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 Judgement
6. Patient Education
, 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
Chronic low back pain Pain on a reoccurring basis
Respirations = 20/min. High respiratory rate, probably because of pain
Requires 4L of oxygen to keep O2 Sat. above 90% Pt. should report controlled pain levels
Patient on hydromorphone PCA 0.2 mg hourly watch for possible overdose and respiratory
depression
COPD
Anticipated low O2 saturation
RELEVANT Data from Social History Clinical Significance
Divorced She may need additional assistance upon d/c
from the hospital. The patient could be at
Estranged from two grown children increased risk for falls due to living alone,
chronic pain, and need for oxygen.
Lives alone
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)
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 Judgement
6. Patient Education
, 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
Chronic low back pain Pain on a reoccurring basis
Respirations = 20/min. High respiratory rate, probably because of pain
Requires 4L of oxygen to keep O2 Sat. above 90% Pt. should report controlled pain levels
Patient on hydromorphone PCA 0.2 mg hourly watch for possible overdose and respiratory
depression
COPD
Anticipated low O2 saturation
RELEVANT Data from Social History Clinical Significance
Divorced She may need additional assistance upon d/c
from the hospital. The patient could be at
Estranged from two grown children increased risk for falls due to living alone,
chronic pain, and need for oxygen.
Lives alone
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)
