Medical Case 04 Carl Shapiro DA PDF

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Medical Case 4: Carl Shapiro Documentation Assignments 1. Document Carl Shapiro’s cardiac rhythms that occurred in the scenario. - Sinus rhythm with an anterior myocardial infarction - Ventricular fibrillation -ventricular premature heart beats 2. Document the changes in Carl Shapiro’s vital signs throughout the scenario. - Heart rate: 82. Pulse: present. Blood pressure: 122/73 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F - Heart rate: 82. Pulse: Present. Blood pressure: 123/74 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F - Heart rate: 81. Pulse: Present. Blood pressure: 121/73 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F - Heart rate: 81. Pulse: Present. Blood pressure: 121/73 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F - Heart rate: 81. Pulse: Present. Blood pressure: 124/74 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F - Heart rate: 81. Pulse: Present. Blood pressure: 125/75 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F - Heart rate: 81. Pulse: Present. Blood pressure: 122/73 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F - Heart rate: 81. Pulse: Present. Blood pressure: 122/72 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F - Heart rate: --. Pulse: Absent. Blood pressure: - mm Hg. Respiration: 0. Conscious state: Unconscious. SpO2: --. Temp: 99 F - Heart rate: 79. Pulse: Absent. Blood pressure: - mm Hg. Respiration: 0. Conscious state: Unconscious. SpO2: --. Temp: 99 F - Heart rate: 78. Pulse: Present. Blood pressure: 95/57 mm Hg. Respiration: 0. Conscious state: Unconscious. SpO2: 97%. Temp: 99 F - Heart rate: 79. Pulse: Present. Blood pressure: 102/61 mm Hg. Respiration: 0. Conscious state: Somnolent. SpO2: 97%. Temp: 99 F - Heart rate: 83. Pulse: Present. Blood pressure: 113/67 mm Hg. Respiration: 9. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F 3. Identify and document key nursing diagnoses for Carl Shapiro. - Acute pain related to tissue ischemia as evidence by changes in level of consciousness, changes in pulse and BP. 4. Referring to your feedback log, document the assessment findings and nursing care you provided. - You arrived at the patient's side. 0:00 You introduced yourself.

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0:05 You washed your hands. To maintain patient safety, it is important to wash your hands as soon as you enter the room. 0:10 Patient status - ECG: Sinus rhythm with an anterior myocardial infarction. Heart rate: 82. Pulse: Present. Blood pressure: 122/73 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F (37 C) 1:10 Patient status - ECG: Sinus rhythm with an anterior myocardial infarction. Heart rate: 82. Pulse: Present. Blood pressure: 123/74 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 1:19 You identified the patient. To maintain patient safety, it is important that you quickly identify the patient. 1:27 You asked: How bad is the pain? He replied: 'There is no pain.' 1:34 You asked the patient if the pain was better after the medication. He replied: 'Yes' 1:42 You looked for normal breathing. He is breathing at 12 breaths per minute. The chest is moving normally on both sides. 2:10 Patient status - ECG: Sinus rhythm with an anterior myocardial infarction. Heart rate: 81. Pulse: Present. Blood pressure: 124/74 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 2:12 You attached the pulse oximeter. It is a good idea to monitor the saturation and pulse here. This will allow you to reassess the patient continuously. 2:29 You attached the automatic noninvasive blood pressure (NIBP) measurement cuff. This will allow you to reassess the patient continuously. 2:42 You attached a 3-lead ECG. It is correct to attach the monitor to the patient. 3:01 You listened to the heart of the patient. There were only normal heart sounds. 3:10 Patient status - ECG: Sinus rhythm with an anterior myocardial infarction. Heart rate: 81. Pulse: Present. Blood pressure: 121/73 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 3:25 You listened to the lungs of the patient. The breath sounds are normal. 3:39 You checked the radial pulse. The pulse is strong, 80 per minute and regular. It is correct to assess the patient's vital signs. 4:06 You measured the blood pressure at 124/74 mm Hg. It is appropriate to monitor the patient by measuring the blood pressure. 4:10 Patient status - ECG: Sinus rhythm with an anterior myocardial infarction. Heart rate: 81. Pulse: Present. Blood pressure: 121/73 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 4:33 You checked the carotid pulse. The pulse is strong, 80 per minute and regular. 4:57 You obtained a 12-lead ECG. It is correct to obtain a 12-lead ECG. 5:10 Patient status - ECG: Sinus rhythm with an anterior myocardial infarction. Heart rate: 81. Pulse: Present. Blood pressure: 124/74 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 6:09 You activated the code team. There was no clear indication for this. 6:10 Patient status - ECG: Sinus rhythm with an anterior myocardial infarction. Heart rate: 81. Pulse: Present. Blood pressure: 125/75 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 6:26 You phoned the provider in order to discuss the patient. © Wolters Kluwer Health | Lippincott Williams & Wilkins

