Exam)

• Advocacy/moral agency: 3%
• Caring practices: 3%
• Response to diversity: 4%
• Facilitation of learning: 2%
• Collaboration: 2%
• Systems thinking: 3%
• Clinical inquiry: 2%

Renewal Requirements

• Frequency: Every 3 years
• Bedside care hours: 432 hours within the past 3 years, with 144 hours in the last 12 months
• Continuing Education Recognition Points (CERPs): Synergy system

Synergy CERPs Categories

• 100 Synergy CERPs earned over the past 3 years are required
• 60 Category A CERPs
• 10 Category B CERPs
• 10 Category C CERPs are required for renewal
• Option: Retake the test every 3 years

Application Process

• Application for the exam needs to be completed
• Verification of clinical practice requirements is needed
• the AACN Certification Corporation notifies Applied Measurement Professional (AMP) of eligibility
• AMP sends a postcard (www.goamp.com)
• Contact AMP to schedule the test ASAP after receiving the postcard or schedule test online
• Take and pass the test

Preparation and Test Day

• ID areas of weakness and focus on those
• AACN preparation has assessment questions to identify weak areas
• Answer at least 50 questions in the first hour
• Don't spend more than 2 minutes on each question; there is no penalty for guessing
• These are typical patients; don't think of atypicals

Question Strategy Tips

• Look for the broadest, most comprehensive answer to the question
• The answer with the most answers in it or all answers may be right
• Pay attention to qualifying words like first, initial, best, better, most, and highest priority

Question Strategy: More Tips

• The qualifying word directs toward what the question is asking and therefore what is likely the right answer
• Negative words to watch out for: not, incorrect, least, false, except, unlikely, inconsistent, inappropriate, all but, unrealistic, atypical, and contraindicated

Absolute Words & Strategy When Clueless

• Avoid absolute words: always, all, every, never, only, and none
• Avoid choosing an answer that is not easily understood
• Remember that nursing care is similar in many situations
• Select the answer that seems most logical

Jeopardy Questions

• Long questions with lots of information are called jeopardy questions
• Focus on the real question, which is often found at the end after distracting information

Cardiac Topics for CCRN

• Acute pulmonary edema
• Cardiac surgery
• Cardiogenic shock
• Cardiomyopathy
• Dysrhythmias
• Heart failure
• Hypertensive crisis
• Cardiac/vascular catheterization
• Myocardial conduction system defects
• Pulmonary hypertension
• Structural heart defects (acquired and congenital)

Testable Nursing Actions - Cardiovascular

• Apply leads for CV monitoring
• Identify, interpret, and monitor rhythms
• Assess hemodynamic status and signs of instability
• Recognize indications for and manage patients requiring: 12 lead ECG, arterial catheter, cardiac catheterization (cath), cardioversion, CVP monitoring, defibrillation, invasive hemodynamic monitoring, and vascular stenting

Cardiovascular Anatomy & Formulas

• Understand normal cardiovascular anatomy to recognize abnormal conditions
• "Flow is the path of least resistance:" if flow is obstructed, it takes another route or things slow down

Blood Flow Order

• IVC/SVC → RA → tricuspid → RV → PV → PA → lungs → Pulm veins → LA → mitral valve → LV-AoV → aorta

Cardiac Output

• Cardiac output Definition: volume of blood ejected from the LV in 1 minute
• Cardiac Output = Heart Rate x Stroke Volume

Cardiac Output Influencers

• Preload
• Afterload
• Compliance
• Contractility
• Cardiac output varies from 200 mL/kg/min (neonate) to 100 mL/kg/min (adolescent/adult)
• Neonates/children are very HR dependent for CO

Cardiac Index

• Definition: CI = Cardiac output / BSA

Stroke Volume (SV)

• Stroke volume - volume of blood ejected from the LV with each contraction
• Normal SV is 65-75% of ventricular volume

SV Influencers

• Preload: adequate volume (VOLUME)
• Contractility: myocardial squeeze (SQUEEZE)
• Compliance: ability of myocardium to stretch (STRETCH and RESISTANCE)
• Afterload: what the heart is pumping against (PUMP)

Preload Factors

• Preload is the volume of blood in the ventricles at the end of diastole and prior to contraction
• Measured by cardiac fiber length/strength and volume of returned blood
• How we measure preload: RA line, CVP estimates preload, PA artery capillary wedge pressure (is an exact measurement, but invasive)

Frank-Starling Law & Myocardial Failure

• The force of contraction of the cardiac muscle is proportional to its initial length
• Venous blood return directly affects CO and can be significant
• Ability of the heart to change the force of the contraction affects SV: muscle fibers can only stretch so far
• Myocardial failure: old pony tail holder, poor function/compliance in muscle fibers; treat by avoiding excess volume

