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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)
1. Gas Exchange
2. Glucose Regulation
3. Perfusion
4. Inflammation
5. Clinical Judgment
6. Patient Education
7. Communication
8. Collaboration
, 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:
RELEVANT Data from Social History: Clinical Significance:
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
lumbar compression 2. Oxycontin SR 40 mg bid
fracture 3. Oxycodone 10 mg every 4
Depression hours prn
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).
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
, 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:
RELEVANT Data from Social History: Clinical Significance:
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
lumbar compression 2. Oxycontin SR 40 mg bid
fracture 3. Oxycodone 10 mg every 4
Depression hours prn
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).
