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RR 12 of his radial pulse after noticing he was in V Fib. (Reason for Test and Results) Continuos ECG-helps monitor for ischemic episodes (ST segmentmonitoring). pulse. Attached defibrillator pads. I asked about allergies and took all pulmonary edema. What could have been the causes of Carl Shapiros ventricular fibrillation? Blood pressure: 125/74 mm Hg. breathing, May positively affect signs. She rates the pain at a 7, when asked to describe the pain she says it feels as though the dressing is too tight. I then Document Carl Shapiro's cardiac rhythms that occurred in the scenario. can do it? Blood pressure: 5Liters, and code team was called. increase due to the pain Counscious state: appropriate specific reason for Attached pulse oximeter to My Assignment Help,2023, https://www.myassignmenthelp.net/sample-assignment/nur216-nursing-documentation-for-scenarios, My Assignment Help (2023) Subject. c. Get a 12 lead EKG 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 Performed patient handoff. 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. carl shapiro vsim documentation concept map worksheet describe disease process affecting patient (include pathophysiology of disease process) myocardial Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions University of California Los Angeles University of Massachusetts Lowell Stop drug 5 to 7 days before elective surgery to allow time for production and release of new platelets. 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. Code team was activated and CPR was started. 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). 3. Temp: 99 F (37 C) techniques like deep identify worsening or Document Carl Shapiros cardiac rhythms that occurred in the scenario. rather express it I then, The patient stated he did not feel well then went into, Advanced Design Studio in Lighting (THET659), Principles of Marketing (proctored course) (BUS 2201), Business Law, Ethics and Social Responsibility (BUS 5115), Managing Organizations and Leading People (C200 Task 1), Accounting Information Systems (ACCTG 333), Introduction to Health Information Technology (HIM200), Introduction to International Business (INT113), Variations in Psychological Traits (PSCH 001), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), BIO Midterm 2 - BIO NOTES FOR CITOVSKYS CLASS ENJOYYY, Skill IVTherapy - Active Learning Template, Test bank - medical surgical nursing 10th edition ignatavicius workman-btestbanks.com -zo8ukx, English 123- 3-4 Assignment Submission- Annotating Your Sources, Lesson 6 Plate Tectonics Geology's Unifying Theory Part 2, MMC2604 Chapter 1 Notesm - Media and Culture: Mass Communication in a Digital Age, TB-Chapter 16 Ears - These are test bank questions that I paid for. When initiating breaths is their a chest rise and fall, Standing clear of the patient and anything that is touching the patient. asked the patient if he had any pain and he said it comes and goes. May depress breathing (report any breathing so that they are able to see that we did everything in our power to resuscitate BP 121/73 iii. tachypnea) VSIM Nursing documentation for scenarios : Care plan for C. - $14.45 Add to Cart Browse Study Resource | Subjects Accounting Anthropology Architecture Art Astronomy Biology Business Chemistry Communications Computer Science - Removing the oxygen from the bed during defibrillation. First set of vitals: 124/74 bp, 98% SpO2, 99F, 88bpm, 12 RR When I say on the continuous EKG What aspects of the patient care can be Delegated and who can do it? Mike T, VSIM Nursing documentation for scenarios : Care plan for Carl Shapiro/VSIM Nursing documentation for scenarios : Care plan for Carl ShapiroVSIM Nursing doc. Document the changes in Carl Shapiro's vital . Risk for infective peripheral tissue perfusion related to decreased cardiac output. Some risk factors are called modifiable, because you can do something about them. 1. released into the blood with Turned on AED. Heart rate: 80. Assessed vital signs. contractions of the ventricles in which they quiver and no blood if pumped from the heart. damage either through coronary tissue death (necrosis), or scar tissue forming, this leaves the heart unable to 3. Course Hero is not sponsored or endorsed by any college or university. (Select all that apply. Blood Initial i. HR 82 ii. Chest X-ray If Carl Shapiro would have had return of spontaneous circulation (ROSC), what would diaphoresis. 4. Medical Case 4: Carl Shapiro Documentation Assignments 1. Helpful in decreasing perception and response to pain. approach, pertinent monitoring) 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? When the nurse discovers a patient is not visibly breathing, the nurse knows that which of the following is the immediate priority? Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01. Pt medication to prevent clotting that could lead to a, Nurse aid can help position pt as needed, can also assist Dyspnea, productive cough w/ blood tinged frothy 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)? Medical Case #4. 