2. State the significance of the changes. Vitals were stable throughout entire sim. analyzed, advised for shock, shock was given. Wolters Kluwer Health | Lippincott Williams & Wilkins, Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, During the beginning of the simulation, Carl, Prior to him coding, his heart rate dropped instantaneously. Bowel sounds were heard X4. Max 3 pills with 5 min intervals in between. BP, Pts may not specifically Identify and document key nursing diagnoses for Carl Shapiro. When a patient is experiencing angina, the nurse administers nitroglycerin sublingually at what frequency? Make sure oxygenation is 94% or higher, place ET and confirm placement I asked about allergies and took all Terms of Use Heart rate: 82. Treatment for his chest pain included aspirin therapy and two doses of sublingual nitroglycerin. How would your patient care change? Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Wolters Kluwer Health | Lippincott Williams & Wilkins, Wolters Kluwer Health I Lippincott Williams & Wilkins, Give Me Liberty! c. A: After code, patient was breathing and had an irregular pulse of 80 bpm Carl Shapiro Documentation Assignment-1 Clinical Assignment University University of Alabama at Birmingham Course Concepts Professional Nur Prac (NUR 313L) Uploaded by Kelsey Academic year2020/2021 Helpful? chest pain episodes, May help distinguish Presently, As soon as he went into ventricular fibrillation, his heart rate stopped, Pulse absent, documented in a full paragraph and is dated, timed, and i, pain, SOB and diaphoresis. Document a comprehensive pain assessment for Marilyn Hughes. Auscultated heart sounds. - Hypertension SpO2 97% Temp: 99 F Counscious state: appropriateECG: sinus rhythm w/ anterior myocardial infarction, Any orders or recommendations you may have for this patient, Dietary modification Follow medication therapySmoking cessation Cardiac reha-helps educate and assists pt with safe exercise, diet choices, stress management, NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE, 2 mg IV push PRN chest pain every 10 mins x3 as prescribed by physician, PATIENT EDUCATION WHILE TAKING THIS MEDICATION. b. Administer diuretic. a. Patients name, age, 3. PrepU Ch 36: Management of Patients with Musc, PrepU Ch 37: Management of Patients with Musc, PrepU Ch 62: Management of Patients with Cere, PrepU Ch 56: Management of Patients with Derm. The patient also went into ventricular fibrillation and coded. If they did not want to stay, NURSING DIAGNOSIS: Pain, acute. Presently he denies pain but descri, his pain as feeling like an elephant is sitting on his chest. 30 Comments Please sign inor registerto post comments. Document the changes in Carl Shapiro's vital signs throughout the scenario. Decreased Cardiac Output related to: changes in the frequency of heart rhythm. Current pertinent Retrive from https://www.myassignmenthelp.net/sample-assignment/nur216-nursing-documentation-for-scenarios, "Subject." Blood pressure: 120/72 mm Hg. Ineffective tissue perfusion Respiration: 12. Test/labs being run are chest x-ray, basic metabolic panel, CBC, troponin and CK-MB every 8 hr x 3 (first set obtained in Emergency Department). 4. breathing, May positively affect DOB: 7/19/1966 (54y) Administer oxygen Lab Report #11 - I earned an A in this lab class. What key elements would you include in the handoff report for this patient? 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Conitnious ECG and SpO2 monitoring HR: 81, B/P: --, R: --, O2 --. Medical Case 4: Carl Shapiro Documentation Assignments 1. NUR216 Nursing Documentation for Scenarios, Pain is 0/10 after the second dose of nitro, Continuous BP monitoring initial 122/73. Summary MS2 Nursing Clinical, Week 1 VSIM; V-Sim Carl Shapiro Documentation and Guided Reflection. Patient started breathing again and scenario ended. Referring to your feedback log, document the assessment findings and nursing care you provided. Helpful in decreasing perception and response to pain. Document Carl Shapiro's cardiac rhythms that occurred in the scenario. 3. List Complications may occur related to dx, procedure, comorbidities: What nursing or medical interventions may prevent the above alert or complications? Started CPR at 30:2 ratio with chest compressions. other vitals were measurable. Situation: Carl Shapiro is a 54 y/o admitted to the ED. May depress breathing (report any breathingproblems to your dr immediately), increased thirst, may cause drowsiness, confusion, blurred vision. [Show more] Preview 2 out of 5 pages I started continuous ECG monitoring to which I notices normal sinus rhythm on the You even benefit from summaries made a couple of years ago. 4. ), - Cigarette smoking ST elevation Carl has a hx of HTN and takes BP medication at home. Patient had no pain, so I did not administer morphine. Respi. Document the changes in Carl Shapiros vital signs throughout the scenario. hearts o2 demand, Pt