Factors That Can Affect Preload

• Variations in volume
• Systemic/pulmonary hypertension: increases pressure, affecting ability to eject
• Excessive PEEP: changes intrathoracic pressure, decreasing venous return
• Dysrhythmias: change atrial/ventricular systole, affecting SV
• Vasopressors/inotropes: increase contractility/heart rate and, therefore, ability of heart to fill

Interventions To Increase Preload

• Volume administration (crystalloids, colloids, or blood products)
• Innate mechanisms of the body include renin angiotensin, ADH, aldosterone, and catecholamines, in order to retain water

Interventions To Decrease Preload

• Diuretics: ANP/BNP = salt losing hormones, increasing kidney excretion of fluid
• Vasodilators: dilate vessels, increasing the volume needed to fill vessels, and afterload reduction with milrinone

Afterload Definitions

• Afterload is workload ventricles must overcome
• Specifically it is the systemic pressure the heart must overcome to pump
• Can be estimated by systemic blood pressure (BP)

Afterload Equation

• Measured by SVR and PVR
• SVR = (MAP – CVP) / CO
• MAP = average pressure in aorta
• MAP = (CO x SVR) + CVP
• MAP depends on the volume in the system and the elastic properties of the arterial walls
• Give vasodilators

Managing Compromised CO

• High afterload can contribute to decreased CO in a sick heart

Increase & Decrease Afterload

• Systemic hypertension: more work the LV has to do
• Pulmonary hypertension: more work the RV has to do
• Polycythemia: blood is thicker, affects how blood flows
• Outflow obstructions: anatomic obstructions that prevent blood from flowing from LV
• Vasoconstrictors
• Sepsis: vasodilatory effect with septic shock
• Heart failure
• Vasodilators: cardene, nipride
• Anaphylaxis: increase histamine release = vasodilation
• Physiologic factors

Understanding Ventricular Function

• Compliance: ability of ventricles to relax and distend (fill) during diastole
• Compliance: Relationship between end-diastolic pressure and end-diastolic volume
• Compliance = change in volume / change in pressure

"Good" vs "Poor" Compliance

• "Good" compliance: takes large volumes of fluid to change the ventricular pressure
• "Poor" compliance: takes small volumes of fluid to change the ventricular pressure, described as a stiff ventricle

Factors Affecting Compliance

• Decreased: Myocardial hypoxemia and acidosis, CHF, ventricular hypertrophy, pericardial tamponade, high PEEP, positive inotropic medications
• Enhanced: Afterload reducers - milrinone!
• Contractility

Contractility

• Squeeze generated by the myocardial muscle
• Measurement: echocardiography (estimates contractility); cardiac cath (directly measures contractility)
• Atrial contraction accounts for 10-40% of LV filling, depending on heart rate (atrial kick)

Shortening/Ejection Fraction

• Shortening Fraction (SF:) Percent change in ventricular DIAMETER during systole and diastole
• Normal Shortening Fraction = 28-44% -- an indication of the myocardial ability to maintain contraction
• Ejection Fraction (EF): Percent of VOLUME change with systole; Affected stroke volume and afterload; Normal should be 50-70%

Factors Affecting Contractility

• Electrolyte imbalances: Calcium plays a big role (both hyper and hypo)
• Sympathetic stimulation (catecholamines): fight or flight response
• Physiological depressants: sedatives, hypoxia, and hypercapnia
• Pharmacological agents: inotropes, Ca channel blockers, barbiturates, and anesthesia

Factors That Increase Contractility

• Positive inotropes
• Sympathetic stimulators
• Hypercalcemia

Factors That Decrease Contractility

• Negative inotropes
• Hypoxia/hypercapnia
• Parasympathetic stimulators
• Long term CHF (intrinsic depression of contractility, or damaged myocardium/disease)
• Acidosis, hypocalcemia, hypoglycemia, hypomagnesemia, hyponatremia, and hyperkalemia

Pharmacology - Autonomic Nervous System (ANS)

• Sympathetic stimulation causes a release of norepinephrine (NE), increased HR and contractility/conduction time
• Encourages heart to beat harder, stronger, faster
• Parasympathetic stimulation causes the release of acetylcholine, which acts on the right and left vagus nerve
• Vagus stimulation: decreases HR and conduction time through AV tissue

Pharmacology - Adrenergic

• Alpha (a) adrenergic (norepi, phenylephrine, dopamine @ higher doses) ◦ Cardiac fiber stimulation results in arterial vasoconstriction, which increases intracellular calcium: increases BP

• Beta (b) adrenergic stimulation increases SA node discharge, causing inotropy, chronotropy, & AV conduction time ◦B1 (epi, dopamine @ lower doses)