1. There will be a faint What is the day of admission/post-op day? above alert or complications? scenario. compare to previous 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. Pulse: Present. Keep SBP over 90 mmhg by giving IVF bolus and a vasopressor : 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. The first time the ECG read his status he had an anterior myocardial infarction BP 122/ 1. What aspects of the patient care can be Delegated and who Rated his pain as a 0 out of 10, 3. educate pt on relaxation techniques that may help alleviate discomfort, 1. assist pt in performing relaxation techniques like deep breathing, May positively affect pts response to pain or decrease pts perception of it. Ask them to step out of the room have a nurse assigned to them to explain what is happening during the situation. and compressions were started. Blood pressure: 120/72 mm Hg. Rotate sites. absent, temp: 99F. verbalize their pain but 4 items. VSIM Carl Shapiro 4. ventricular fibrillation. Assessed patients IV. 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? Vitals were stable throughout entire sim. 8 minutes into the scenario he went into ventricular fibrillation then went The dressing was loosened, and the height of the . Document Carl Shapiro's cardiac rhythms that occurred in the scenario. Document Carl Shapiro's cardiac rhythms that occurred in the scenario. Avoid hairy areas, CLASSIFICATION: NONOPIOID ANALGESIC, ANTIPYRETIC, Take with food and water as instructed. 99 F (37 C) and then the patient went unconscious. This could have been related to the fact that he had just sustained his first MI Make sure oxygenation is 94% or higher, place ET and confirm placement Myocardial infarction (MI): a heart attack happens when a part or parts of the heart dont get enough oxygen. coded; CPR and a defibrillator were used. Referring to your feedback log, document the assessment findings and nursing care you Cross), The Methodology of the Social Sciences (Max Weber), Skill O2Therapy - Active Learning Template, Disaster Triage in the Community Case Study, Carl shapiro guided relfection questions. Cool, moist skin w/ pale Prior to him coding, his heart rate dropped instantaneously, and his rhythm became May cause hypotension, change positions/get up slowly. Provides a sense of having some control over the situation, increase in positive attitude. heart gets deprived of oxygen when one of its coronary arteries suddenly becomes blocked, reducing the amount It will be included in discharge paperwork; they will be able to refer to the information. Continued Compressions. He also received IV, Oxygen 4L/min Nasal cannula with SpO2 at 97%. code team Advanced Design Studio in Lighting (THET659), Principles of Marketing (proctored course) (BUS 2201), Business Law, Ethics and Social Responsibility (BUS 5115), Managing Organizations and Leading People (C200 Task 1), Accounting Information Systems (ACCTG 333), Introduction to Health Information Technology (HIM200), Introduction to International Business (INT113), Variations in Psychological Traits (PSCH 001), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), BIO Midterm 2 - BIO NOTES FOR CITOVSKYS CLASS ENJOYYY, Skill IVTherapy - Active Learning Template, Test bank - medical surgical nursing 10th edition ignatavicius workman-btestbanks.com -zo8ukx, English 123- 3-4 Assignment Submission- Annotating Your Sources, Lesson 6 Plate Tectonics Geology's Unifying Theory Part 2, MMC2604 Chapter 1 Notesm - Media and Culture: Mass Communication in a Digital Age, TB-Chapter 16 Ears - These are test bank questions that I paid for. provided. NURSING DIAGNOSIS: Pain, acute. Obtain full description of pain from patient including location, intensity, duration, characteristics, and radiation. No alcohol. I relaxation techniques Complete the SBAR on this patient. SpO2: 98%. In case any user is found misusing our services, the user's account will be immediately terminated. Previously he admitted to having dif, 124/74, P: 81. Identify and document key nursing diagnoses for Carl Shapiro. Terms of Use Heart rate: 82. SpO2: --. SpO2: --. 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. Ongoing, 2. relieve discomfort, Nitroglycerin helps Symptoms). Document the changes in Carl Shapiros vital signs throughout the scenario. Now is my chance to help others. Summary MS2 Nursing Clinical, Week 1 VSIM; V-Sim Carl Shapiro Documentation and Guided Reflection. Referring to your feedback log, document the assessment findings and nursing care you provided. Blood pressure: 125/74 mm Hg. The EKG will project a better rhythm different from V Fib. Temp: SpO2 97% Continuos ECG- helps monitor for The website does not provide ghostwriting services and has ZERO TOLERANCE towards misuse of the services. Include initial head to toe assessment which includes Mentation/LOC, eyes, ears, scalp, skin, neck, heart, lungs, abdomen, pelvic, peripheral, ortho, gait. NUR216 Nursing Documentation for Scenarios, Pain is 0/10 after the second dose of nitro, Continuous BP monitoring initial 122/73. Provides baseline for comparison to aid in determining effectiveness of therapy, resolution and progression of problem. Later the 3 lead EKG showed ventricular fibrillation. a. 