University:
Oak Point University
Course:
NUR 3030 | Fundamentals Of Nursing Care
Academic year:

2024
Views:

307

Pages:

1
Author:

Alexa Livingston

Medical Case 4: Carl Shapiro Documentation Assignments 1. Document Carl Shapiro’s cardiac rhythms that occurred in the scenario. a. Shapiros’s cardiac rhythm during majority of the scenario was Sinus Rhythm with an anterior myocardial infarction. b. Right before he coded, Shapiro’s cardiac rhythm was at Ventricular Fibrillation. c. After CPR and resuscitation efforts, Shapiro’s cardiac rhythm returned to Sinus Rhythm with an anterior myocardial infarction. 2. Document the changes in Carl Shapiro’s vital signs throughout the scenario. a. At the beginning of the scenario 0:10 time: HR: 82, BP: 125/74 mm/Hg, Respirations: 12, SpO22: 97%, Temp: 99F. For most of the scenario, it remained relatively the same until 8 minutes into the scenario. At this point his vital signs were as follows: HR: absent, blood pressure: absent, respirations: 0, SpO2: absent, temp: 99F. He also did not have any cardiac rhythms present. This is because he was unconscious. After CPR and resuscitation efforts his vital signs were as follows: HR: 81, BP: 113/68, Respirations: 7, SpO2: 97%, Temp: 99F. 3. Identify and document key nursing diagnoses for Carl Shapiro. a. Risk for decreased cardiac output related to left ventricular failure b. Risk for infective peripheral tissue perfusion related to decreased cardiac output 4. Referring to your feedback log, document the assessment findings and nursing care you provided. a. Upon entering the room, I asked the patient about any pain he may have experienced using the COLDSPA method. He was not in any pain at the time; however, he did say that when h was in pain, it felt like “an elephant was sitÝng on his chest.” He also said that the pain radiated down his right arm and felt better with medication. Provided patient education. Attached pulse oximeter to left forefinger to monitor saturation and pulse. Assessed vital signs. Attached 3lead ECG. Assessed patients IV. There was no redness, swelling, infiltration, bleeding, or drainage. Dressing was dry and intact. Auscultated heart sounds. Normal heart sounds heard. Activated code team after patient developed ventricular fibrillation. Started CPR at 30:2 ratio with chest compressions. Placed backboard under patient. Attached defibrillator pads. Turned on AED. Delivered shock as directed by AED. Continued Compressions. Patient resumed breathing and I stopped CPR. Performed patient handoff.

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