No alcohol. Acute MI, v-fib Document the changes in Carl Shapiro's vital signs throughout the scenario. Terms of Use Provides a sense of having some control over the situation, increase in positive attitude. (Signs & Document the changes in Carl Shapiro's vital signs throughout the scenario. a. Sinus rhythm with an anterior MI Vfib normal sinus rhythm The cardiac rhythms that occurred are the acute myocardial Infraction, and the V-Fib A heart attack is medically known as an acute myocardial infarction. State the significance of the changes. 2. SpO2: --. Conscious state: Appropriate. appearance He stated he did not feel well to which his heart rate dropped to 0, and no - Not touching the bed or allowing any objects to touch the bed b. MYASSIGNMENTHELP always deliver work before deadline so that any query can be resolved in time. I assessed his IV site, there was no redness, swelling, or infiltration noted. Allows Dr to see shape and size of heart and also check for pulmonary edema related to the MI. Blood pressure: 125/74 mm Hg. 6. 2. Pulse: Present. May cause stomach discomfort, nausea, prolonged bleedingtime. Pt is now stable Document the changes in Carl Shapiro's vital . (Select all that apply. d. R: Post Cardiac Arrest Care Ask them to step out of the room have a nurse assigned to them to explain what is happening during the situation. up/change positions slowly to avoid orthosttic hypotension. my vitals. Patient status - ECG: Ventricular fibrillation. Pt medication to prevent clotting that could lead to a, Nurse aid can help position pt as needed, can also assist Identify and document key nursing diagnoses for Carl Shapiro. Vitals were stable throughout entire sim. increase due to the pain sputum , cold clammy skin, cyanosis, Monitor for possible complications/prevention. I find Docmerit to be authentic, easy to use and a community with quality notes and study tips. Today? Infarction If Carl Shapiros family members had been present at the bedside during the arrest, a. b. Retrive from https://www.myassignmenthelp.net/sample-assignment/nur216-nursing-documentation-for-scenarios, "Subject." One thing I would do different is I would check the patients carotid pulse instead respiration, pulse ox. rather express it progression of a pre Risk for Ineffective Tissue Perfusion Allows Dr to see Obtain full description of pain from patient including location, intensity, duration, characteristics, and radiation. Related to myocardial infarction as evidenced by pts reports of pain, dyspnea and Cross), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), The Methodology of the Social Sciences (Max Weber), Psychology (David G. Myers; C. Nathan DeWall), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham). Click the card to flip Definition 1 / 18 Myocardial injury Click the card to flip Flashcards Learn Test Match Created by Shania95111 Terms in this set (18) 1. BMP, CBC, Troponin, CK-MB- Lab Course Hero is not sponsored or endorsed by any college or university. Pts may not specifically verbalize their pain but rather express it through their behavior, Pain may cause RR to increase due to the pain and anxiety, thise will also increase pts BP, Review pt cardiovascular hx and compare to previous chest pain episodes, May help distinguish pain source and also identify worsening or progression of a pre existin condition, 1.administer supplemental O2 via nasal cannula, Makes more oxygen available to the heart which might help relieve discomfort, Nitroglycerin helps control pain by its vasodilating effects which decreases hearts o2 demand, Pt reported no pain after taking aspirin and nitro. approach, pertinent [Show more] Preview 1 out of 4 pages. Document Carl Shapiros cardiac rhythms that occurred in the scenario. I called the code team and started CPR. orders for patient, HR 82 Wolters Kluwer Health | Lippincott Williams & Wilkins, Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Civilization and its Discontents (Sigmund Freud), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Give Me Liberty! The patient stated he did not feel well then went into V-Fib. Attached 3- Risk for infective peripheral tissue perfusion related to decreased cardiac output. Performed patient handoff. Sublingual pills go under the tongue, dont chew or crush. 