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 Judgment
6. Patient Education
7. Communication
8. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
, UNFOLDING Reasoning Case Study: 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 is RELEVANT and has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
• Estimated blood loss 675 mL and 2500 • Her HGB level lowered d/t blood that was lost along with the LR
mL of LR • Her pain needs to be monitored and controlled so she is able to
• Pain is 2/10 that does increase with move
movement • We want to monitor for S/S of over sedation
• Posterior spinal fusion of L4-S1 • She will need positioning after surgery d/t chronic back pain
• Started on 0.2 mg/hr hydromorphone • Her COPD plus her need for so much oxygen increases the priority
PCA and 0.1 mg of IV bolus for incentive spirometry in order to clear the airway along with
• Chronic lower back pain coughing and deep breathing
• HX of COPD • Continue to monitor her O2 sat to ensure it is above 90%
• She is on 4L of O2
RELEVANT Data from Social History: Clinical Significance:
• She is divorced and lives at home alone • She has lack of support at home and does not have a spousal
support. She may need extra assistance once she is discharged and
could be at an increased risk for a fall at home d/t her living alone
and having chronic pain
• She may benefit from being referred to a skilled nursing facility
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
• Low back pain with 1. Citalopram 40 mg daily • SSIR • Treat depression,
lumbar compression 2. Oxycontin SR 40 mg bid • Opioid pain, and aid in
fracture 3. Oxycodone 10 mg every 4 • Corticosteroid breathing tx
• Depression hours prn • Long-acting beta 2
• COPD 4. Fluticasone/salmeterol
• Pulmonary hypertension 250/50 diskus 1 puff every
• 2 ppd smoker x 32 years 12 hours
5. Sildenafil 20 mg tid
One disease process often influences the development of other illnesses. Based on your knowledge of
pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in her life?
• Circle what PMH problem likely started FIRST.
• Underline what PMH problem(s) FOLLOWED as domino(s).
(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 Judgment
6. Patient Education
7. Communication
8. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
, UNFOLDING Reasoning Case Study: 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 is RELEVANT and has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
• Estimated blood loss 675 mL and 2500 • Her HGB level lowered d/t blood that was lost along with the LR
mL of LR • Her pain needs to be monitored and controlled so she is able to
• Pain is 2/10 that does increase with move
movement • We want to monitor for S/S of over sedation
• Posterior spinal fusion of L4-S1 • She will need positioning after surgery d/t chronic back pain
• Started on 0.2 mg/hr hydromorphone • Her COPD plus her need for so much oxygen increases the priority
PCA and 0.1 mg of IV bolus for incentive spirometry in order to clear the airway along with
• Chronic lower back pain coughing and deep breathing
• HX of COPD • Continue to monitor her O2 sat to ensure it is above 90%
• She is on 4L of O2
RELEVANT Data from Social History: Clinical Significance:
• She is divorced and lives at home alone • She has lack of support at home and does not have a spousal
support. She may need extra assistance once she is discharged and
could be at an increased risk for a fall at home d/t her living alone
and having chronic pain
• She may benefit from being referred to a skilled nursing facility
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
• Low back pain with 1. Citalopram 40 mg daily • SSIR • Treat depression,
lumbar compression 2. Oxycontin SR 40 mg bid • Opioid pain, and aid in
fracture 3. Oxycodone 10 mg every 4 • Corticosteroid breathing tx
• Depression hours prn • Long-acting beta 2
• COPD 4. Fluticasone/salmeterol
• Pulmonary hypertension 250/50 diskus 1 puff every
• 2 ppd smoker x 32 years 12 hours
5. Sildenafil 20 mg tid
One disease process often influences the development of other illnesses. Based on your knowledge of
pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in her life?
• Circle what PMH problem likely started FIRST.
• Underline what PMH problem(s) FOLLOWED as domino(s).
