Sheila Dalton_Final_Clinical_Surgical_Pain_Management_Unfolding_Reasoning_1 | NURSE 400 Post-op Pain Management: Cardiac Arrest (2/2) - American River College

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. 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 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: RELEVANT Data from History: Clinical Significance: COPD Chronic low back pain Recent spinal fusion surgery Hydromorphone use with worsened pain Nausea, relieved with Zofran Low SpO2 89% Low BP 92/48 History of respiratory issues, likely retains CO2, potential alveoli dysfunction Use of pain medication with chronic back pain? Post-op day 0, need to assess for surgical complications/expected findings, risk for infection/bleeding Narcotic use (decr. RR) Low oxygenation status on 4L NC 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... Current Assessment: GENERAL APPEARANCE: Lethargic, unresponsive, ashen pale in color 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: 24/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 - - - - - - - - - - - - - - - - - - - - - Caring and the “Art” of Nursing 1. What is the patient and FAMILY likely experiencing/feeling right now in this situation? The pt/family is likely distraught, frustrated, confused, and feeling powerless. 2. What can you do to engage yourself with this patient’s experience and show that he/she matters to you as a person? Taking time to answer their questions and reassure them, providing emotional support, explain what happened/procedures performed. Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment and transfer what is learned to improve nurse thinking and patient care in the future. 1. What did I learn from this scenario? I learned how to care for a pt in cardiac arrest following ACLS guidelines and how to interpret changes in the pt condition. 2. What would I do differently (if applicable) in this situation to prevent this outcome? The pt’s symptoms of nausea and uncontrolled pain could have been further assessed to rule out other causes rather than just administering medications. Finding the root cause may have led to a further cardiac assessment and earlier interventions. 3. How can I use what has been learned from this situation to improve patient care in the future? Following protocol (ACLS) to improve patient outcome, incorporating a multi-disciplinary approach, engaging with the pt to adapt the care plan, investigating the WHY behind symptoms prior to administering medication, educate pt on symptoms and side effects to report.