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:
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 92/48History 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? 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 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 RELEV ANT and must be recognized as clinically significant by the nurse?
RELEV ANT Assessment Data: Clinical Significance:
Unresponsive
Ashen pale
Minimal resp. effort
Liquid emesis in mouth
Weak carotid pulse 24 bpm
Does not awake or arouse to painful stimuli signs of cardiac arrest, heart is not pumping blood and shunting to core is likely occurring
Loss of consciousness from sudden lack of blood flow
Aspiration of gastric contents during arrest could have occurred
Needs immediate intervention!!! Current VS:
T: not assessed
P: 24
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:
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 92/48History 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? 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 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 RELEV ANT and must be recognized as clinically significant by the nurse?
RELEV ANT Assessment Data: Clinical Significance:
Unresponsive
Ashen pale
Minimal resp. effort
Liquid emesis in mouth
Weak carotid pulse 24 bpm
Does not awake or arouse to painful stimuli signs of cardiac arrest, heart is not pumping blood and shunting to core is likely occurring
Loss of consciousness from sudden lack of blood flow
Aspiration of gastric contents during arrest could have occurred
Needs immediate intervention!!! Current VS:
T: not assessed
P: 24
