Medical Case 4: Carl
ShapiroDocumentation
Assignments
1. Document Carl Shapiro’s cardiac rhythms that occurred in the scenario.
Carl Shapiro had sinus rhythm to begin with and then after the 12-lead ECG was done it showed
ventricular fibrillation. He went unconscious soon after.
2. Document the changes in Carl Shapiro’s vital signs throughout the scenario.
RR: 12 O2: 98 BP: 122/72 T: 99 HR:80. Pulses were strong and steady during assessment.
The heart was auscultated and only S1 and S2 were auscultated. Everything seemed stable until
the ECGs were completed; the patient went into cardiac arrest with ventricular dysrhythmias- the
respirations and pulse were no longer present. The patient was resuscitated, and vitals returned.
3. Identify and document key nursing diagnoses for Carl Shapiro.
-Decreased cardiac output R/T ventricular fibrillation and cardiac dysfunction AEB patient
coding due to cardiac arrest
-Ineffective health maintenance R/T modifiable risk factors such as continuous smoking, obesity,
and diet high in fat AEB the ventricular dysrhythmia and history of hyperlipidemia
-Activity intolerance R/T imbalance of oxygen demand and supply AEB patient stating distress
during exercise
4. Referring to your feedback log, document the assessment findings and nursing care
you provided.
-Identified patient and washed my hands
- Looked for normal breathing. His respiration rate was 12.
-Attached the pulse oximeter.
-Checked the radial pulse. The pulse was strong, 80 per minute and regular, checked the pedal
and carotid pulses as well.
-Measured the blood pressure at 122/72 mm Hg.
-Checked the temperature of the mouth. The temperature was 99 F (37 C).
- Listened to the heart of the patient. There were only normal heart sounds.
- Attached the automatic noninvasive blood pressure (NIBP) measurement cuff.
ShapiroDocumentation
Assignments
1. Document Carl Shapiro’s cardiac rhythms that occurred in the scenario.
Carl Shapiro had sinus rhythm to begin with and then after the 12-lead ECG was done it showed
ventricular fibrillation. He went unconscious soon after.
2. Document the changes in Carl Shapiro’s vital signs throughout the scenario.
RR: 12 O2: 98 BP: 122/72 T: 99 HR:80. Pulses were strong and steady during assessment.
The heart was auscultated and only S1 and S2 were auscultated. Everything seemed stable until
the ECGs were completed; the patient went into cardiac arrest with ventricular dysrhythmias- the
respirations and pulse were no longer present. The patient was resuscitated, and vitals returned.
3. Identify and document key nursing diagnoses for Carl Shapiro.
-Decreased cardiac output R/T ventricular fibrillation and cardiac dysfunction AEB patient
coding due to cardiac arrest
-Ineffective health maintenance R/T modifiable risk factors such as continuous smoking, obesity,
and diet high in fat AEB the ventricular dysrhythmia and history of hyperlipidemia
-Activity intolerance R/T imbalance of oxygen demand and supply AEB patient stating distress
during exercise
4. Referring to your feedback log, document the assessment findings and nursing care
you provided.
-Identified patient and washed my hands
- Looked for normal breathing. His respiration rate was 12.
-Attached the pulse oximeter.
-Checked the radial pulse. The pulse was strong, 80 per minute and regular, checked the pedal
and carotid pulses as well.
-Measured the blood pressure at 122/72 mm Hg.
-Checked the temperature of the mouth. The temperature was 99 F (37 C).
- Listened to the heart of the patient. There were only normal heart sounds.
- Attached the automatic noninvasive blood pressure (NIBP) measurement cuff.
