Summary SHEILA DALTON ,52 YEARS POST-OP PAIN MANAGEMENT: DAY OF SURGERY

FUNDAMENTAL Reasoning: STUDENT 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: RELEVANT Data from Social History: Clinical Significance: Developing Nurse Thinking by Identifying Significance of Clinical Data Patient Care Begins–Arrives from PACU to Surgical Floor What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 100.2 F/37.9 C (oral) Provoking/Palliative: Movement/lying still P: 110 (regular) Quality: Ache R: 24 Region/Radiation: Lumbar-incisional BP: 98/50 Severity: 6/10-gradually increasing O2 sat: 88% 4 liters per n/c Timing: Continuous since arrival from PACU © 2016 Keith Rischer/www.KeithRN.com What assessment data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: Developing Nurse Thinking through APPLICATION of the Sciences Fluid & Electrolytes/Lab/diagnostic Results: What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Current Assessment: GENERAL APPEARANCE: Appears uncomfortable, body tense, frequent grimacing–last used PCA 10 minutes ago RESP: Breath sounds clear with equal aeration ant/post but diminished bilaterally, non-labored respiratory effort, occasional moist–nonproductive cough CARDIAC: Pale-pink, warm and dry, no edema, heart sounds regular–S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert and oriented to person, place, time, and situation (x4) GI: Abdomen soft/non-tender, bowel sounds hypoactive a