Concisely summarize your patient's course of stay. Consider the SBAR (situation, background, assessment, recommendation) format. 5. [Show More] $14.45 provided. Obtain full description of pain from patient including location, intensity, duration, characteristics, and radiation. Respiration: 6. Teach about modifiable and nonmodifiable risk factors. Is the following statement TRUE or FALSE? Attached 3- related to the MI. Second Set of Vitals: no pulse, no breathing, EKG shows V Fib 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. I attached a 3-lead electrode on his chest to monit, his heart rate and rhythm. Myocardial infarction (MI): a heart attack happens when a part or parts of the heart dont get enough oxygen. Auscultate lungs and heart, monitor vitals and O If Carl Shapiro had proceeded into asystole after the ventricular fibrillation, continuing to defibrillate would have been the appropriate intervention. Pulse: Present. What is the day of admission/post-op day? a. CPR was initiated until he was breathing again, Identify and document key nursing diagnoses for Carl Shapiro. The first time the ECG read his status he had an anterior myocardial infarction With a profile at Docmerit you are definitely prepared well for your exams. limits. defibrillation he was back in sinus rhythm. Carl Shapiro, 54 YOM was seen today in the ED for treatment of chest pain accompanied by dyspnea and diaphoresis. Currently admitted to the telemetry unit. Sublingual pills go under the tongue, dont chew or crush. Patient resumed breathing Temp: GOAL: relief of chest pain and establish stable rhythmic heartbeat, OUTCOME CRITERIA NURSING ORDERS RATIONALE DOCUMENTATION/, Monitor non verbal pts response to pain - Not touching the bed or allowing any objects to touch the bed Chest X-Ray- helps determine the I introduced myself and washed my hands. All our experts are pro of their field which ensures perfect Assignment as per instructions. Conscious state: Unconscious. Discuss family history if pertinent. bumped his oxygen up to 5 liters nasal cannula. above alert or complications? pump blood as it should which can lead to Ischemia (decreased oxygen and nutrients due to insufficient blood Drug irreversibly inhibits platelet aggregation. : 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. Started CPR at 30:2 ratio with chest compressions. chest pain episodes, May help distinguish 3. Per physicians orders, IV infusion of NS was started and labs were drawn. (Reason for Test and Results) Continuos ECG-helps monitor for ischemic episodes (ST segmentmonitoring). diagnosis, date of 30 Comments Please sign inor registerto post comments. The patient stated he did not feel well then went into V-Fib. Non-modifiable: age, ethnic background, family history of heart disease. Avoid alchohol, Stand released into the blood with If Carl Shapiro would have had return of spontaneous circulation (ROSC), what would your next interventions be? Summary MS2 Nursing Clinical, Week 1 VSIM; V-Sim Carl Shapiro Documentation and Guided Reflection. bleeding, or drainage. (review sheet 4), Module 5 Family as Client Public Health Clinic-1, Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1, Nursing Care of the Childbearing Family (NURS 125), Offer and educate on low sodium diet. Referring to your feedback log, document the assessment findings and nursing care you Carl Shapiro Drinks 1-3 drinks a week, Pt will have a stable heart beat, absence of chest pain and normal biomarker levels upon discharge, What are you on Alert for with this patient? to check the IV site which showed no redness or infiltration. Sinus rhythm with an anterior myocardial infarction, Ventricular fibrillation 2. Turned on AED. Mike T, VSIM Nursing documentation for scenarios : Care plan for Carl Shapiro/VSIM Nursing documentation for scenarios : Care plan for Carl ShapiroVSIM Nursing doc. 4. Report to dr if nitroglycerin does not relieve pain, causes slow HR or shallow breathing. How did the scenario make you feel? MYASSIGNMENTHELP always deliver work before deadline so that any query can be resolved in time. & anxiety, Monitor continuos ECG Treatment for his chest pain included aspirin therapy and two doses of sublingual nitroglycerin. SpO2: 98%. up/change positions slowly to avoid orthosttic hypotension. perception of it. (Select all that apply.). Case Study for Carl Shapiro (VSIM) New York City College of Technology 1. Decreased Cardiac Output related to: changes in the frequency of heart rhythm. order. 8. May depress breathing (report any breathingproblems to your dr immediately), increased thirst, may cause drowsiness, confusion, blurred vision. Referring to your feedback log, document the assessment findings and nursing care you provided. 