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Post-op Pain Management: Cardiac
Arrest (2/2)
Sheila Dalton, 52 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
1. Gas Exchange
2. Acid-Base Balance
, 3. Fluid and Electrolyte Balance
4. Clinical Judgment
5. Patient Education
6. Communication
7. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
UNFOLDING Reasoning Case Study: STUDENT
Post-op Pain Management 2/2: Cardiac Arrest
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 earlier today. Her 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
that is 0.2 mg and continuous rate of 0.2 mg/hour.
The nurse reported that her nausea has improved after receiving ondansetron IV four hours ago. She was
having increased pain despite using the PCA every 10 minutes. Her pain has decreased from 6/10 to 2/10
since the PCA bolus was increased from 0.1 mg to 0.2 mg of hydromorphone IV one hour ago.
Patient Care Begins:
Current VS:
T: 99.8 F/37.7 C (oral)
P: 78
RELEVANT Data from History:
Clinical Significance:
R: 12
COPD History of respiratory issues, likely retains CO2, potential alveoli
BP: 92/48low back pain
Chronic dysfunction
Recent spinal fusion surgery Use of pain medication with chronic back pain?
Post-op day 0, need to assess for surgical complications/expected
O2 sat: 89% room use
Hydromorphone air 4with
liters n/c findings, risk for infection/bleeding
worsened pain
Nausea, relieved with Zofran Narcotic use (decr. RR)
Low SpO2 89% Low oxygenation status on 4L NC
Low BP 92/48 Is BP complication of meds, sign of bleeding?
, Your shift continues...
Thirty minutes later she is feeling more nauseated, and you administer ondansetron 4 mg IV push
prn. Five minutes later she puts the call light on again. You are not able to respond immediately
because you are helping your other patient get on the commode. Little do you know that Sheila is
going to depend on your ability to THINK LIKE A NURSE and clinically reason to save her life.
When you arrive in her room you observe the following...
© 2016 Keith Rischer/www.KeithRN.com
What assessment data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data: Clinical Significance:
Unresponsive
Ashen pale signs of cardiac arrest, heart is not pumping blood and
Minimal resp. effort shunting to core is likely occurring
Liquid emesis in mouth Loss of consciousness from sudden lack of blood flow
Weak carotid pulse Aspiration of gastric contents during arrest could have
24 bpm occurred
Does not awake or arouse to Needs immediate intervention!!!
painful stimuli
Current VS:
T: not assessed
P: 24
Post-op Pain Management: Cardiac
Arrest (2/2)
Sheila Dalton, 52 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
1. Gas Exchange
2. Acid-Base Balance
, 3. Fluid and Electrolyte Balance
4. Clinical Judgment
5. Patient Education
6. Communication
7. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
UNFOLDING Reasoning Case Study: STUDENT
Post-op Pain Management 2/2: Cardiac Arrest
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 earlier today. Her 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
that is 0.2 mg and continuous rate of 0.2 mg/hour.
The nurse reported that her nausea has improved after receiving ondansetron IV four hours ago. She was
having increased pain despite using the PCA every 10 minutes. Her pain has decreased from 6/10 to 2/10
since the PCA bolus was increased from 0.1 mg to 0.2 mg of hydromorphone IV one hour ago.
Patient Care Begins:
Current VS:
T: 99.8 F/37.7 C (oral)
P: 78
RELEVANT Data from History:
Clinical Significance:
R: 12
COPD History of respiratory issues, likely retains CO2, potential alveoli
BP: 92/48low back pain
Chronic dysfunction
Recent spinal fusion surgery Use of pain medication with chronic back pain?
Post-op day 0, need to assess for surgical complications/expected
O2 sat: 89% room use
Hydromorphone air 4with
liters n/c findings, risk for infection/bleeding
worsened pain
Nausea, relieved with Zofran Narcotic use (decr. RR)
Low SpO2 89% Low oxygenation status on 4L NC
Low BP 92/48 Is BP complication of meds, sign of bleeding?
, Your shift continues...
Thirty minutes later she is feeling more nauseated, and you administer ondansetron 4 mg IV push
prn. Five minutes later she puts the call light on again. You are not able to respond immediately
because you are helping your other patient get on the commode. Little do you know that Sheila is
going to depend on your ability to THINK LIKE A NURSE and clinically reason to save her life.
When you arrive in her room you observe the following...
© 2016 Keith Rischer/www.KeithRN.com
What assessment data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data: Clinical Significance:
Unresponsive
Ashen pale signs of cardiac arrest, heart is not pumping blood and
Minimal resp. effort shunting to core is likely occurring
Liquid emesis in mouth Loss of consciousness from sudden lack of blood flow
Weak carotid pulse Aspiration of gastric contents during arrest could have
24 bpm occurred
Does not awake or arouse to Needs immediate intervention!!!
painful stimuli
Current VS:
T: not assessed
P: 24
