JACKSON STATE COMMUNITY COLLEGE
Department of Nursing
220 Adult Health II
Adult Simulation
Chest Pain/Myocardial Infarction Case Study Markers
1. Quick, focused assessment including VS, O2 saturation, ABC, LOC, heart and lung
sounds, color, skin assessment, capillary refill, N/V, Pain scale, cardiac rhythm. Quick
focused History and Physical (H&P) including ht., wt., allergies, past history of cardiac
problems, present illness and chief complaint, medications, last time patient ate and drank
anything.
2. Apply low-flow O2.
Obtain stat 12-lead EKG. (Know to look for ST elevation, ST depression, or T-wave
inversion and the significance of each).
3. Notify physician of all above information. When notifying MD include their name,
patient’s name and room number, admission date and diagnosis, present reason for
notification, patient assessment with VS. Report what interventions have been carried out
for the patient and results. Have patient’s chart with them. Obtain physician orders. The
student nurse should know that when receiving verbal or telephone orders to repeat back
to the MD the orders and then write them and place a check-mark beside them per
hospital policy. The student nurse in the real hospital setting is NOT allowed to call a
MD but may simulate for campus lab practice as deemed by campus lab instructor to
prepare student for RN duties.
4. Obtain IV access.
5. Start MONA (Unless contraindicated: give ASA 325 mg. chew and swallow,
nitroglycerin sublingual or spray X 3 every 5 minutes up to 3, if not relieved then give
Morphine 2-4 mg IV every 5 minutes till patient relieved or LOC change or RR, BP, or
6. HR begin to decrease too much. Perform physician orders for labs (ROMI, CBC, CMP,
UA), CXR.
7. Continue to monitor patient for CP or relief of symptoms and perform patient reevaluation of assessment and VS. Monitor lab results. Notify physician of significant
findings.
8. Prepare patient for possible transfer to ICU or to Cardiac Catherization Lab which
includes having all the above information on the patient’s chart, call report to receiving
area and complete accurate documentation on nurse’s notes.
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JACKSON STATE COMMUNITY COLLEGE
Department of Nursing
220 Adult Health II
Clinical Simulation Rubric
Chest Pain & Myocardial Infarction
Required Activity
01. Focused Assessment
Met/Not Met
Comments
02. Focused History
03. Start low flow O2 and initiate
cardiac monitor
04. Stat 12 lead EKG
05. Notify MD
06. IV access
07. Meds and Labs: student to know
specific medications and
applicable labs.
08. Continue assessment, VS,
monitor, pain level
09. Prepare for transfer to ICU or
Cardiac Cath Lab
10. Documentation
Score:
Student successfully completed the clinical simulation:
Yes
No
Comments: ___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Student Name:______________________________ Date: _____________________________
Faculty Signature:_____________________________________________