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WEEK 7 SIM LAB: RESPIRATORY AND CARDIAC

PATIENT CHART
Chart for Carl Shapiro

STUDENT NAME: Russell O. Flores and Emily Banal

PATIENT INITIALS: CS

CLINICAL DATE(S): 5 August 2022

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WEEK 7 SIM LAB: RESPIRATORY AND CARDIAC

INSTRUCTOR: Tabitha Somers

FDAR NOTES
Client Name: Carl Shapiro Practitioner Name: Meredith Grey
Date/Time Focus Progress Notes
5 August 2022 Pain, D: Stress or pain level BEFORE intervention. No
Hypertension, stress/pain is “0” and the worst pain is “10”
and
Respiratory. 0 1 2 3 4 5 6 7 8 9 10

A:

R: Stress or pain level AFTER intervention. No

stress/pain is “0” and the worst pain is “10”

0 1 2 3 4 5 6 7 8 9 10

Date/Time Focus Progress Notes

D: Stress or pain level BEFORE intervention. No
stress/pain is “0” and the worst pain is “10”

1 1 2 3 4 5 6 7 8 9 10

A:

R: Stress or pain level AFTER intervention. No

stress/pain is “0” and the worst pain is “10”

1 1 2 3 4 5 6 7 8 9 10
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WEEK 7 SIM LAB: RESPIRATORY AND CARDIAC

Name: Russell O. Flores Date: 5 August 2022

Instructor: Tabitha Somers Term 1

S B A RSituation: At 1230, 54-year-old Carl Shapiro was admitted at the ED

complained of dull aching chest pain and shortness of breath.

S Background: Patient has history of hypertension and takes a water pill for
blood pressure. He works out of state and reports being stressed and
currently smokes ½ pack of cigarettes and occasionally consumes alcohol.

B
AGE: 54, WEIGHT: 110 kg, GENDER: Male, HEIGHT: 175 cm

VITALS (TEMP: 39.6 C, HR: 120bpm, RR: 24 rpm, BP: 158/92 mmHg,
SPO2: 90%, HEART RHYTHM: Sinus Tachycardia)

Assessment: He has a right hand IV with normal saline infusing at 25

mL/hour. Labs were drawn: BMP, CBC, Platelets, PTT, INR, BNP, and
troponin I. No family is present.

A Recommendation: Chest Pain Standing Orders:

12-Lead ECG, Cardiac monitoring,Continuous, SpO2 monitoring, Apply
oxygen for SpO2 less than 90% or respiratory distress with SpO2 target

R
range 90-96%
Meds: Normal Saline 25 mL/hour IV, Aspirin 325 mg orally (chewed),
Nitroglycerin 0.4 mg sublingual every 5 minutes PRN for chest pain up to 3
doses in 15 minutes
If chest pain not relieved by nitroglycerin sublingual times 3, notify
provider immediately and obtain 12-Lead ECG
Call provider with any change in patient status
Patient Initials: CS Pt. Age: 54 Week 8

Medical Diagnosis: Hypertension and Angina.

Objective Data: Patient had difficulty breathing and heart palpitations.
Subjective Data: Patient reports pain scale 7.
Overall Patient Situation: Patient admitted to ED reporting Chest Pain and Difficulty Breathing.
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WEEK 7 SIM LAB: RESPIRATORY AND CARDIAC

He has a right hand IV with normal saline infusing at 25 mL/hour.

Labs were drawn: BMP, CBC, Platelets, PTT, INR, BNP, and

A
troponin I. No family is present.

VITALS (TEMP: 39.6 C, HR: 120bpm, RR: 24 rpm, BP: 158/92 mmHg,
SPO2: 90%, HEART RHYTHM: Sinus Tachycardia)

D
Patient was Hypertensive and had low SPO2 levels.

Plan to administer Aspirin for hypertension and have nitroglycerin

ready just in case for signs of Angina Attack. IV saline 500 mL for

P
fluid and electrolyte balance.

Will implement patient education, focus respiratory and cardiac

assessment. Will administer Aspirin and Nitroglycerin sublingual prn

I
for blood pressure and angina.

Will assess blood values and CXR and will continue to monitor vitals q2hr.

E
Name: Russell O. Flores Date: 5 August 2022
Instructor: Tabitha Somers Term 1

Debriefing Questions
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WEEK 7 SIM LAB: RESPIRATORY AND CARDIAC

1. How do you feel about the group’s simulation performance?

After performing the simulation we felt confident on knowing the knowledge needed to assess and
diagnose patient problems.

2. What went well with the group’s scenario and why?

We were able to effectively collaborate during the critical setting.

3. What would you do differently and why?

Aspects in which we would need more for improvement is to practice performing without
hesitation. Many steps I noticed I would rush through interventions. A simple stop breathe
and think.

4. What was the patient’s key problem(s)?

The patient’s key problems were angina and respiratory.

5. What nursing intervention(s) was done and how did the patient respond?
Nursing interventions that was performed were taking vitals, assessing patient pain scale, assessing
cardiac and respiratory, ECG application and reading, medication administration of aspirin and
nitroglycerin sublingual, oxygen therapy, CPR, and communicating what was performed and next
steps with the physician.
6. What feedback would you give to your peers?
Feed back I would give to my peers is to don’t forget to stop, breathe, and think whenever you are in
stressful situations.