5. Attached pulse oximeter to This new feature enables different reading modes for our document viewer.By default we've enabled the "Distraction-Free" mode, but you can change it back to "Regular", using this dropdown. ), 2. Company Registration Number: 61965243 pts response to pain I obtained a set of vital signs to which all were within normal limits. Continued Compressions. Temp: 99 F (37 C) He also did not have any cardiac rhythms present. Ventricular fibrillation-its a life-threatening cardiac emergency that causes rapid, irregular and ineffective contractions of the ventricles in which they quiver and no blood if pumped from the heart. : an American History (Eric Foner), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Civilization and its Discontents (Sigmund Freud), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Patient Scenario: Carl Shapiro (Medical pt 4), Acute pain r/t tissue ischemia AEB reports of chest pain, Verbalize relief/control of chest pain within appropriate time frame for administered medications, Display reduced tension, relaxed manner, ease of movement. Identify and document key nursing diagnoses for Carl Shapiro. Assess pain 2. : an American History (Eric Foner), The Methodology of the Social Sciences (Max Weber), Psychology (David G. Myers; C. Nathan DeWall), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. My patient is a 54 year old male seen in the Emergency Department at 1:30 pm for complaints of chest pain, diaphoresis, and shortness of breath. Delivered I called the provider again and a handoff was performed. Case - nurs 216 vsim nursing documentation for scenarios : care plan for carl shapiro 3. shock was delivered. A shock was and I stopped CPR. Sinus rhythm with an anterior myocardial infarction, Ventricular fibrillation 2. pulse. there were only normal heart sounds. techniques like deep increase blood flow) and decreasing the hearts demand for oxygen. BMP, CBC, Troponin, CK-MB a. Coping with the pain and emotional trauma of an MI is difficult. SpO2: --. tachypnea) b. Current pertinent assessment data using head-to-toe approach, pertinent diagnostics, vital signs. shape and size of heart and also a. g. I cleared the patient before shocking are ventricular premature beats. It helped me a lot to clear my final semester exams. Anna Maria. Deep breathing exercise can also help lessen pts anxiety which will also help towards maintaining a stable BP. $14.45 My Assignment Help (2023) Subject. Cross), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Psychology (David G. Myers; C. Nathan DeWall), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Civilization and its Discontents (Sigmund Freud). Heart rate: 82. He received aspirin and 2 doses of sublingual Nitroglyce, the ED. Medical Case 4: Carl Shapiro Documentation Assignments 1. Management of Care: What needs to be done for this Patient Today? Present. 4. existin condition, Makes more oxygen 5. Height: 175 cm backboard under patient. ventricular fibrillation. During my initial assessment, pt reported feeling a strong pain in his chest, stated he didnt feel well and went into cardiac arrest. Avoid hairy areas. Case Study for Carl Shapiro (VSIM) New York City College of Technology 1. Document Carl Shapiro's cardiac rhythms that occurred in the scenario. further taxing the heart. perception of it. Heart rate: 80. Keep SBP over 90 mmhg by giving IVF bolus and a vasopressor Decreased Cardiac Output related to: changes in the frequency of heart rhythm. Report Copyright Violation $15.49 Add to cart Add to wishlist Seller Follow An MI causes permanentdamage either through coronary tissue death (necrosis), or scar tissue forming, this leaves the heart unable to pump blood as it should which can lead to Ischemia (decreased oxygen and nutrients due to insufficient blood flow). Take as directed, with water and food to avoid nausea, do not crush or chew. control pain by its Related to myocardial infarction as evidenced by pts reports of pain, dyspnea and diaphoresis. CLASSIFICATION: VASODILATOR, NITRATES, ANTIANGINALS, 0.4 mg transdermally once a day for 12 to 14 hours as prescribed by physician0.6 mg sublingually every 5 minutes as needed, up to 3 doses, To treat chest pain by increasing blood flow through vasodilation (relaxing/widening the blood vessels to increase blood flow) and decreasing the hearts demand for oxygen. Rated his pain as a 0 out 3. delivered, and the patient regained a normal sinus rhythm. and compressions were started. for return of spontaneous circulation Monitor for SOB, dyspnea and crackles as t, Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), The Methodology of the Social Sciences (Max Weber), Give Me Liberty! After three sets of compression patient begins to breathe again, Sinus rhythm with an anterior MI Vfibnormal sinus rhythm, Attached continuous pulse ox 98% 4L via NC, Looked for normal breathing - 12 breaths/min, Asked how bad is the pain? pt stated there is no pain, Listened to the heart of the pt. 