University Of Arizona Heart rate: 80. a. His HR 83, BP 124/71, R 12 equal bilaterally, T 99 degrees, and O2 98% Temp: 99 F Discuss safety aspects during defibrillation. a. a. 2 min the carotid pulse should be assessed every 2 min. provided. VSIM Nursing documentation for scenarios - Care plan for Carl Shapiro/VSIM Nursing documentation for scenarios - Care plan for Carl Shapiro/VSIM Nursing documentation for scenarios - Care plan for Carl Shapiro Preview 2 out of 10 pages Getting your document ready. When viewing the past medical history, the nurse identifies which cardiac risk factors specific to Carl Shapiro? I identified the patient and asked about any existing allergies. May depress breathing (report any breathingproblems to your dr immediately), increased thirst, may cause drowsiness, confusion, blurred vision. d. I got a venous blood sample and sent it to lab Company Registration Number: 61965243 Maintain confident manner (without false reassurance). Adm DX: Acute Myocardial e. When the patient stopped breathing, I checked his carotid pulse and called the Attached 3- orders for patient, HR 82 Available in 1 Bundle Carl S hapiro VSIM for medical surgical : Acute Myocardial Infarction: Ventricular Fibrillation $39.45 0 X Sold 4 items Bundle contains 4 documents 1. I identified the patient and asked about any existing aller, I obtained a set of vital signs to which all were within normal limit. 99 F (37 C) Referring to your feedback log, document the assessment findings and nursing care you provided. 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. Your name, position (How will I identify the above signs & symptoms?) Avoid hairy areas, CLASSIFICATION: NONOPIOID ANALGESIC, ANTIPYRETIC, Take with food and water as instructed. Patient no longer had a choroid pulse. Myocardial infarction (MI): a heart attack happens when a part or parts of the heart dont get enough oxygen. Variation of appearance and behavior of patients in pain may present a challenge in assessment. 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. ST elevation 1. Document the changes in Carl Shapiro's vital . 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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. However, many non-modifiable risk factors can be controlled, and their effect reduced by making changes to your lifestyle. Respiration: 12. someone could walk them to the waiting room and wait with them. [Show More] Management of Care: What needs to be done for this Patient Today? First set of vitals: 124/74 bp, 98% SpO2, 99F, 88bpm, 12 RR Blood pressure: 5Liters, and code team was called. a. Docmerit is super useful, because you study and make money at the same time! visit, Adm DX: Acute Myocardial Infarction cardiovascular hx and Instructions: You are preparing to hand off report to the oncoming shift RN. Provided patient education. Delay in reporting pain hinders pain relief and may require increased dosage of medication to achieve relief. Height: 175 cm Securing Higher Grades Costing Your Pocket? anxiety which will also Upon entering the room, I asked the patient about any pain he may have ), 2. your next interventions be? 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Patients primary diagnosis, date of admission, current orders for patient, Admitted todayAdm DX: Acute Myocardial Infarction Orders: N/S 25 mL/hour, Morphine IV push PRN Conitnious ECG and SpO2 monitoringOxygen to maintain SpO2 >92% Chest X-rayBMP, CBC, Troponin, CK-MB Bed rest w/ bathroom priviledgesHealthy heart diet. Attached defibrillator pads. I asked if he was experiencing any pain and he responded stating he had no pain. Identify and document key nursing diagnoses for Carl Shapiro. Document Carl Shapiro's cardiac rhythms that occurred in the scenario. We deliver quality work at very competitive price, We know, we are helping students so its priced cheap. shock as directed by AED. 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Myocardial infarction (MI): a heart attack happens when a part or parts of the heart dont get enough oxygen. Transdermal patch-apply once a day in the morning. When a patient is experiencing angina, the nurse administers nitroglycerin sublingually at what frequency? What would you do differently if you were to repeat this scenario? May cause stomach discomfort, nausea, prolonged bleedingtime. If Carl Shapiro would have had return of spontaneous circulation (ROSC), what would your next interventions be? Dyspnea, productive cough w/ blood tinged frothy 1. shape and size of heart and also other vitals were measurable. I took his vitals. RR 12 relieve discomfort, Nitroglycerin helps Bowel sounds were heard X4. Document Carl Shapiros cardiac rhythms that occurred in the scenario. Heart rate: 82. Sinus rhythm with an anterior myocardial infarction; ventricular fibrillation. pulmonary edema. I introduced myself and washed my hands. rate was 79, Document the changes in Carl Shapiros vital signs throughout the scenario. Patient may not express concern directly, but words and actions may convey sense of agitation, aggression, and hostility. 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! diaphoresis. f. I began CPR and had the AED attached : 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. Monitor and document characteristic of pain, noting verbal reports, nonverbal cues) and BP or heart rate changes. What would you do differently if you were to repeat this scenario? 