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Post-op Pain Management: Day of Surgery (1/2)
Sheila Dalton, 52 years old
Primary Concept Pain Interrelated Concepts (In order of emphasis)
- Gas Exchange
- Glucose Regulation
- Perfusion
- Inflammation
- Clinical Judgement
- Patient Education
Post-op Pain Management: Day of Surgery (1/2)
History of Present Problem:
Sheila Dalton is a 52-year-old woman who has a history of chronic low back pain and COPD. She had a posterior spinal fusion of L4-S1 today. She had an estimated blood loss (EBL) of 675 mL during surgery and received 2500 mL of Lactated Ringers (LR). Pain is currently controlled at 2/10 and increases with movement. She was started on a hydromorphone patient-controlled analgesia (PCA) with IV bolus dose of 0.1 mg and continuous hourly rate of 0.2 mg. Last set of VS in post-anesthesia care unit (PACU) P: 88; R: 20; BP: 122/76; requires 4 liters per n/c to keep her O2 sat >90 percent. You are the nurse receiving the patient directly from the PACU.
Personal/Social History:
Sheila is divorced and currently lives alone in her own apartment. She has two grown children from whom she is estranged.What data from the histories are RELEVANT and have clinical significance to the nurse?RELEVANT Data from Present Problem Clinical Significance Chronic low back pain Respirations = 20/min.Requires 4L of oxygen to keep O2 Sat. above 90% Patient on hydromorphone PCA 0.2 mg hourly COPD Pain on a reoccurring basis
High respiratory rate, probably because of pain Pt. should report controlled pain levels watch for possible overdose and respiratory depression
Anticipated low O2 saturation RELEVANT Data from Social History Clinical Significance
Divorced
Estranged from two grown children Lives alone She may need additional assistance upon d/c from the hospital. The patient could be at increased risk for falls due to living alone, chronic pain, and need for oxygen.
Developing Nurse Thinking by Identifying Significance of Clinical Data Patient Care Begins–Arrives from PACU to Surgical Floor
P-Q-R-S-T Pain Assessment (5 th VS) Current VS
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