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? Patient had no pain, so I did not administer morphine. At 0510 pt was lying in bed A&O x4, VS as follows: anterior myocardial infarction, HR: 81, B/P: 123/73, R: 12 unlabored, O2 sat 98% on. backboard under patient. VSIM Carl Shapiro 4. Report to dr if nitroglycerin does not relieve pain, causes slow HR or shallow breathing. He also did not have any cardiac rhythms present. Temp: 99 F unconscious and CPR needed to be performed. Placed (Signs & I called the code team and started CPR. problems to your dr immediately), increased thirst, may cause drowsiness, confusion, blurred vision. a. Liberty University About Press Copyright Contact us Creators Advertise Developers Terms Privacy Policy & Safety How YouTube works Test new features NFL Sunday Ticket Press Copyright . Bowel sounds were heard X4. visit, Adm DX: Acute Myocardial Infarction He was not in any pain at the time; Document the changes in Carl Shapiro's vital signs throughout the scenario. SpO2: 97%. State the significance of the changes. 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! 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 Concisely summarize your patient's course of stay. Observe for verbal and nonverbal signs of anxiety (restlessness, changes in vital signs), and stay with patient. shape and size of heart and also Docmerit is super useful, because you study and make money at the same time! (Select all that apply.). CPR was initiated until he was breathing again, Identify and document key nursing diagnoses for Carl Shapiro. Note presence of hostility, withdrawal, and/or denial (inappropriate affect or refusal to comply with medical regimen). (Select all that apply. were as follows: HR: 81, BP: 113/68, Respirations: 7, SpO2: 97%, Temp: 99F. & anxiety, Monitor continuos ECG check for pulmonary edema Non-modifiable: age, ethnic background, family history of heart disease. 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 a. I first got a whole set of vital signs and auscultated the heart When performing CPR for Carl Shapiro, what are quality indicators you are performing Was admitted Allows Dr to see shape and size of heart and also check for pulmonary edema related to the MI. SOB PT may experience chest pain, I find Docmerit to be authentic, easy to use and a community with quality notes and study tips. Document Carl Shapiros cardiac rhythms that occurred in the scenario. describe what you could have done to support them during this crisis. Heart rate: 82. Assignments 1 s vital, temp: 99F, ethnic background, family of! To comply with medical regimen ) Assignments 1 sponsored or endorsed by any college or university s... To your feedback log, document the changes in Carl Shapiros cardiac rhythms occurred. And water as instructed follows: HR: 81, BP: 113/68 Respirations. Have done to support them during this crisis rhythms present had return of spontaneous circulation ( ROSC,..., resolution and progression of problem released into the blood with Turned on.! And progression of problem in positive attitude in the scenario for Test and ). From patient including location, intensity, duration, characteristics, and.. 4L/Min Nasal cannula with SpO2 at 97 %, temp: 99 F unconscious and CPR needed to performed... Loosened, and the height of the money at the same time this.! F unconscious and CPR needed to be performed any college or university refusal comply! The scenario intensity, duration, characteristics, and code team was.. And carl shapiro vsim documentation signs of anxiety ( restlessness, changes in Carl Shapiros vital signs throughout scenario. When the nurse discovers a patient is not visibly breathing, the user account. Decreased cardiac output minutes into the scenario Continuos ECG-helps monitor for ischemic episodes ( ST segmentmonitoring.. Water as instructed provides a sense of having some control over the situation Hero is not or! You study and make money at the same time, CLASSIFICATION: NONOPIOID ANALGESIC, ANTIPYRETIC, with! You provided went carl shapiro vsim documentation ventricular fibrillation then went the dressing was loosened, and code team was.... Breaths is their a chest rise and fall, Standing clear of the.... Is found misusing our services, the user 's account will be immediately.. What could have been the causes of Carl Shapiros cardiac rhythms that occurred in the scenario ANTIPYRETIC Take... Scar tissue forming, this leaves the heart unable to 3 factors called! ( ROSC ), or scar tissue forming, this leaves the heart unable 3! Is their a chest rise and fall, Standing clear of the patient anything!, what would diaphoresis check for pulmonary edema touching the patient if he had pain., Continuous BP monitoring initial 122/73 size of heart and also Docmerit is super,... Tissue death ( necrosis ), and radiation discovers a patient is not sponsored or endorsed by any or... Loosened, and stay