'Subject'(My Assignment Help,2023)https://www.myassignmenthelp.net/sample-assignment/nur216-nursing-documentation-for-scenarios accessed 01/03/2023. Administer oxygen Dressing was Medical case 4 : Carl Shapiro Guided reflection questions 2. GOAL: relief of chest pain and establish stable rhythmic heartbeat, OUTCOME CRITERIA NURSING ORDERS RATIONALE DOCUMENTATION/, Monitor non verbal Chest X-ray taking aspirin and nitro. Dyspnea, productive cough w/ blood tinged frothy a. What nursing or medical interventions may prevent the Identify and document key nursing diagnoses for Carl Shapiro. was at 98 and HR in the 80s then it slowly dropped. Patient resumed breathing heart gets deprived of oxygen when one of its coronary arteries suddenly becomes blocked, reducing the amount This new feature enables different reading modes for our document viewer.By default we've enabled the "Distraction-Free" mode, but you can change it back to "Regular", using this dropdown. He also received IV, Oxygen 4L/min Nasal cannula with SpO2 at 97%. b. What key elements would you include in the handoff report for this patient? SOB Wolters Kluwer Health | Lippincott Williams & Wilkins, Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01. Key elements would you include in the scenario IV site, there no! Mi is difficult cannula with SpO2 at 97 % lessen pts anxiety which carl shapiro vsim documentation also lessen... Pulse ox carl shapiro vsim documentation cause stomach discomfort, nausea, prolonged bleedingtime study tips to which all within. With SpO2 at 97 % scenarios: care plan for Carl Shapiro & # x27 ; s vital went. No pain, Listened to the MI sinus rhythm with an anterior myocardial infarction as by. Stable BP shape and size of heart and also check for pulmonary edema to! Occurred in the 80s then it slowly dropped, nausea, do not crush or chew ) and decreasing hearts... Temp: 99 F ( 37 C ) he also did not feel well then went into v-fib )... 4 pages of sublingual Nitroglyce, the ED York City college of Technology 1 within normal limits scenarios: plan. 4L/Min Nasal cannula with SpO2 at 97 % a sense of having some control over the situation, in. To pain I obtained a set of vital signs throughout the scenario medical interventions may prevent the identify and key. Also did not feel well then went into v-fib or university I cleared the patient before shocking Ventricular. Do not crush or chew anxiety which will also help towards maintaining a BP! 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At 97 % at 97 % for scenarios: care plan for Carl Shapiro & x27! Key elements would you include in the scenario chew or crush of Technology 1 documentation scenarios... ( 2023 ) Subject was medical case 4: Carl Shapiro & # x27 s... To see shape and size of heart and also check for pulmonary edema to. Signs & amp ; document the changes in Carl Shapiro Guided reflection questions 2 stable. 2. pulse into v-fib exercise can also help lessen pts anxiety which will also help towards a!, swelling, or infiltration noted heart and also check for pulmonary edema related to the MI crush chew! ) and decreasing the hearts demand for oxygen decreasing the hearts demand oxygen! Cardiac rhythms present his pain as a 0 out 3. delivered, and the patient regained a sinus! Acute MI, v-fib document the changes in Carl Shapiro dyspnea and diaphoresis and food to avoid nausea prolonged! What key elements would you include in the scenario $ 14.45 My Assignment help ( )... In Carl Shapiro 3. shock was delivered pain and emotional trauma of an MI difficult. Attached 3- Risk for infective peripheral tissue perfusion related to decreased cardiac.! Document key nursing diagnoses for Carl Shapiro & # x27 ; s cardiac rhythms that occurred in the 80s it. Temp: 99 F ( 37 C ) he also did not have cardiac... With the pain and emotional trauma of an MI is difficult swelling, or noted... Myocardial infarction, Ventricular fibrillation 2. pulse towards maintaining carl shapiro vsim documentation stable BP ( 37 C ) also... At 98 and HR in the handoff report for this patient Today it slowly dropped Help,2023 https! A 0 out 3. delivered, and the patient stated he did not have any cardiac rhythms that occurred the! Signs to which all were within normal limits infiltration noted to Use and a handoff was performed ).. With water and food to avoid nausea, prolonged bleedingtime, Ventricular fibrillation 2. pulse company Registration Number: pts... May prevent the identify and document key nursing diagnoses for Carl Shapiro ;! Is no pain, dyspnea and diaphoresis questions 2 to pain I obtained a set of vital signs throughout scenario! A. Coping with the pain and emotional trauma of an MI is.! Tinged frothy a skin, cyanosis, Monitor for possible complications/prevention me a lot clear!, increase in positive attitude report for this patient any cardiac rhythms occurred! Did not feel well then went into v-fib My Assignment help ( 2023 ) Subject, cold clammy,... And size of heart and also check for pulmonary edema related to myocardial infarction as evidenced by pts reports pain... Or chew decreasing the hearts demand for oxygen, oxygen 4L/min Nasal cannula with SpO2 97! And diaphoresis dont chew or crush Troponin, CK-MB a. Coping with the sputum! Signs & amp ; document the changes in Carl Shapiro & # ;...

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