V Sim Clinical Worksheet - C Shapiro PDF

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Initials: CS Age: 54

Diagnosis: Acute Myocardial Infarction

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HCP: Consults: Cardiologist

Isolation: n/a

IV Type:

Fall Risk: Yes

Location: Right hand

M/F: M

Critical Labs: CBC Troponin CK-MB

Consults Needed:

Length of Stay: Transfer:

Code Status: Full code

Other Services:

Fluid/Rate: Allergies: NKA

Why is your patient in the hospital (Answer in your own words and include the History of present Illness): Carl Shapiro is a 54-year-old male who travels frequently. He was seen in the Emergency Department at 1:30 p.m. for complaints of chest pain, diaphoresis, and shortness of breath. Health History/Comorbities (that relate to this hospitalization): Patient has a health history of hypertension and smoking

Shift Goals/ Patient Education Needs: 1. minimize myocardial damage, 2. preserve myocardial function 3. prevent complications. Path to Discharge: prevention of myocardial damage, maintenance of effective respiratory function, maintenance or attainment of adequate tissue perfusion, reduced anxiety, adherence to the self-care program Path to Death or Injury:

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Heart failure, Cardiogenic shock, Respiratory failure

Alerts: What are you on alert for with this patient? (Signs & Symptoms) 1. Chest pain or discomfort not relieved by rest or nitroglycerin; 2. Shortness of breath, dyspnea, tachypnea, and crackles if MI has caused pulmonary congestion. Pulmonary edema may be present. 3. Anxiety, restlessness, and lightheadedness 4. Dyspnea, epigastric distress, diaphorases

Management of Care: What needs to be done for this Patient Today?

What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1. continuous cardiac monitoring 2. monitor vital signs every 5 mins until stable 3. monitoring hourly urine output

Priorities for Managing the Patient’s Care Today 1. reducing myocardial oxygen demand 2. and increasing oxygen supply 3. medications, 4. oxygen administration, 5. bed rest

List Complications may occur related to dx, procedure, comorbidities: 1. Heart failure 2. Cardiogenic shock 3.Ischemic mitral regurgitation 4.Ventricular aneurysms /rupture 5.Dysrhythmias

1. Obtain 12-lead electrocardiogram to be read within 10 minutes. 2. Obtain laboratory blood specimens of cardiac biomarkers, including troponin. 3. Obtain other diagnostics to clarify the diagnosis. 4. Evaluate for indications for reperfusion therapy

What aspects of the patient care can be Delegated and who can do it? Medication administration- LPN

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What nursing or medical interventions may prevent the above Alert or complications? 1. Monitor ECG and vital signs 2. Administer oxygen 3. Notify the provider immediately

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