V-Sim Carl Shapiro Documentation and Guided
Reflection
Medical Case 4: Carl Shapiro
Documentation and Reflection Assignments
1. Document Carl Shapiro’s cardiac rhythms that occurred in the scenario.
Ans) The patient had sinus rhythm with anterior myocardial infarction. The patient also went
into ventricular fibrillation and coded. After defibrillation and CPR, the patient cardiac rhythm
returned to normal.
2. Document the changes in Carl Shapiro’s vital signs throughout the scenario.
Ans) Initial assessments were as follows, ECG: Sinus rhythm with an anterior myocardial
infarction. Heart rate: 82. Pulse: Present. Blood pressure: 123/74 mm Hg. Respiration: 12.
Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C). Vital signs remained almost
constant until the patient coded. At that time, his vital signs were as follows, HR: absent, blood
pressure: absent, respirations: 0, SpO2: absent, temp: 99F. After CPR and resuscitation efforts
his vital signs were Heart rate: 81. Pulse: Present. Blood pressure: 110/66 mm Hg. Respiration:
7. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F (37 C)
3. Identify and document key nursing diagnoses for Carl Shapiro.
Ans) 1. Risk for infective peripheral tissue perfusion related to decreased cardiac output
2. Risk for decreased cardiac output related to left ventricular failure
4. Referring to your feedback log, document the assessment findings and nursing care you
provided.
Ans) After I introduced myself to the patient, I then followed proper protocol by performing
hand hygiene, identifying the patient, obtaining consent for care and asking about any
allergies. Vital signs assessment was conducted. Heart rate normal, capillary refill less than 2
seconds, respiration rate normal, Blood pressure within normal range, temperature was also
normal. Pain assessment was also conducted. Patient was not experiencing any pain but
indicated that when he did, it felt like an elephant was sitting on his chest. Patient also stated
that the pain radiated down his left arm. Assessed patients IV. There was no redness, swelling,
infiltration, bleeding, or drainage. Dressing was dry and intact. Auscultated heart sounds.
Normal heart sounds heard. Blood sample collected per physicians’ order and sent to the lab
for testing. Activated code team after patient developed ventricular fibrillation. Started CPR at
30:2 ratio with chest compressions. Attached defibrillator pads. Turned on AED. Delivered
shock as directed by AED. Continued Compressions. Patient resumed breathing and I stopped
CPR.
Performed patient handoff
Reflection
Medical Case 4: Carl Shapiro
Documentation and Reflection Assignments
1. Document Carl Shapiro’s cardiac rhythms that occurred in the scenario.
Ans) The patient had sinus rhythm with anterior myocardial infarction. The patient also went
into ventricular fibrillation and coded. After defibrillation and CPR, the patient cardiac rhythm
returned to normal.
2. Document the changes in Carl Shapiro’s vital signs throughout the scenario.
Ans) Initial assessments were as follows, ECG: Sinus rhythm with an anterior myocardial
infarction. Heart rate: 82. Pulse: Present. Blood pressure: 123/74 mm Hg. Respiration: 12.
Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C). Vital signs remained almost
constant until the patient coded. At that time, his vital signs were as follows, HR: absent, blood
pressure: absent, respirations: 0, SpO2: absent, temp: 99F. After CPR and resuscitation efforts
his vital signs were Heart rate: 81. Pulse: Present. Blood pressure: 110/66 mm Hg. Respiration:
7. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F (37 C)
3. Identify and document key nursing diagnoses for Carl Shapiro.
Ans) 1. Risk for infective peripheral tissue perfusion related to decreased cardiac output
2. Risk for decreased cardiac output related to left ventricular failure
4. Referring to your feedback log, document the assessment findings and nursing care you
provided.
Ans) After I introduced myself to the patient, I then followed proper protocol by performing
hand hygiene, identifying the patient, obtaining consent for care and asking about any
allergies. Vital signs assessment was conducted. Heart rate normal, capillary refill less than 2
seconds, respiration rate normal, Blood pressure within normal range, temperature was also
normal. Pain assessment was also conducted. Patient was not experiencing any pain but
indicated that when he did, it felt like an elephant was sitting on his chest. Patient also stated
that the pain radiated down his left arm. Assessed patients IV. There was no redness, swelling,
infiltration, bleeding, or drainage. Dressing was dry and intact. Auscultated heart sounds.
Normal heart sounds heard. Blood sample collected per physicians’ order and sent to the lab
for testing. Activated code team after patient developed ventricular fibrillation. Started CPR at
30:2 ratio with chest compressions. Attached defibrillator pads. Turned on AED. Delivered
shock as directed by AED. Continued Compressions. Patient resumed breathing and I stopped
CPR.
Performed patient handoff