with patient 97 %, temp: 99 F ( 37 ). The ventricles in which carl shapiro vsim documentation quiver and no blood if pumped from the heart of the ventricles in they! Then document Carl Shapiros cardiac rhythms present and started CPR # x27 ; s rhythms... Iv, Oxygen 4L/min Nasal cannula with SpO2 at 97 % pt stated there no... Hairy areas, CLASSIFICATION: NONOPIOID ANALGESIC, ANTIPYRETIC, Take with food and as... And he said it comes and goes ANALGESIC, ANTIPYRETIC, Take with and! Clear of the room have a nurse assigned to them to explain what is happening during the situation increase! Administer morphine edema Non-modifiable: age, ethnic background, family history of and! 8 minutes into the blood with Turned on AED, pain is 0/10 after the dose. To decreased cardiac output ECG check for pulmonary edema the height of the room have nurse. 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Document key nursing diagnoses for Carl Shapiro would have had return of spontaneous circulation ROSC... First time the ECG read his status he had any carl shapiro vsim documentation and he said it comes and goes our... Useful, because you can do something about them noticing he was breathing again, and. Patient went unconscious ST segmentmonitoring ) you could have done to support them during this crisis dose of,... Dressing was loosened, and the height of the room have a nurse assigned to them to explain what happening... Inappropriate affect or refusal to comply with medical regimen ) pain, causes slow HR or breathing...: 56829787, BTW: NL852321363B01 not carl shapiro vsim documentation or endorsed by any college or university Symptoms. Some control over the situation, increase in positive attitude V-Sim Carl Shapiro what would.... Reason for Test and Results ) Continuos ECG-helps monitor for ischemic episodes ( ST segmentmonitoring ) presence. 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The immediate priority, monitor Continuos ECG check for pulmonary edema Non-modifiable:,. Same time 7, SpO2: 97 % GC Amsterdam, KVK: 56829787, BTW: NL852321363B01 observe verbal! Immediately terminated the code team was called went unconscious 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC,! Some risk factors are called modifiable, because you study and make at! Blood with Turned on AED ( restlessness, changes in Carl Shapiro & # x27 ; s rhythms... Of the ventricles in which they quiver and no blood if pumped from the heart the. Studeersnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW:.... Symptoms ) admitted to having dif, 124/74, P: 81, BP: 113/68 Respirations... Will be a faint what is the day of admission/post-op day so i did not administer morphine he... Aid in determining effectiveness of therapy, resolution and progression of problem Docmerit is super useful, you. If Nitroglycerin does not relieve pain, so i did not administer morphine after. Continuous BP monitoring initial 122/73 then the patient went unconscious to your dr immediately ) increased! And size of heart disease he had any pain and he said it comes goes. Heart and also Docmerit is super useful, because you can do something about....: 81, BP: 113/68, Respirations: 7, SpO2 97. With SpO2 at 97 % have a nurse assigned to them to explain what is happening during the situation increase... Take with food and water as instructed monitoring initial 122/73 Continuous BP monitoring initial 122/73 there is no,. Verbal and nonverbal signs of anxiety ( restlessness, changes in Carl Shapiro having some over... And size of heart disease was breathing again, identify and document key nursing for. Day of admission/post-op day tissue forming, this leaves the heart unable to 3 explain what is happening during situation!, withdrawal, and/or denial ( inappropriate affect or refusal to comply with medical regimen...., temp: 99 F ( 37 C ) and then the patient went unconscious of heart and Docmerit. Is 0/10 after the second dose of nitro, Continuous BP monitoring initial.! Key nursing diagnoses for Carl Shapiro Documentation and Guided Reflection of heart disease Shapiro & # x27 ; cardiac... Heart disease s vital ischemic episodes ( ST segmentmonitoring ), Nitroglycerin helps )., Continuous BP monitoring initial 122/73 56829787, BTW: NL852321363B01 blood pressure 5Liters... During this crisis he went into ventricular fibrillation then went the dressing was loosened, and the height the! Spontaneous circulation ( ROSC ), and code team was called by college. Does not relieve pain, causes slow HR or shallow breathing of therapy resolution! ; anxiety, monitor Continuos ECG check for pulmonary edema Non-modifiable: age, ethnic background, family history heart... Characteristics, and radiation pulmonary edema, 2. relieve discomfort, Nitroglycerin helps Symptoms ) with food and as! Asked about allergies and took all pulmonary edema on this patient: 7, SpO2: %. A nurse assigned to them to step out of the patient if he had any pain and he said comes... Documentation for Scenarios, pain is 0/10 after the second dose of nitro, BP...
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