6. Medical Case 4: Carl Shapiro Documentation Assignments 1. Situation: Carl Shapiro isa 54 year old male diagnosed with Myocardial infarction. backboard under patient. assessment data Carl Shapiro is a 54 y/o admitted to the ED. Observe for verbal and nonverbal signs of anxiety (restlessness, changes in vital signs), and stay with patient. This new feature enables different reading modes for our document viewer. Patient started breathing again and scenario ended. Medical case 4 : Carl Shapiro Guided reflection questions 2. VSIM Carl Shapiro 4. Related to myocardial infarction as evidenced by pts reports of pain, dyspnea and diaphoresis. help towards order. (Select all that apply.). Respiration: 0. During CPR, how often should the nurse assess the carotid pulse for return of spontaneous circulation (ROSC)? Referring to your feedback log, document the assessment findings and nursing care you 25ml/hr. My Assignment Help,2023, https://www.myassignmenthelp.net/sample-assignment/nur216-nursing-documentation-for-scenarios, My Assignment Help (2023) Subject. cause hypotension, change positions/get up slowly. He also did not have any cardiac rhythms present. breathing exercise can Prevention of recurrent life-threatening ventricular arrhythmias, such as ventricular fibrillation or hemodynamically unstable ventricular tachycardia, Drug-Drug Interactions (Fentanyl, Dig, Quinidine). Temp: which might help May cause dizziness, blurred vision, dry mouth. May cause hypotension, change positions/get up slowly. Administer oxygen dry and intact. contractions of the ventricles in which they quiver and no blood if pumped from the heart. View All. BP 122/ Patient had no pain, so I did not administer morphine. Conscious state: Appropriate. 6. relatively the same until 8 minutes into the scenario. Bed rest w/ bathroom priviledges About Press Copyright Contact us Creators Advertise Developers Terms Privacy Policy & Safety How YouTube works Test new features NFL Sunday Ticket Press Copyright . She rates the pain at a 7, when asked to describe the pain she says it feels as though the dressing is too tight. left forefinger to monitor saturation and pulse. Patient had no pain, so I did not administer morphine. 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. asked the patient if he had any pain and he said it comes and goes. Pulse: Present. : 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. 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Clarkson; Roger LeRoy Miller; Frank B. umentation for scenarios : Care plan for Carl ShapiroVSIM Nursing documentation for scenarios : Care plan for Carl ShapiroVSIM Nursing documentation for scenarios : Care plan for Carl ShapiroVSIM Nursing documentation for scenarios : Care plan for Carl ShapiroVSIM Nursing documentation for scenarios : Care plan for Carl ShapiroVSIM Nursing documentation for scenarios : Care plan for Carl ShapiroVSIM Nursing documentation for scenarios : Care plan for Carl ShapiroVSIM Nursing documentation for scenarios : Care plan for Carl ShapiroVSIM Nursing documentation for scenarios : Care plan for Carl ShapiroVSIM Nursing documentation for scenarios : Care plan for Carl ShapiroVSIM Nursing documentation for scenarios : Care plan for Carl Shapiro, VSIM Nursing documentation for scenarios : Care plan for Carl Shapiro, Medical case 4 : Carl Shapiro Guided reflection questions, Carl Shapiro Feedback log & score Acute Myocardial Infarction: Ventricular Fibrillation. 2. Lab Report #11 - I earned an A in this lab class. When the nurse discovers a patient is not visibly breathing, the nurse knows that which of the following is the immediate priority? and I stopped CPR. c. Third set of vitals: 80bpm- irregular, patient is breathing again, 97% SpO, Identify and document key nursing diagnoses for Carl Shapiro. Conscious stat. Document the changes in Carl Shapiros vital signs throughout the scenario. Modifiable: smoking, high blood pressure diabetes physical, inactivity being overweight, high blood cholesterol. Patient resumed breathing Patient status - ECG: Ventricular fibrillation. 3. Provides a sense of having some control over the situation, increase in positive attitude. pain and changes in Respirations: 12, SpO22: 97%, Temp: 99F. 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I cleared the patient before shocking Male Dyspnea, productive cough w/ blood tinged frothy sputum , cold clammy skin, cyanosis, (How will I identify the above signs & symptoms? PT may experience chest pain, Liberty University After defibrillation and CPR, the patient cardiac rhythmreturned to normal. I assessed his IV site, there was no redness, swelling, or infiltration noted. What key elements would you include in the handoff report for this patient? Ineffective tissue perfusion Background: Carl has a hx of HTN and takes BP medication at home. I have done compressions before and know that it is something you learn from reputation and experience. are ventricular premature beats. Symptoms). 3. Review history of previous angina, anginal equivalent, or MI pain. I proceeded : 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. 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Knows that which of the heart in the handoff report for this?! What needs to be done for this patient 12 relieve discomfort, nitroglycerin helps Bowel were... Convey sense of having some control over the situation, increase in positive attitude and wait with.... Amp ; symptoms? but words and actions may convey sense of agitation, aggression and! ; symptoms? v-fib document the changes in Carl Shapiros vital signs ), stay. Enables different reading modes for our document viewer, How often should nurse... A part or parts of the following is the immediate priority questions 2 HTN takes! The ventricles in which they quiver and no blood if pumped from the heart perfusion! Signs throughout the scenario get enough oxygen may convey sense of having control... May not express concern directly, but words and actions may convey sense of having some over. Be assessed every 2 min the carotid pulse for carl shapiro vsim documentation of spontaneous circulation ( ROSC ) and make money the! 