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
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.
Current VS:
T: 99.8 F/37.7 C (oral)
P: 78
R: 12
BP: 92/48
O2 sat: 89% room air 4 liters n/c
.
What data from the history is RELEVANT and has clinical significance to the nurse?
RELEVANT Data from History: Clinical Significance:
History of chronic low back pain Needs spinal infusion of L4-S1 today
COPD Risk for respiratory obstruction during surgery and 02
2/10 pain that increases with insufficiency Due to lack of movement puts pt at risk for pressure
movement
sores.
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…
Patient Care Begins:
Current Assessment:
, GENERAL Lethargic, unresponsive, ashen pale in color
APPEARANCE:
RESP: Minimal spontaneous respiratory effort present. When you arrive at the bedside you
observe that her mouth is full of liquid emesis with chunks of undigested food that is
drooling out the side of her mouth
CARDIAC: Unable to palpate radial pulse, you go straight to the carotid pulse on the neck and
note a weak pulse with 2 palpable beats in 5 seconds.
Calculate pulse rate: /minute
NEURO: Unresponsive, does not arouse or awaken to vigorous physical stimuli
GI: Not assessed
GU: Not assessed
SKIN: Not assessed
© 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:
GENERAL Ashen pale color shows the pt is experiencing a decrease of oxygen and
APPEARANCE: Lethargic, blood flow.
unresponsive, ashen pale in color
RESP: Minimal spontaneous respiratory Lack of respiratory effort from decreased oxygen which can be
effort present, her mouth is full of liquid from emesis containing chunks of undigested food clogging her
emesis with chunks of undigested food airway.
that is drooling out the side of her
mouth.
CARDIAC: Unable to palpate radial
pulse, you go straight to the carotid pulse Her pulse rate is only 24 BPM which means she is bradycardic and in
on the neck and note a weak pulse with cardiac arrest.
2 palpable beats in 5 seconds
Current VS:
T: not assessed
P: 24
R: 4
BP: 72/40
(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
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.
Current VS:
T: 99.8 F/37.7 C (oral)
P: 78
R: 12
BP: 92/48
O2 sat: 89% room air 4 liters n/c
.
What data from the history is RELEVANT and has clinical significance to the nurse?
RELEVANT Data from History: Clinical Significance:
History of chronic low back pain Needs spinal infusion of L4-S1 today
COPD Risk for respiratory obstruction during surgery and 02
2/10 pain that increases with insufficiency Due to lack of movement puts pt at risk for pressure
movement
sores.
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…
Patient Care Begins:
Current Assessment:
, GENERAL Lethargic, unresponsive, ashen pale in color
APPEARANCE:
RESP: Minimal spontaneous respiratory effort present. When you arrive at the bedside you
observe that her mouth is full of liquid emesis with chunks of undigested food that is
drooling out the side of her mouth
CARDIAC: Unable to palpate radial pulse, you go straight to the carotid pulse on the neck and
note a weak pulse with 2 palpable beats in 5 seconds.
Calculate pulse rate: /minute
NEURO: Unresponsive, does not arouse or awaken to vigorous physical stimuli
GI: Not assessed
GU: Not assessed
SKIN: Not assessed
© 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:
GENERAL Ashen pale color shows the pt is experiencing a decrease of oxygen and
APPEARANCE: Lethargic, blood flow.
unresponsive, ashen pale in color
RESP: Minimal spontaneous respiratory Lack of respiratory effort from decreased oxygen which can be
effort present, her mouth is full of liquid from emesis containing chunks of undigested food clogging her
emesis with chunks of undigested food airway.
that is drooling out the side of her
mouth.
CARDIAC: Unable to palpate radial
pulse, you go straight to the carotid pulse Her pulse rate is only 24 BPM which means she is bradycardic and in
on the neck and note a weak pulse with cardiac arrest.
2 palpable beats in 5 seconds
Current VS:
T: not assessed
P: 24
R: 4
BP: 72/40
