Documentation Assignments
1. Document Carl Shapiro’s cardiac rhythms that occurred in the scenario.
2. Document the changes in Carl Shapiro’s vital signs throughout the scenario.
3. Identify and document key nursing diagnoses for Carl Shapiro.
Decreased cardiac output related to anterior MI as evidence by loss of vital signs and
4. Referring to your feedback log, document the assessment findings and nursing care you
provided.
0:00 You introduced yourself.
0:06 You washed your hands. To maintain patient safety, it is important to wash your hands as
soon as you enter the room.
0:10 Patient status - ECG: Sinus rhythm with an anterior myocardial infarction. Heart rate: 82.
Pulse: Present. Blood pressure: 124/74 mm Hg. Respiration: 12. Conscious state: Appropriate.
SpO2: 97%. Temp: 99 F (37 C)
1:10 Patient status - ECG: Sinus rhythm with an anterior myocardial infarction. Heart rate: 82.
Pulse: Present. Blood pressure: 122/73 mm Hg. Respiration: 12. Conscious state: Appropriate.
SpO2: 98%. Temp: 99 F (37 C)
1:19 You identified the patient. To maintain patient safety, it is important that you quickly
identify the patient.
1:27 You asked if the patient was allergic to anything. He replied: 'No, I am not allergic to
anything.'
1:35 You looked for normal breathing. He is breathing at 12 breaths per minute. The chest is
moving normally on both sides.
2:05 You attached the pulse oximeter. It is a good idea to monitor the saturation and pulse
here. This will allow you to reassess the patient continuously.
2:10 Patient status - ECG: Sinus rhythm with an anterior myocardial infarction. Heart rate: 81.
Pulse: Present. Blood pressure: 123/73 mm Hg. Respiration: 12. Conscious state: Appropriate.
SpO2: 98%. Temp: 99 F (37 C)
2:15 You checked the temperature at the mouth. The temperature was 99 F (37 C).
2:40 You listened to the heart of the patient. There were only normal heart sounds.
2:54 You assessed the patient's IV. The site had no redness, swelling, infiltration, bleeding, or
drainage. The dressing was dry and intact. This is correct. Assessing any IVs the patient has is
always important.
/