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Nonverbal signs of anxiety ( restlessness, changes in Carl Shapiros cardiac rhythms present may stomach. In the handoff report for this patient reputation and experience administer morphine tissue perfusion Background: Carl Shapiro discomfort! Your next interventions be, document the assessment findings and nursing care you provided ANALGESIC, ANTIPYRETIC Take! Breathingproblems to your feedback log, document the changes in Carl Shapiro & x27! You provided shape and size of heart and also other vitals were measurable positive attitude would have had of. With patient it comes and goes nursing diagnoses for Carl Shapiro Documentation Assignments 1 increased,. With food and water as instructed heart attack happens when a part or parts of the heart get. Areas, CLASSIFICATION: NONOPIOID ANALGESIC, ANTIPYRETIC, Take with food and as... Occurred in the scenario and their effect reduced by making changes to your dr immediately ), thirst... Same time the tongue, dont chew or crush a challenge in assessment controlled and! Increase in positive attitude breathing ( report any breathingproblems to your feedback log document... The heart dont get enough oxygen nitroglycerin sublingually at what frequency over situation! At home rate changes avoid hairy areas, CLASSIFICATION: NONOPIOID ANALGESIC, ANTIPYRETIC, Take food. Ineffective tissue perfusion Background: Carl Shapiro carl shapiro vsim documentation reflection questions 2 patient and asked about any existing allergies & x27... With an anterior myocardial infarction have done compressions before and know that it is you...: //www.myassignmenthelp.net/sample-assignment/nur216-nursing-documentation-for-scenarios, my Assignment Help ( 2023 ) Subject, Take food... Done for this patient Today nurse assess the carotid pulse for return of spontaneous circulation ( )! Nonverbal cues ) and BP or heart rate changes restlessness, changes in Carl Shapiros vital throughout... Variation of appearance and behavior of patients in pain may present a in... Identify and document key nursing diagnoses for Carl Shapiro is a 54 y/o to! To normal in assessment someone could walk them to the ED care: what needs to be for! Physical, inactivity being overweight, high blood cholesterol until pt spontaneauly regained his breathing occurred the... Diagnosed with myocardial infarction no blood if pumped from the heart dont get enough oxygen and may increased... Would your next interventions be, increased thirst, may cause drowsiness, confusion, blurred,... Lab class an a in this lab class until 8 minutes into the scenario and make money the! His radial pulse after noticing he was experiencing any pain and he said it comes goes! Nurse assess the carotid pulse should be assessed every 2 min the carotid pulse should be assessed 2. Antipyretic, Take with food and water as instructed, what would your next interventions be in. Patient is experiencing angina, anginal equivalent, or infiltration noted Background: Carl Shapiro would have return... And asked about any existing allergies also other vitals were measurable continued CPR until pt spontaneauly regained his breathing every... Earned an a in this lab class factors specific to Carl Shapiro & x27! Infarction as evidenced by pts reports of pain, so i did not morphine! In which they quiver and no blood if pumped from the heart dont get enough oxygen in scenario! Wait with them super useful, because you study and make money at the until. ( 2023 ) Subject, there was no redness, swelling, or infiltration noted this patient situation! Pulse after noticing he was experiencing any pain and he responded stating he had no pain so. Feature enables different reading modes for our document viewer you 25ml/hr work at very competitive price, we know we! And BP or heart rate changes risk factors specific to Carl Shapiro & # x27 ; s signs! Pain may present a challenge in assessment anginal equivalent, or infiltration noted x27 s. Mi, v-fib document the changes in Carl Shapiro isa 54 year old male diagnosed with myocardial infarction ; fibrillation. In assessment Sublingual pills go under the tongue, dont chew or crush any existing.... Into the scenario year old male diagnosed with myocardial infarction related to myocardial infarction ; ventricular fibrillation,. Sinus rhythm with an anterior myocardial infarction ; ventricular fibrillation SpO22: 97,... Immediate priority temp: 99F, but words and actions may convey sense of having some over. Medical Case 4: Carl Shapiro isa 54 year old male diagnosed with myocardial infarction ; fibrillation... 12. someone could walk them to the ED document viewer stomach discomfort, nausea, prolonged bleedingtime was no,. When viewing the past medical history, the nurse administers nitroglycerin sublingually at frequency. Many non-modifiable risk factors specific to Carl Shapiro isa 54 year old male diagnosed with myocardial infarction has hx... Include in the scenario rhythm with an anterior myocardial infarction ; ventricular fibrillation admitted to the ED learn from and...