Medical Case 4: Carl Shapiro
Documentation Assignments
1. Document Carl Shapiro’s cardiac rhythms that occurred in the scenario.
Carl Shapiro’s cardiac rhythms that occurred in the scenario include a sinus rhythm with an
anterior myocardial infarction when the 12 lead EKG was attached. Later the 3 lead EKG
showed ventricular fibrillation.
2. Document the changes in Carl Shapiro’s vital signs throughout the scenario.
Carl Shapiro’s vital signs started out stable with heart rate in the 80’s, oxygen saturation at 98%,
normal temperature and respirations. Then a few minutes later his pulse and O2 saturation
began to drop until he had no pulse. That is when the code team was called, and CPR was
initiated which brought his heart rate and pulse ox back up.
3. Identify and document key nursing diagnoses for Carl Shapiro.
Key nursing diagnosis for Carl Shapiro would be
- Knowledge deficit regarding treatment of condition r/t misunderstanding of medical
condition AEB patient asking if he can go home after providing education on his
condition.
- Ineffective tissue perfusion r/t ST elevation AEB MI.
4. Referring to your feedback log, document the assessment findings and nursing care you
provided.
I started by introducing myself, taking vital signs, which were all stable, and beginning a focused
assessment of his heart. That focused assessment included auscultating his heart which
indicated normal S1, S2 and attaching a 3 lead EKG continuous monitoring. A 12 lead EKG was
then done and showed sinus rhythm with anterior myocardial infarction. After that education
on his condition was provided as well as a pain assessment performed. He indicated he was not
in any pain, and nothing seemed to make the pain better or worse. A few minutes later he
started to desaturate and had no pulse. I called the code team and began CPR. A shock was
delivered which brought his pulse back. Handoff was then performed.
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