Carl Shapiro - vsim PDF

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CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT Myocardial Infarction: ("heart attack") is the irreversible damage of myocardial tissue caused by prolonged ischemia and hypoxia. This most commonly occurs when a coronary artery becomes occluded following the rupture of an atherosclerotic plaque, which then leads to the formation of a blood clot (coronary thrombosis). This event can also trigger coronary vasospasm. If a vessel becomes completely occluded, the myocardium normally supplied by that vessel will become ischemic and hypoxic. Without sufficient oxygen, the tissue dies. The damaged tissue is initially comprised of a necrotic core surrounded by a marginal (or border) zone that can either recover normal function or become irreversibly damaged. The hypoxic tissue within the border zone may become a site for generating arrhythmias. Ventricular Fibrillation: Ventricular fibrillation is a heart rhythm problem that occurs when the heart beats with rapid, erratic electrical impulses. This causes pumping chambers in your heart (the ventricles) to quiver uselessly, instead of pumping blood. Mechanic OJ, Grossman SA. Acute Myocardial Infarction. StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459269/

DIAGNOSTIC TESTS

PATIENT INFORMATION

- Creatinine Kinase Test: Test is not specific to the heart and is more general. Overuse of muscles causes creatinine to spill out. - Creatinine Kinase Isoenzymes (CKMB): 0-5% of total. Total: Male: 38-174 U/L; Female: 26-140 U/L - Troponin Level Test: Less than 0.04 ng/mL; Above 0.40 ng/mL may indicate MI - Lipid profile, c-reactive protein, BNP, PTT, PT, INR, CBC

- Chest x-ray, electrocardiogram

ANTICIPATED PHYSICAL FINDINGS

- Male - 54 years old - Frequent traveler - Complaints: chest pain, diaphoresis, and SOB - Peripheral IV running normal saline - Receiving oxygen at 4L/min - SpO2 at 97% - Last rated chest pain as a 0 out of 10 - Meds: nitroglycerine - Telemetry unit

- No pain during beginning of assessment - During assessment patient experienced ventricular fibrillation. Symptoms anticipated are lightheadedness or dizziness, palpitations, fatigue, chest pressure, shortness of breath, fainting - Admitting complaint: chest pain, diaphoresis, and shortness of breath

ANTICIPATED NURSI

- Frequently assess vital signs - Auscultate lungs and heart frequently - Pain assessment - Cardiac monitor - Cardiac stress test: NPO x 4 hours, educate patient on the importance of avoiding stimulants such as caffeine and tobacco - Prepare patient for any cardiac evaluations ordered (myocardial perfusion imaging, CT scan, MRI, PET scan) - Hemodynamic monitoring - Intra-arterial blood pressure monitoring - Obtaining a venous blood sample

vSim ISBAR ACTIVITY INTRODUCTION

STUDENT WORKSHEET “Hello, my name is Jessica Fernandez. I am the nurse taking care of the patient in room 6 in the Telemetry unit. Is this ____________? “

Your name, position (RN), unit you are working on

SITUATION

“Patients name is Carl Shapiro. He is a 54-year-old male being seen for acute chest pain, diaphoresis, and shortness of breath.”

Patient’s name, age, specific reason for visit

BACKGROUND Patient’s primary diagnosis, date of admission, current orders for patient

“The patient’s primary diagnosis is myocardial infarction and was admitted on 8/25/2020. Current orders are as follows: Morphine hydrochloride 2mg IV q10 min x3 PRN for chest pain Nitroglycerin 0.6 mg SL PRN q5min x 3 NS 25 mL/hr IV continued infusion Oxygen 4L/min nasal cannula Notify HCP when labs are reported

“Vital signs are as follows: HR 82 Current pertinent assessment data using head to RR 12 toe approach, pertinent diagnostics, vital signs BP 122/74 SpO2 98 T 99 HCO3 18 Creatinine 0.7 CK MB 20 Troponin T 2.2 ASSESSMENT

RECOMMENDATION Any orders or recommendations you may have for this patient

“The patient experienced a Myocardial infarction while under my care. So, my recommendations are to place pt on continuous 12 lead ECG, continuous pulse oximetry, continuous BP monitoring, and maintain oxygen therapy at 4L/min. Consult with physical therapy on planning an appropriate activity program. Insert secondary IV site for emergency medication administration”

PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: 1. Amiodarone 2. Aspirin 3. Epinephrine 4. Morphine 5. Nitroglycerin 6. Vasopressin CLASSIFICATION: 1. Antiarrhythmics 2. Antipyretics; nonopioid analgesics 3. Antiasthmatics; bronchodilators; vasopressors; adrenergics 4. Opioid analgesics; opioid agonists 5. Antianginals; nitrates 6. Antidiuretic hormones; vasopressors PROTOTYPE: 1. Nexterone; Pacerone 2. Acuprin; Asaphen; Aspergum; Bayer Aspirin; Easprin; Empirin; Halfprin; Rivasa; Sloprin; Vazalore; and more. 3. Adrenaclick; Adrenalin; Allerject; Anapen; Auvi-Q; EpiPen; Primatene Mist; and more 4. Doloral; Duramorph; Embeda; Infumorph, Kadian; Morphine EPD; Morphine HP; MS Contin; Statex 5. Nitro-Time; Nitrogard SR; Nitroject; GoNitro; Nitrostat; Nitrol; Minitran; Nitro-Dur; and more 6. Vasostrict SAFE DOSE OR DOSE RANGE, SAFE ROUTE 1.