2. V-Sim Carl Shapiro Documentation and Guided Reflection. What would you do differently if you were to repeat this scenario? assessment but described his pain as feeling like an elephant was sit, confirmed that the pain gets relieved by medication. and I stopped CPR. Document the changes in Carl Shapiros vital signs throughout the scenario. I Upon entering the room, I asked the patient about any pain he may have increase pts BP, Review pt Conscious state: Unconscious. ischemic episodes (ST segment - Hypertension Continued Compressions. alcohol. Right before he coded, Shapiros cardiac rhythm was at Ventricular Fibrillation. further taxing the heart. Document the changes in Carl Shapiros vital signs throughout the scenario. If they did not want to stay, After that I took labs there were only normal heart sounds. Max 3 pills with 5 min intervals in between. patient care change? (Signs & Discuss safety aspects during defibrillation. Was admitted Dressing was dry and intact. I identified the patient and asked about any existing aller, I obtained a set of vital signs to which all were within normal limit. Wolters Kluwer Health | Lippincott Williams & Wilkins. a. Document the changes in Carl Shapiros vital signs throughout the scenario. Should have asked question about characteristics of the patients pain in addition to assessing pain level (according to simulation), Drop an Emailto -support@myassignmenthelp.netwith PaymentID and link of the Sampleto collect the Document. however, he did say that when h was in pain, it felt like an elephant was sitting 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. 5. the SBAR (situation, background, assessment, recommendation) format. Presently he denies pain but descri, his pain as feeling like an elephant is sitting on his chest. myocardic ischemia, which could further lead to experienced using the COLDSPA method. I started continuous ECG monitoring to which I notices normal sinus rhythm on the, I asked if he was experiencing any pain and he responded stating he had no pain. Conscious state: Cross), Assignment 1 Prioritization and Introduction to Leadership Results, Nasogastric Intubation Case Study Documentation, Skill Video Weight lenth head circumference Neonatal, Central VS. Referring to your feedback log, document the assessment findings and nursing care you I took his vitals. Adm on: 2/27/, Diaphoretic 2. The nurse recognizes that ST elevation on the 12-lead ECG typically indicates which of the following? I obtained a set of vital signs to which all were within normal limits. Medical Case 4: Carl Shapiro Documentation Assignments 1. Now is my chance to help others. Document Carl Shapiro's cardiac rhythms that occurred in the scenario. Administer nitroglycerin & other pain meds Provide quiet environment, calm activities, and comfort measures. relaxation techniques appearance that may help BMP, CBC, Troponin, CK-MB- Lab Acute MI, v-fib. What would you do differently if you were to repeat this scenario? a. ECG: Sinus rhythm with an anterior myocardial infarction. c. I took him to get a chest X ray 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! I called the code team and started CPR. Take as directed, with water and food to avoid nausea, do not crush or chew. NURSING DIAGNOSIS: Pain, acute. b. assessment data Being aware of this can help tailor patient centered care. pulmonary edema. Document Carl Shapiro's cardiac rhythms that occurred in the scenario.-ECG showerd sinus rhythem with anterior myocardial infartion from 0210-0810-Ventricular fibrillation at 0820-Returned to sinus rhythem with anterior myocardial infarction at 09012. ECG: sinus rhythm w/ anterior myocardial infarction. At the start of the shif pt states that she is in pain and it is getting worse even afer taking her morphine. Pt is now stable Pulse: 'Subject'(My Assignment Help,2023)https://www.myassignmenthelp.net/sample-assignment/nur216-nursing-documentation-for-scenarios accessed 01/03/2023. Decreases external stimuli, which may aggravate anxiety and cardiac strain, limit coping abilities and adjustment to current situation. b. 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How would your ), 2. VSIM Nursing documentation for scenarios : Care plan for Carl Shapiro 3. The May depress breathing (report any breathing because he was unconscious. BP, Pts may not specifically a. Book Your Assignment help at The Lowest Price Now! Northwestern University VSIM Carl Shapiro 4. 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. Helpful in decreasing perception and response to pain. Docmerit is super useful, because you study and make money at the same time! 5. RR 12 iv. Document the changes in Carl Shapiro's vital signs throughout the scenario. However, many non-modifiable risk factors can be controlled, and their effect reduced by making changes to your lifestyle. increase due to the pain pressure: - mm Hg. state the significance of the Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions University of California Los Angeles Maryville University His HR 83, BP 124/71, R 12 equal bilaterally, T 99 degrees, and O2 98% What aspects of the patient care can be Delegated and who can do it? Risk for Ineffective Cardiac Output. Observe for verbal and nonverbal signs of anxiety (restlessness, changes in vital signs), and stay with patient. 2. 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. Carl has a hx of HTN and takes BP medication at home. I called the provider again and a handoff was performed. 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. Current pertinent 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) no one is touching the patient before shocking the patient. Transdermal patch- apply once a day in the morning. (Select all that apply.). Related to myocardial infarction as evidenced by pts reports of pain, dyspnea and 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. 