Patient Overview Carl Shapiro Age 54 years Weight 110 kg Race…
Question Answered step-by-step Patient Overview Carl Shapiro Age 54 years Weight 110 kg Race… Patient OverviewCarl ShapiroAge54 yearsWeight110 kgRaceCaucasianGenderMaleHeight175 cmReligionJewishMajor SupportNone, out of town on businessAllergiesNo known allergiesImmunizationsCurrentInitial Vital SignsTemperature39.6 °CHeart Rate120 bpmRespiration Rate24 rpmBlood Pressure158/92 mmHgspO290%Heart RhythmSinus tachycardiaMedical HistoryPast Medical HistoryHas a history of hypertension. He states he takes “water pills” for his blood pressure (he is not sure of the name of the pill) and has been trying to exercise and lose weight but admits it is very hard when he travels. He smokes less than half a pack of cigarettes a day and drinks alcohol occasionally. He describes his work as “stressful.”History of Present IllnessHas been “pushing” himself lately and feels the “stress” is starting to get to him. He has noticed this type of chest pain before, but it usually goes away when he rests. He started worrying when he began to sweat and became short of breath.Social HistoryTravels frequently on business. He is currently in town, butdoesn’t reside locally.Primary Medical DiagnosisAngina – coronary artery disease.Surgeries/Procedures and DatesNo recording.DiagnosticsLaboratory DataComplete blood count, complete metabolic panel, troponin, and CK-MB lab values are pending.Provider’s OrdersChest Pain Standing Orders• 12-lead ECG• Cardiac monitoring• Oxygen to maintain SpO2 greater than 92%• Meds:o IV normal saline 1000 mL at 25 mL/houro Aspirin 325 mg PO (chewed)o 1 NTG tablet sublingual, may be repeated after 5 minutes max 3 doseso If pain is not relieved by NTG may give morphine 2 mg IV push, may repeat × 1• Labs:o Cardiac enzymes (CK-MB, troponin), stat and 8 hours x 3o Chemistry profile stato Chest x-ray stato PT/PTT stat• Call provider with any change in patient statusStat Orders• 500 mL normal saline fluid bolus stat• Repeat for systolic blood pressure below 90• Hold nitro until systolic blood pressure is above 100Scenario-Specific Questions• EBP: What assessments led you to the problems you identified?• EBP: Discuss the rationale for the focused assessments that you completed.• PCC: How did you communicate with the patient?• PCC: Discuss the patient-centered caregiving you provided for Mr. Shapiro.• PCC: When you reflect on his situation, are there additional areas you could focus on that might be helpful and contribute to a restful environment?• EBP: How did the chest pain protocol facilitate your assessment, planning, and prioritization?• EBP: How did you prioritize a plan of care for the patient?• EBP: Discuss your rationale for the evaluation and intervention steps you implemented.• EBP: What are complications associated with administering nitroglycerin?• EBP: How did you evaluate for potential complications?• EBP: How would you explain his lightheadedness?• S: What measures did you implement to ensure safe patient care?• S: Discuss the important drug interactions that need to be assessed before administering nitroglycerin (e.g., erectile dysfunction medications). Explain these interactions.• T&C: What assessment findings did you report to the provider?• T&C: Describe the impact of your communication with the provider and with the patient.• T&C: Discuss the information team members need to transition this patient’s care safely.• T&C: Discuss the SBAR you provided.• T&C: What other members of the care team would you consider important to achieving good care outcomes?• I: Discuss the information resources you used to assess this patient.• I: What information management tools did you use to monitor this patient’s outcomes?• PCC: Describe the patient education you provided.• PCC: How do you think this contributed to this patient’s unique circumstances?• QI: How would you assess the quality of care provided?• QI: What could you do improve the quality of care for this patient?• QI: What areas did you identify for self-improvement? For team-improvement? Health Science Science Nursing SCR 210 Share QuestionEmailCopy link Comments (0)
