University:
Excelsior College
Course:
NUR213 | Health Differences Across the Life Span 3
Academic year:

2023
Views:

244

Pages:

2
Author:

Dallas Robinson

M3.3 v VSim SBAR Assignment Now that you have completed your care for Carl Shapiro, create an SBAR report for the Primary Care Provider. Situation: Hello Dr. Quincy, this is Susan Kruger RN in the ICU. I am calling you about Mr. Carl Shapiro, the patient in bed # 3. He is the 54-year-old man admitted at 1:30 pm today from the Emergency Department with complaints of chest pain, diaphoresis, and shortness of breath. The Emergency department gave him Aspirin, Sublingual Nitro times two,and a 0.4mg nitro patch. Since his transfer to the Telemetry Unit his pain remained controlled, his vital signs, SPO2, and Chest Xray were within normal but he went into Ventricular Fibrillation and required a round of CPR, a shock, and two more cycles of compressions before spontaneous breathing and a normal sinus rhythm were restored. Background 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. He has NO allergies. He was treated in the Emergency Department with aspirin and two doses of sublingual nitroglycerin and then a Nitroglycerin patch 0.4 mg. His chest pain improved with nitroglycerin administration. IV infusion of normal saline was started in the Emergency Department and is running at 25 mL/hour. First set of ordered labs drawn in the ED came back as HCO3-18, Sodium-14-, Hemaaglobin-14, Hematacrit-44, WBC’s-8.2, Platelets-295, Creatinine0.7, CK-MB-20, and Troponin of 2.2. Assessment Mr. Shapiros current vital signs are temperature-99, pulse-80 with regular rate and rhythm, respirations 12 unlabored, SPO2- 98%. His Chest Xray is normal, and his cardiac monitor is showing normal sinus rhythm with anterior myocardial infarction. Patient is conscious and alert and oriented X 3. He denies any pain, is not diaphoretic and peripheral capillary refills are under 2 seconds. His lung sounds are clear bilaterally. He has the Nitro 0.4mg patch in place, O2 via Nasal cannula at 4lpm, and an Iv running of normal saline at 25ml per hour. The ECG monitor shows normal sinus rhythm with anterior wall myocardial infarction. This is same as before the episode of VFib. Recommendation The patient remains here on the Telemetry unit. The second set of ordered lab values are still pending. We will call you as soon as the labs are available. All initial orders have been implemented except for the IV Morphine because the patient has not had any further pain. Would you like me to give it to him now anyway? Are there any new orders you would like us to implement considering this episode of ventricular fibrillation with resuscitation?

SIM SBAR Carl Shapiro

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