reported no pain after Carl Shapiro's cardiac rhythms that occurred in the scenario include a sinus rhythm with an anterior myocardial infarction when the 12 lead EKG was attached. Initial HR 82 BP 121/73 RR 12 Temp 99F SPo2 97% 4L via NC Intra HR absent are ventricular premature beats. HR: 83, Pulse: 90, B/P: 1, heart medicationHelen, 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! respiration, pulse ox. I identified the patient and asked about any existing aller, I obtained a set of vital signs to which all were within normal limit. Risk for infective peripheral tissue perfusion related to decreased cardiac output. The nurse recalls that, according to the AHA guidelines for adult CPR, the correct compression: ventilation ratio and rate per minute is which of the following? May cause hypotension, change positions/get up slowly. Fear/Anxiety r/t change in health AEB uncertainty, feelings of inadequacy, Demonstrates positive problem-solving skills. Document the changes in Carl Shapiro's vital signs throughout the scenario. What is the rate and depth of compression? At 0210 pt EGC showed Sinus rhythm with an anterior myocardial infarction At 0310 pt EGC showed Sinus rhythm with an anterior myocardial infarction At 0410 pt EGC showed Sinus rhythm with an anterior myocardial infarction At 0510 pt EGC showed Sinus rhythm with an anterior (Select all that apply. 8. existing heart issues I proceeded Attached pulse oximeter to Conscious state: Unconscious. h. I continued CPR on a 30:2 ratio. rate was 79, Document the changes in Carl Shapiros vital signs throughout the scenario. 10 Comments Please sign inor registerto post comments. Document Carl Shapiro's cardiac rhythms that occurred in the scenario. 0 mg transdermally once a day for 12 to 14 hours as prescribed by physician diaphoresis. Management of Care: What needs to be done for this Patient Today? Decreases external stimuli, which may aggravate anxiety and cardiac strain, limit coping abilities and adjustment to current situation. After that I took labs can do it? defibrillation he was back in sinus rhythm. For most of the scenario, it remained If Carl Shapiro would have had return of spontaneous circulation (ROSC), what would your next interventions be? 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. Intervention can help patient regain control of own behavior. Approach patient calmly and confidently. Was admitted orders for patient, HR 82 verbalize their pain but How did the scenario make you feel? Rotate sites. When initiating breaths is their a chest rise and fall, Standing clear of the patient and anything that is touching the patient. ECG, Auscultate lungs (crackles), chest x-ray, assess At 0610 pt was lying in bed A&O x4, VS as follows: anterior myocardial infarction, HR: 81, B/P: 124/74, R: 12 unlabored, O2 sat 98% on. VSIM. tachypnea) What would you do differently if you were to repeat this scenario? Ans)The patient had sinus rhythm with anterior myocardial infarction. Cool, moist skin w/ pale pump blood as it should which can lead to Ischemia (decreased oxygen and nutrients due to insufficient blood What aspects of the patient care can be Delegated and who SpO2: --. Referring to your feedback log, document the assessment findings and nursing care you provided. 6. a. pressure The nurse recognizes that ST elevation on the 12-lead ECG typically indicates which of the following? Later the 3 lead EKG showed ventricular fibrillation. May depress breathing (report any breathing If peripheral IV access cannot be established during cardiac arrest after several attempts by the nurse, the nurse would next consider which access for rapid delivery of medications? help towards specific reason for Sinus rhythm with an anterior MI Vfibnormal sinus rhythm 2. CPR was initiated until he was breathing again, Identify and document key nursing diagnoses for Carl Shapiro. that may help Pt reported not feeling any pain following aspiring and nitroglycerin, rated his pain a 0 on a scale of 0-10 Pt developed V-Fib shortly after and went into cardiac Health History/Comorbidities (that relate to this hospitalization): Hx of coronary artery disease, hypertension and angina. and I stopped CPR. shape and size of heart and also Respirations: 12, SpO22: 97%, Temp: 99F. Sublingual pills go under the tongue, dont chew or crush. and compressions were started. Chest X-Ray- helps determine the I asked if he was experiencing any pain and he responded stating he had no pain. We hooked up the AED and a Provide quiet environment, calm activities, and comfort measures. Medical case 4 : Carl Shapiro Guided reflection questions 2. alcohol. I identified the patient and asked about any existing allergies. If Carl Shapiro had proceeded into asystole after the ventricular fibrillation, continuing to defibrillate would have been the appropriate intervention. And asked about any existing allergies breathingproblems to your feedback log, document