• Acts primarily on heart - increase heart rate and contractility

• Agonists increase inotropy, chronotropy, and rennin secretion

◦B2 (dobutamine) - bronchodilator

• Acts primarily on lungs
• Agonists prompt smooth muscle relaxation, and bronchodilation

Vasopressors/Into/Chronotropic Drugs:

• Vasoactive: Raise or lower BP and HR
• Vasopressors usually act to raise BP
• Inotropic work through alpha and beta receptors to vasodilate, vasoconstrict, & enhance contractility
• Actions depends on the receptors
• Chronotropic change HR by affecting nerves controlling the heart or by changing the rhythm from the SA node
• Decreasing HR is more important in kids

Heart Disorders: Cardiac Failure

• Cardiac output is not sufficient to meet the body's metabolic demands
• Left Heart Failure: LV loses ability to totally empty during systole causes CO drop

• Backflow of blood from LV into the LA causes increased PCMP, CVP, PAP

• Causes of LHF caused by a weakened or poorly functioning left ventricle
• Respiratory issues: Pulmonary venous congestion and pulmonary edema
• Cardiac issues: Cardiomegaly with decreased myocardial function
• Late signs involve acidosis and decreases GFR as well as decreased mentation

Heart disorders: Right Heart Failure

• Right heart failure often occurs as a progression of left heart failure: Causes include. pulm HTN and RV infarct
• Pathophysiology includes increased pulmonary resistance and increased O2 demand
• JVD, Hepatomegaly, and Dependent pitting edema
• Clinical Manifestations may lead to anorexia Increased CVP and PVR

Diagnosis and Treatment- Congestive Heart Failure

• History: PE, Labs, CXR
• Pulm sounds/resp status are also key tests and ECG
• Goals: To max cardiac performance with inotropic agents and promote contractility. Then decrease Myocardial 02 demand

Treatment-Congestive Heart Failure

• Enhance Contractility:Digoxin, Dobutamine (sometimes can increase myocardial oxygen demand
• Decrease Myocardial Demand-Bedrest and Anxiolytics
• Optimize Proload- Diuretics/ Sodium and Fluid restrictions Decrease Afterload-Nipride, Milirone and ACE inhibitors

Cardiomyopathies:

• Idiopathic or related to systemic disease in 3 types Dilated (the big)- massive cardiomegaly Restrictive (“the ugly”) Increase Compliance: The ability of ventricles to relax and extend. “Good” compliance-large volume only creates a small change in pressure

Cardiogenic Shock:

• Physiology- Myocardial dysfx

• Goal: Improve or Interuppt blood cycle -

• Can cause- CHD/sequelae, cardiomyopathy or Ischemia along with prolonged high doses of beta agonist.

• Management Goals Minimizing 02 demands- intubation, sedation or pain -

• Maxes with correct cardiac arrhythmias or optimal preload

• Increase or decrease Cardiac output and give surgical support if needed

Management of Cardiogeneic/Abstructive Shock:

• Caused by obstruction to cardiac output, affecting systemic perfusion
• Pulmonary Embolism
• Valve Stenosis
• Treatment:
• Great Vessel Trauma/ Abonomaily

Hypertensive Crisis:

• HTN- >95% for age , Sex and Height on atlease 3 separate times is not needed
• Management- Alpha/Beta Blockers and diuretics along with life Style Change

Cardiovascular Lecture #2:

• The heart is formed by 4-7 weeks . and can tolerate lower saturations
• Shunting occurs with an Intracardiac Shunt that is Ductus Arteriousus or foramen Ovale
• High PVR or low CO will cause shunt on blood
• During birth DA and FO should close at Birth in 12-24 hours

Cardiac Shunting Vascular resistence

• Shunting- Vasal Resistance low PVR- increased- vasoconstriction or decreased flow In Left to Right- Oxygenated blood from stem to pulmonic / Acynotic
• in right to left shunts Dexoygenated blood will lower O2 - cyanotic

Congenital Heart disaease

Most commonly occurs with these disorders

• Tromosomy 21- VSG or ASD
• Tromosomy18- VSD or HLHS

Increased pulmonary Blood FLow

Will end up in pulmonary system

• ASD + VSG shunting are common
• ASD- >5 years old

decreased pulmonary Blood FLow Tetrology of fallot

• 1.VSB
• Overinging Aorta and more
• Tet Spells often Occur with infibulum

Congenital Heart Disease Postoperative

• Management - Comfort is key
• dysrythmias- common is Jet
• low PVR during bleeds

Transposition of Great Arteies (TGA)

• Aorta comes from RV/Pulmanry Arter comes from Lv
• Requires PDA as well