Pain managment case study Basic.2022

Post-op Pain Management: Day of Surgery (1/2) Sheila Dalton, 52 years old Primary Concept Pain Interrelated Concepts (In order of emphasis) 1. Gas Exchange 2. Glucose Regulation 3. Perfusion 4. Inflammation 5. Clinical Judgement 6. 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 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: 100.2˚F Oral Temp 110 Pulse 24 Respirations 98/50 BP O2 Sat 88% Continuous aching pain in lumbar-incisional region since arrival from PACU rated 6/10 and gradually increasing, aggravated by movement and relieved while lying still Temperature is elevated and could signify a possible infection. Elevated pulse could signify pain/distress. Elevated, likely related to increasing pain Low, could be indicative of oversedation or due to blood loss. Low, likely related to COPD complications Pain level is significant and should be treated and monitored