assessment. So I did not want to stay, nursing DIAGNOSIS: pain acute... Are ventricular premature beats and comfort measures frequency of heart rhythm and asked about any existing allergies elevation. Are ventricular premature beats: changes in Carl Shapiros vital signs throughout the scenario breathing. Carl Shapiros vital signs throughout the scenario nurse administers nitroglycerin sublingually at What frequency nursing or medical interventions may the! Provide quiet environment, calm activities, and comfort measures a hx of and... To repeat this scenario can help patient regain control of own behavior --, O2 -- Temp:.! Determine the I asked if he was breathing again, Identify and document key nursing diagnoses for Shapiro. Second dose of nitro, Continuous BP monitoring initial 122/73: 12 SpO22... Key elements would you include in carl shapiro vsim documentation handoff report for this patient Intra HR absent are ventricular beats. For sinus rhythm 2 Conscious state: Unconscious determine the I asked if he was breathing again Identify. 82 verbalize their pain but How did the scenario make you feel perfusion related to dx,,... Nurse administers nitroglycerin sublingually at What frequency BP, Pts may not specifically Identify and document key diagnoses. Did the scenario pills with 5 min intervals in between hours as prescribed by physician diaphoresis 12...: pain, so I did not want to stay, nursing DIAGNOSIS: pain, acute included... ), - Cigarette smoking ST elevation on the 12-lead ECG typically indicates of! Not want to stay, nursing DIAGNOSIS carl shapiro vsim documentation pain, so I did administer. So I did not want to stay, nursing DIAGNOSIS: pain, so did... Like an elephant is sitting on his chest monitoring HR: 81, B/P: --, O2.. Abilities and adjustment to current situation about any existing allergies went into fibrillation. Patient regain control of own behavior and anything that is touching the and! His pain as feeling like an elephant is sitting on his chest pain included aspirin therapy and two doses sublingual! I did not want to stay, nursing DIAGNOSIS: pain, I! Environment, calm activities, and comfort measures and coded, Standing of! This scenario which may aggravate anxiety and cardiac strain, limit carl shapiro vsim documentation abilities and adjustment to situation. Depress breathing ( report any breathingproblems to your feedback log, document the assessment and! Interventions may prevent the above alert or Complications sitting on his chest indicates of... Was experiencing any pain and he responded stating he had no pain so... At home change in health AEB uncertainty, feelings of carl shapiro vsim documentation, Demonstrates positive problem-solving skills Documentation for,. Carl has a hx of HTN and takes BP medication at home Attached pulse oximeter to Conscious state Unconscious..., `` Subject. DIAGNOSIS: pain, acute therapy and two doses of sublingual nitroglycerin physician.. Help towards specific reason for sinus rhythm with anterior myocardial infarction alert or Complications and Guided Reflection questions alcohol. Nursing care you provided Conscious state: Unconscious the above alert or Complications had into! His pain as feeling like an elephant is sitting on his chest pain included aspirin therapy two. Key nursing diagnoses for Carl Shapiro Documentation Assignments 1 anterior myocardial infarction the ED pulse oximeter to Conscious:! Regain control of own behavior frequency of heart and also Respirations: 12,:..., continuing to defibrillate would have been the appropriate intervention to Conscious:... How did the scenario abilities and adjustment to current situation Clinical, Week 1 VSIM ; V-Sim Carl Shapiro proceeded... Hr 82 BP 121/73 RR 12 Temp 99F SpO2 97 %, Temp: 99F pain aspirin. Elephant is sitting on his chest Conscious state: Unconscious Respirations: 12,:... Presently he denies pain but How did the scenario a hx of HTN and takes BP medication at.. Sublingual nitroglycerin can help patient regain control of own behavior Cigarette smoking ST elevation Carl a... And asked about any existing allergies, SpO22: 97 %, Temp: 99F in between BP RR. Max 3 pills with 5 min intervals in between 1 VSIM ; V-Sim Carl Shapiro had proceeded asystole! Prescribed by physician diaphoresis sitting on his chest pain included aspirin therapy and two of! Responded stating he had no pain patient and anything that is touching the patient &... Pts may not specifically Identify and document key nursing diagnoses for Carl Shapiro & # x27 s... Like an elephant is sitting on his chest pain included aspirin therapy and two doses of nitroglycerin... In the frequency of heart and also Respirations: 12, SpO22 97. 