7:10 Patient status - ECG: Sinus rhythm with an anterior myocardial infarction. Heart rate: 81. Pulse: Present. Blood pressure: 122/73 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 7:50 You assessed the patient's IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact. This is correct. Assessing any IVs the patient has is always important. 8:10 Patient status - ECG: Sinus rhythm with an anterior myocardial infarction. Heart rate: 81. Pulse: Present. Blood pressure: 122/72 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 8:34 The patient developed ventricular fibrillation. 8:34 Patient status - ECG: Ventricular fibrillation. Heart rate: --. Pulse: Absent. Blood pressure: - mm Hg. Respiration: 0. Conscious state: Unconscious. SpO2: --. Temp: 99 F (37 C) 8:40 You turned the defibrillator on. 8:43 You started CPR at a ratio of 30:2, starting with chest compressions. It was correct to perform high-quality CPR at this point to minimize hands-off time while preparing the defibrillator. 8:44 You stopped CPR. 8:45 You placed a backboard under the patient. It is reasonable to place a backboard under the patient as long as interruptions in CPR can be avoided. 8:46 You resumed CPR at a ratio of 30:2, starting with chest compressions. 8:49 You attached the defibrillator pads. It is correct to prepare for defibrillation here. 8:59 The AED could not analyze the patient's heart rhythm because a rescuer touched the patient. 8:59 You warned your colleague to stand clear. 8:59 You stopped CPR. 9:06 The AED gave a 'Shock needed' message. 9:15 You delivered a shock with the AED. Defibrillation was the correct action here. You did it! The patient was successfully defibrillated. 9:16 Patient status - ECG: Sinus rhythm with an anterior myocardial infarction. There are ventricular premature beats. Heart rate: 79. Pulse: Absent. Blood pressure: - mm Hg. Respiration: 0. Conscious state: Unconscious. SpO2: --. Temp: 99 F (37 C) 9:20 You resumed CPR at a ratio of 30:2, starting with chest compressions. It was correct to perform high-quality CPR here. CPR might be required to make the heart start circulating blood again. 9:25 The patient obtained return of spontaneous circulation (ROSC). 9:26 Patient status - ECG: Sinus rhythm with an anterior myocardial infarction. There are ventricular premature beats. Heart rate: 78. Pulse: Present. Blood pressure: 95/57 mm Hg. Respiration: 0. Conscious state: Unconscious. SpO2: 97%. Temp: 99 F (37 C) 9:35 You stopped CPR. 9:36 Patient status - ECG: Sinus rhythm with an anterior myocardial infarction. There are ventricular premature beats. Heart rate: 79. Pulse: Present. Blood pressure: 102/61 mm Hg. Respiration: 0. Conscious state: Somnolent. SpO2: 97%. Temp: 99 F (37 C) 9:56 You looked for normal breathing. The patient was not breathing normally. 9:59 The patient started breathing spontaneously again. © Wolters Kluwer Health | Lippincott Williams & Wilkins

9:59 Patient status - ECG: Sinus rhythm with an anterior myocardial infarction. There are ventricular premature beats. Heart rate: 83. Pulse: Present. Blood pressure: 113/67 mm Hg. Respiration: 9. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37 C) 10:04 You assisted the code team and eventually performed a patient handoff. You managed to perform CPR most of the time it was recommended. 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. - You got 100%

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