Post-op Pain Management Case Study: Day of Surgery
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 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%. 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:
EBL of 675 mL EBL > 500 mL is an emergency and requires
immediate intervention. This combined with
2500 mL of Lactated Ringers 2500 mL Lactated Ringers will significantly
lower Ms. Dalton’s Hgb level. Because
Pain 2/10 and increases with movement Lactated Ringers is an isotonic solution, I
would be concerned about fluid/electrolyte
Posterior spinal fusion of L4-S1 imbalance as well.
0.2 mg/hr hydromorphone PCA and 0.1 mg of Pain level, even at a low level should continue
IV bolus to be monitored post-op. Because her pain is
affected by movement, I would administer
Chronic low back pain pain medication about 30 minutes prior to
activity. I would also make sure that she has
History of COPD assistance when getting up.
On 4L of oxygen Hydromorphone (dilaudid) is an opioid
narcotic. Although this dose is standard and
acceptable, Ms. Dalton should be monitored
for mild signs and symptoms of oversedation,
which includes altered mental status and
altered consciousness.
Her history of chronic back pain and posterior
spinal fusion would indicate a need for
positioning after surgery. I would also be
, careful to log roll them and be cautious not to
twist her back.
Her previous history of COPD combined with
her need for this much oxygen increases a
priority for incentive spirometry, postural
drainage, and percussion in order to clear the
airways of mucus and secretions and promote
lung expansion. I would want to continue
monitoring her oxygen saturation so that it
stays above 90% as well.
RELEVANT Data from Social History: Clinical Significance:
She lives alone and has no nearby relatives This indicates a lack of support system; 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.
Possible referral needed to skilled nursing
facility or TCU upon discharge
Developing Nursing Thinking by Identifying Significance of Clinical Data
Patient Care Begins – Arrives from PACU to Surgical Floor
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
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
Temperature of 100.2 Temperature is elevated and could signify a
possible infection. Ms. Dalton should begin
pain medication and use of an incentive
spirometer to lower temperature. I would
continue to monitor for a change in
temperature.
Pulse of 110 BPM Elevated pulse could signify pain/distress.
Respirations of 24 and 88% oxygen sat on 4 L
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 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%. 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:
EBL of 675 mL EBL > 500 mL is an emergency and requires
immediate intervention. This combined with
2500 mL of Lactated Ringers 2500 mL Lactated Ringers will significantly
lower Ms. Dalton’s Hgb level. Because
Pain 2/10 and increases with movement Lactated Ringers is an isotonic solution, I
would be concerned about fluid/electrolyte
Posterior spinal fusion of L4-S1 imbalance as well.
0.2 mg/hr hydromorphone PCA and 0.1 mg of Pain level, even at a low level should continue
IV bolus to be monitored post-op. Because her pain is
affected by movement, I would administer
Chronic low back pain pain medication about 30 minutes prior to
activity. I would also make sure that she has
History of COPD assistance when getting up.
On 4L of oxygen Hydromorphone (dilaudid) is an opioid
narcotic. Although this dose is standard and
acceptable, Ms. Dalton should be monitored
for mild signs and symptoms of oversedation,
which includes altered mental status and
altered consciousness.
Her history of chronic back pain and posterior
spinal fusion would indicate a need for
positioning after surgery. I would also be
, careful to log roll them and be cautious not to
twist her back.
Her previous history of COPD combined with
her need for this much oxygen increases a
priority for incentive spirometry, postural
drainage, and percussion in order to clear the
airways of mucus and secretions and promote
lung expansion. I would want to continue
monitoring her oxygen saturation so that it
stays above 90% as well.
RELEVANT Data from Social History: Clinical Significance:
She lives alone and has no nearby relatives This indicates a lack of support system; 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.
Possible referral needed to skilled nursing
facility or TCU upon discharge
Developing Nursing Thinking by Identifying Significance of Clinical Data
Patient Care Begins – Arrives from PACU to Surgical Floor
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
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
Temperature of 100.2 Temperature is elevated and could signify a
possible infection. Ms. Dalton should begin
pain medication and use of an incentive
spirometer to lower temperature. I would
continue to monitor for a change in
temperature.
Pulse of 110 BPM Elevated pulse could signify pain/distress.
Respirations of 24 and 88% oxygen sat on 4 L
