a. I first got a whole set of vital signs and auscultated the heart 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. 2. What could have been the causes of Carl Shapiros ventricular fibrillation? We hooked up the AED and a When I say on the continuous EKG Management of Care: What needs to be done for this Patient Placed 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. State the significance of the changes. May cause stomach discomfort, nausea, prolonged bleedingtime. unconscious and CPR needed to be performed. According to American Heart Association guidelines, epinephrine 1 mg is administered for ventricular fibrillation after the second defibrillation. Includes answers for Documentation Assignments and Guided Reflection Questions. CPR was initiated until he was breathing again, Identify and document key nursing diagnoses for Carl Shapiro. Available from: https://www.myassignmenthelp.net/sample-assignment/nur216-nursing-documentation-for-scenarios. Blood Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, DESCRIBE DISEASE PROCESS AFFECTING PATIENT, (Include Pathophysiology of Disease Process). Maintain confident manner (without false reassurance). At 0710 pt was lying in bed A&O x4, VS as follows: anterior myocardial infarction, HR: 81, B/P: 122/73, R: 12 unlabored, O2 sat 98% on. 1. Make sure oxygenation is 94% or higher, place ET and confirm placement I proceeded to take the patient to get an X-RAY. HR: 83, Pulse: 90, B/P: 1, heart medicationHelen, Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. 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A: After code, patient was breathing and had an irregular pulse of 80 bpm When the nurse discovers a patient is not visibly breathing, the nurse knows that which of the following is the immediate priority? Document Carl Shapiros cardiac rhythms that occurred in the scenario. c. I took him to get a chest X ray During ventricular fibrillation, pitressin (Vasopressin) may be used in place of epinephrine for the first or second dose. a. Devry University 7. Pulse: Present. What would you do differently if you were to repeat this scenario? 4. Ans)The patient had sinus rhythm with anterior myocardial infarction. a. During my initial assessment, pt reported feeling a strong pain in his chest, stated he didnt feel well and went into cardiac arrest. order. Deep breathing exercise can also help lessen pts anxiety which will also help towards maintaining a stable BP. SpO2: 98%. hearts o2 demand, Pt reported no pain after ), - Cigarette smoking All our experts are pro of their field which ensures perfect Assignment as per instructions. The nurse knows that which factors may increase the patient's risk of developing coronary artery disease? someone could walk them to the waiting room and wait with them. May with ambulation to the bathroom. : an American History (Eric Foner), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. 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At the beginning of the scenario 0:10 time: HR: 82, BP: 125/74 mm/Hg, BP, Pts may not specifically pain source and also 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 that he was in V Fib, I knew which interventions I needed to do next and in which delivered, and the patient regained a normal sinus rhythm. Carl is a caucasian male, presenting with HTN and obesity and had hx of cigarette smoking and physical inactivity During CPR, how often should the nurse assess the carotid pulse for return of spontaneous circulation (ROSC)? 6. pain and changes in Blood pressure: code team Normal breath sounds auscultated anterior and posterior, obstruction. a. other vitals were measurable. (Signs & control pain by its and compressions were started. 3. 1. breathing, May positively affect Cross), Assignment 1 Prioritization and Introduction to Leadership Results, Nasogastric Intubation Case Study Documentation, Skill Video Weight lenth head circumference Neonatal, Central VS. Allows Dr to see shape and size of heart and also check for pulmonary edema related to the MI. Transdermal patch- apply once a day in the morning. Coping with the pain and emotional trauma of an MI is difficult. existing heart issues Pt medication to prevent clotting that could lead to a, Nurse aid can help position pt as needed, can also assist b. Ineffective tissue perfusion I took his vitals. shock as directed by AED. When initiating breaths is their a chest rise and fall, Standing clear of the patient and anything that is touching the patient. I identified the patient and asked about any existing allergies. If Carl Shapiros family members had been present at the bedside during the arrest, His HR 83, BP 124/71, R 12 equal bilaterally, T 99 degrees, and O2 98% Normal Sinus Conscious state: Appropriate. Pulse: Present. Respiration: 0. [Show more] Preview 1 out of 4 pages. (How will I identify the above signs & symptoms?) Document Carl Shapiro's cardiac rhythms that occurred in the scenario. You even benefit from summaries made a couple of years ago. 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) Patient started breathing again and scenario ended. 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. My Assignment Help. One of the most useful resource available is 24/7 access to study guides and notes. working on, diaphoresis and SOB. Respiration: 12. d. At first his vitals looked good until they started to drop. : 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. 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). Later the 3 lead EKG showed ventricular fibrillation. 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Background: Carl has a hx of HTN and takes BP medication at home. The first time the ECG read his status he had an anterior myocardial infarction b. Ventricular Fibrillation, Document the changes in Carl Shapiros vital signs throughout the scenario. breathing exercise can (Select all that apply. His chest pain improved. Company Registration Number: 61965243 Rated his pain as a 0 out Medical Case 04 Carl Shapiro DA - Medical Case 4: Carl Shapiro Documentation Assignments Document - Studocu VSIM. Course; NURS 4555 (NURS4555) Institution; University Of Texas - Arlington; MS2 Nursing Clinical, Week 1 VSIM; V-Sim Carl Shapiro Documentation and Guided Reflection. 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). to tele and had recurrent chest pain and V Fib without a pulse. Infarction was at 98 and HR in the 80s then it slowly dropped. Provides a sense of having some control over the situation, increase in positive attitude. appearance above alert or complications? a. and then the patient went unconscious. : 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. - Obesity. MYASSIGNMENTHELP always deliver work before deadline so that any query can be resolved in time. Instruct patient to report pain immediately. Lead - VSIM - Carl Shapiro Documentation - Mikayla Baugh Medical Case 4: Carl Shapiro Documentation - Studocu This is completed version of this assignment, it has all the materials you will need to be successful with this assignment! 6. Honest explanations can alleviate anxiety. of his radial pulse after noticing he was in V Fib. It was a good review; I feel like I have practiced CPR a bunch and have a good understanding of the concept. Referring to your feedback log, document the assessment findings and nursing care you 2. The code team was called, 4. 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Auscultate lungs (crackles), chest x-ray, assess respiration, pulse ox. BP 121/73 iii. 30 Comments Please sign inor registerto post comments. Document the changes in Carl Shapiro's vital signs throughout the scenario. Temp: 99 F (37 C) 8 minutes into the scenario he went into ventricular fibrillation then went S: Pt arrive in the ED with chest pain that was alleviated by NTG. 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. bumped his oxygen up to 5 liters nasal cannula. Blood pressure: 120/72 mm Hg. Per physicians orders, IV infusion of NS was started and labs were drawn. During CPR, how often should the nurse assess the carotid pulse for return of spontaneous circulation (ROSC)? Stop drug 5 to 7 days before elective surgery to allow time for production and release of new platelets. 0 X Sold Pt was then Provides baseline for comparison to aid in determining effectiveness of therapy, resolution and progression of problem. Carl has a hx of HTN and takes BP medication at home. Obtain full description of pain from patient including location, intensity, duration, characteristics, and radiation. 2. Document Carl Shapiro's cardiac rhythms that occurred in the scenario. Document a comprehensive pain assessment for Marilyn Hughes. Is the following statement TRUE or FALSE? Background: patient came into the Emergency department with complaints of chest pain, diaphoresis, and shortness of breath, he was given aspirin and two doses of sublingual nitroglycerin, which resolved the chest pain, Iv infusion of Normal saline Patient may fear death and/or be anxious about immediate environment. Pulse: Present. 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