SHEILA DALTON ,52 YEARS POST-OP PAIN MANAGEMENT:
DAY OF SURGERY
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
, FUNDAMENTAL Reasoning: 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 are RELEVANT and have clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
RELEVANT Data from Social History: Clinical Significance:
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:
DAY OF SURGERY
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
, FUNDAMENTAL Reasoning: 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 are RELEVANT and have clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
RELEVANT Data from Social History: Clinical Significance:
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:
