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 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 that is continuously occurring
COPD Effects the O2 saturation levels
Respirations = 20/min. Slightly elevated, may be due to pain
Requires 4L of oxygen to keep O2 Sat. above May be related to her COPD
90%
To avoid patient from excessive pain, should
Patient on hydromorphone PCA 0.2 mg hourly monitor for overdose and adverse effects
RELEVANT Data from Social History Clinical Significance
Divorced These all indicate that the patient will be
dealing with her recovery on her own and there
Estranged from two grown children is no support system in place. This can lead to
the patient being anxious, stress, and depressed.
Lives alone She may also experience high levels of pain
while in recovery since she will have to do
everything on her own.
Developing Nurse Thinking by Identifying Significance of Clinical Data
Patient Care Begins–Arrives from PACU to Surgical Floor
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 that is continuously occurring
COPD Effects the O2 saturation levels
Respirations = 20/min. Slightly elevated, may be due to pain
Requires 4L of oxygen to keep O2 Sat. above May be related to her COPD
90%
To avoid patient from excessive pain, should
Patient on hydromorphone PCA 0.2 mg hourly monitor for overdose and adverse effects
RELEVANT Data from Social History Clinical Significance
Divorced These all indicate that the patient will be
dealing with her recovery on her own and there
Estranged from two grown children is no support system in place. This can lead to
the patient being anxious, stress, and depressed.
Lives alone She may also experience high levels of pain
while in recovery since she will have to do
everything on her own.
Developing Nurse Thinking by Identifying Significance of Clinical Data
Patient Care Begins–Arrives from PACU to Surgical Floor