IV (Adults): 150 mg over 10 min, followed by 360 mg over the next 6 hr. and then 540 mg over the next 18 hr. Continue infusion at 0.5 mg/min until oral therapy is initiated. If arrhythmia recurs, a small loading infusion of 150 mg over 10 min should be given; in addition, the rate of the maintenance infusion may be ↑. PO (Adults): 600–800 mg/day for 1 week or until desired response occurs or side effects develop, then ↓ to 400 mg/day for 3 weeks, then maintenance dose of 200–400 mg/day.

2.

PO Rect: (Adults): 325–1000 mg every 4–6 hr (not to exceed 4 g/day). Extended-release tablets– 650 mg every 8 hr or 800 mg every 12 hr. PO (Adults): 2.4 g/day initially; ↑ to maintenance dose of 3.6–5.4 g/day in divided doses (up to 7.8 g/day for acute rheumatic fever).

3.

IV (Adults): Severe anaphylaxis– 0.1–0.25 mg every 5–15 min; may be followed by 1–4 mcg/min continuous infusion; Cardiopulmonary resuscitation (ACLS guidelines)– 1 mg every 3–5 min; Bradycardia (ACLS guidelines)– 2–10 mcg/min continuous infusion; Hypotension associated with septic shock– 0.05–2 mcg/kg/min continuous infusion; titrate every 10–15 min by 0.05–0.2 mcg/kg/min to achieve desired mean arterial pressure. Inhaln (Adults): Inhalation solution– 1 inhalation of 1% solution; may be repeated after 1–2 min; additional doses may be given every 3 hr; Racepinephrine– Via hand nebulizer, 2–3 inhalations of 2.25% solution; may repeat in 5 min with 2–3 more inhalations, up to 4–6 times daily. Intracardiac (Adults): 0.3–0.5 mg. Endotracheal: (Adults): Cardiopulmonary resuscitation (ACLS guidelines)– 2–2.5 mg. Topical (Adults and Children ≥6 yr): Nasal decongestant– Apply 1% solution as drops, spray, or with a swab.

4.

PO Rect: (Adults ≥50 kg): Usual starting dose for moderate to severe pain in opioid-naive patients– 30 mg every 3–4 hr initially or once 24-hr opioid requirement is determined, convert to extended-release morphine by administering total daily oral morphine dose every 24 hr (as Kadian or other ER capsules), 50% of the total daily oral morphine dose every 12 hr (as Kadian, Morphabond, MS Contin ), or 33% of the total daily oral morphine dose every 8 hr (as Morphabond, MS Contin ). PO Rect: (Adults and Children 100 or 80% Compression rate of 100-120/min. Compression depth of at least 50 mm (2 inches) in adults and at least 1/3 the AP dimension of the chest in infants and children. No excessive ventilation.-High-quality CPR includes compressing hard and fast, allowing complete recoil after each compression, reducing hands-off time by minimizing interruptions in compressions, switching providers every 2 minutes, and avoiding excessive ventilation 4. Discuss safety aspects during defibrillation. Do not touch the patient during defibrillation (clearing bed at least twice before defibrillating), do not allow any objects to touch the bed, ensure the patient is dry before using the AED, do not use AED over a pacemaker/metallic device, ensure the AED is functional, ensure pads are in correct position, ensure patient does not have nitroglycerin patch, ensure there are no flammable substances (remove oxygen from the bed) 5. If Carl Shapiro would have had return of spontaneous circulation (ROSC), what would your next interventions be? I would first assess the carotid pulse, administer epinephrine, administer amiodarone 6. What key elements would you include in the handoff report for this patient? Consider the SBAR (situation, background, assessment, recommendation) format. S- This is 54-year old Carl Shapiro experienced VFIB, code team was called, emergency response measures were implemented to include CPR and AED shock. B- 54-year-old male. He was seen in the Emergency Department at 1:30 p.m. for complaints of chest pain, diaphoresis, and shortness of breath. He was treated in the Emergency Department with aspirin and two doses of sublingual nitroglycerin. Chest pain improved with nitroglycerin administration. A- Patient started breathing spontaneously again. R- Recommend patient cardiac status is closely monitored 7. If Carl Shapiro’s family members had been present at the bedside during the arrest, describe what you could have done to support them during this crisis. The patient is the main concern during this situation, but I would ensure they were escorted out of the room so the focus could be on the patient, but if they insisted to stay, I would reassure them that we are doing everything we can to ensure his health and safety 8. What would you do differently if you were to repeat this scenario? How would your patient care change? I would have reviewed the suggested readings on cardiac arrest and the protocol more in-depth. I felt that I knew what to do, but this simulation showed me that the steps are not so simple and any small change away from the correct technique can cause serious damage to the patient.

Clinical Judgement Components Scoring: Exemplary = 4 point Accomplished = 3 points Developing = 2 points Beginning = 1 point Noticing:

Score: vSim 1

Focused Observation: Recognizing Deviations from Expected Patterns: Information Seeking:

EAD B

D

EAD B EAD B

D A

Total for category:

7

Interpreting: Prioritizing Data: Making Sense of Data:

EAD B EAD B

D D

Total for category: 4 Responding: Calm, Confident Manner: EAD B Clear Communication: EAD B Well-Planned Intervention/Flexibility: EAD B Being Skillful EAD B

A D D D

Total for category: 9 Reflecting: Evaluation/Self-Analysis: EAD B Commitment to Improvement: E A D B

A E

Total for category: 7

Score: vSim 2

Score: vSim 3...