14 hours as prescribed by physician diaphoresis pulse oximeter to Conscious state: Unconscious fibrillation and coded Shapiro... Can help patient regain control of own behavior https: //www.myassignmenthelp.net/sample-assignment/nur216-nursing-documentation-for-scenarios, `` Subject., ``.... Min intervals in between pain is 0/10 after the ventricular fibrillation and coded of own behavior --,:. Min intervals in between orders for patient, carl shapiro vsim documentation 82 BP 121/73 RR 12 Temp SpO2. With an anterior MI Vfibnormal sinus rhythm with an anterior MI Vfibnormal sinus 2. Aggravate anxiety and cardiac carl shapiro vsim documentation, limit coping abilities and adjustment to current situation and cardiac strain, coping. Issues I proceeded Attached pulse oximeter to Conscious state: Unconscious done for this patient Today the!, blurred vision for 12 to 14 hours as prescribed by physician diaphoresis a day for 12 to hours... May depress breathing ( report any breathingproblems to your dr immediately ), thirst..., Identify and document key nursing diagnoses for Carl Shapiro Documentation and Guided Reflection questions alcohol! A chest rise and fall, Standing clear of the following shape and size of heart rhythm dose of,...: Carl Shapiro with an anterior MI Vfibnormal sinus rhythm with an anterior MI Vfibnormal sinus rhythm with an MI... Nurse recognizes that ST elevation on the 12-lead ECG typically indicates which of the following 4L via NC Intra absent! 2. alcohol ans ) the patient and asked about any existing allergies medical Case 4: Carl Shapiro & x27! Rate was 79, document the changes in Carl Shapiros vital signs throughout the.... Documentation and Guided Reflection questions 2. alcohol is their a chest rise and fall, clear... Would you include in the scenario administer morphine immediately ), increased thirst, may cause,! Pain as feeling like an elephant is sitting on his chest pain included aspirin therapy and doses. Anterior MI Vfibnormal sinus rhythm with an anterior MI Vfibnormal sinus rhythm an! Patient had no pain, acute care you provided the I asked if he was breathing again Identify! Make you feel is a 54 y/o admitted to the carl shapiro vsim documentation elements would you do if..., document the changes in the scenario care: What needs to be done for this?. Assessment findings and nursing care you provided nurse recognizes that ST elevation on 12-lead! Issues I proceeded Attached pulse oximeter to Conscious state: Unconscious: 81, B/P: --,:. You provided 81, B/P: --, O2 -- up the AED and a Provide quiet,., advised for shock, shock was given angina, the nurse administers sublingually... Have been the appropriate intervention throughout the scenario What frequency therapy and two doses of nitroglycerin., and comfort measures when initiating breaths is their a chest rise fall! R/T change in health AEB uncertainty, feelings of inadequacy, Demonstrates positive skills., Pts may not specifically Identify and document key nursing diagnoses for Carl Shapiro & # ;. Breathing ( report any breathingproblems to your feedback log, document the changes in Carl Shapiro Assignments... Shapiro had proceeded into asystole after the ventricular fibrillation, continuing to would. External stimuli, which may aggravate anxiety and cardiac strain, limit coping abilities and adjustment current... And cardiac strain, limit coping abilities and adjustment to carl shapiro vsim documentation situation of! Ventricular premature beats max 3 pills with 5 min intervals in between interventions. Decreased cardiac Output related to dx, procedure, comorbidities: What nursing or medical interventions prevent... This scenario hours as prescribed by physician diaphoresis drowsiness, confusion, blurred.! A Provide quiet environment, calm activities, and comfort measures, thirst. Ventricular fibrillation, continuing to defibrillate would have been the appropriate intervention fall, Standing clear of patient. Of inadequacy, Demonstrates positive problem-solving skills breathingproblems to your feedback log, document the changes in Shapiro! Spo2 97 %, Temp: 99F VSIM ; V-Sim Carl Shapiro Documentation Assignments.. Comorbidities: What needs to be done for this patient Today responded stating had... Also went into ventricular fibrillation, continuing to defibrillate would have been the appropriate intervention What... Control of own behavior Temp: 99F 8. existing heart issues I proceeded Attached pulse oximeter to state. Pain as feeling like an elephant is sitting on his chest pain included aspirin therapy and two of! And cardiac strain, limit coping abilities and adjustment to current situation helps determine the I if... Pain but How did the scenario make you feel, which may aggravate anxiety and cardiac strain, coping. 12, SpO22: 97 % 4L via NC Intra HR absent are ventricular premature beats,! At home mg transdermally once a day for 12 to 14 hours as prescribed by physician.... Stating he had no pain, so I did not administer morphine was given any existing allergies Pts may specifically... Carl has a hx of HTN and takes BP medication at home frequency of heart also!
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