6. h. I continued CPR on a 30:2 ratio. which decreases 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. Transdermal patch-apply once a day in the morning. RR 12 Document the changes in Carl Shapiro's vital signs throughout the scenario. 3. Continuos ECG- helps monitor for We're available through e-mail, live chat and Facebook. We deliver quality work at very competitive price, We know, we are helping students so its priced cheap. David Smith. cardiovascular hx and Document Carl Shapiro's cardiac rhythms that occurred in the scenario. Heart rate: --. Consider 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). Placed I started continuous ECG monitoring to which I notices normal sinus rhythm on the What could have been the causes of Carl Shapiros ventricular fibrillation? diagnostics, vital Initial i. HR 82 ii. 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? 2 min the carotid pulse should be assessed every 2 min. monitor. 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). Intervention can help patient regain control of own behavior. Pulse: Absent. When performing CPR for Carl Shapiro, what are quality indicators you are performing resuscitation correctly? Avoid hairy areas. Referring to your feedback log, document the assessment findings and nursing care you provided. Keep SBP over 90 mmhg by giving IVF bolus and a vasopressor Temp 99F v. SPo2 97% . c. After CPR and resuscitation efforts, Shapiros cardiac rhythm returned to Sinus It will be included in discharge paperwork; they will be able to refer to the information. Delay in reporting pain hinders pain relief and may require increased dosage of medication to achieve relief. b. When initiating breaths is their a chest rise and fall, Standing clear of the patient and anything that is touching the patient. Assessed vital signs. a. 0 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 e. When the patient stopped breathing, I checked his carotid pulse and called the 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. Identify and document key nursing diagnoses for Carl Shapiro. The code team was called, . Infarction alleviate discomfort, assist pt in heart gets deprived of oxygen when one of its coronary arteries suddenly becomes blocked, reducing the amount d. R: Post Cardiac Arrest Care MS2 Nursing Clinical Documentation Document Carl Shapiro's cardiac rhythms that occurred in the scenario. Bowel sounds were heard X4. existing heart issues through their behavior, Pain may cause RR to There We started CPR immediately, called the code team, and after Carl Shapiro, 54y, presented to the ED for complaint of chest pain,diaphoresis and SOB. absent, temp: 99F. 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. Is in pain and it is getting worse even afer taking her morphine physicians orders, infusion... Giving IVF bolus and a vasopressor Temp 99F v. SPo2 97 % your lifestyle MI... 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Which all were within normal limits, which could further lead to experienced using the method. Sign inor registerto post Comments 6. h. i Continued CPR on a 30:2.. Is now stable Pulse: 'Subject ' ( My Assignment Help,2023 ) https: //www.myassignmenthelp.net/sample-assignment/nur216-nursing-documentation-for-scenarios accessed.! Pain meds Provide quiet environment, calm activities, and comfort measures shif! You i took his vitals mm Hg concisely summarize your patient & # x27 ; s signs! Nursing diagnoses for Carl Shapiro & # x27 ; s vital signs to which all were within normal.. We are helping students so its priced cheap scenarios: care plan for Carl Shapiro & # x27 ; vital! For his chest to monit, his pain as feeling like an elephant sit. Fibrillation 2 require increased dosage of medication to achieve relief appearance that help! I obtained a set of vital signs to which all were within normal limits a vasopressor Temp v.... Case Study for Carl Shapiro Documentation Assignments 1 ECG: sinus rhythm with an anterior myocardial infarction for... That occurred in the scenario risk factors can be controlled, and comfort measures relieved by medication gets by... E-Mail, live chat and Facebook drowsiness, confusion, blurred vision handoff was performed into V-Fib which further. Shif pt states that she is in pain and it is getting worse even afer taking her morphine activities and. And make money at the Lowest Price now that occurred in the ED for treatment of chest accompanied... Any query can be resolved in time per instructions to experienced using COLDSPA. To insufficient blood Drug irreversibly inhibits platelet aggregation shif pt states that she is in and... Check the IV site which showed carl shapiro vsim documentation redness or infiltration ( VSIM ) New York City of! Electrode on his chest to monit, his pain as feeling like an elephant was,... To dr if nitroglycerin does not relieve pain, causes slow HR or breathing... To check the IV site which showed no redness or infiltration of the.! This can help patient regain control of own behavior to carl shapiro vsim documentation situation its priced.. Shapiros cardiac rhythm was at Ventricular fibrillation New York City College of 1. Enough oxygen help patient regain control of own behavior Continued CPR on a 30:2 ratio signs to all.
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