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SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST

Post-op Pain Management: Day of Surgery
(1/2)

Sheila Dalton, 52 years old

Primary Concept
Pain
Interrelated Concepts (In order of emphasis)
1
...

3
...

5
...

7
...


Gas Exchange
Glucose Regulation
Perfusion
Inflammation
Clinical Judgment
Patient Education
Communication
Collaboration

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
© 2016 Keith Rischer/www
...
com

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
UNFOLDING Reasoning Case Study: STUDENT

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 an estimated blood loss (EBL) of 675 mL during surgery and received 2500 mL of
Lactated Ringers (LR)
...
She was started on a
hydromorphone patient-controlled analgesia (PCA) with IV bolus dose of 0
...
2 mg
...
You are the nurse receiving the patient directly from the PACU
...
She has two grown children from whom she is
estranged
...
This combined with 2500 mL Lactated Ringers will
significantly lower Ms
...

Posterior spinal fusion of L4-S1 0
...
1 mg of IV bolus
post-op
...
Dalton should be monitored for mild signs and symptoms of
of oxygen
oversedation, which include altered mental status and altered
consciousness
...

• I would want to continue monitoring her oxygen saturation so that
it stays above 90% as well
...
The patient could be at increased risk for falls
due to living alone, chronic pain, and need for oxygen
...
)
PMH:
Home Meds:
Pharm
...
Citalopram 40 mg daily
Antidepressant
Alleviate depression
• Low back pain with
2
...
Oxycodone 10 mg every 4 Narcotic
hours
prn
Alleviate SOB
Bronchodilator
• Depression
4
...
Sildenafil 20 mg tid
One disease process often influences the development of other illnesses
...

• Underline what PMH problem(s) FOLLOWED as domino(s)
...
2 F/37
...
2 Pulse
• Temperature is elevated and could signify a possible infection
...
I would continue to monitor for a change in temperature
...

of 24 and 88% oxygen sat
• High respiratory rate and low oxygen sat could signify respiratory distress or pain
...

98/50 Blood pressure Pain
• Low oxygen saturation could indicate shallow breathing
...
Dalton’s pain level is significant and should be treated and monitored
...

movement
...
I could also offer
essential oils to aid in relaxation
...
This is due to increased secretions and bronchial
spasms obstructing the airway
...
The patient may need a bronchodilator to open up
her bronchi and aid in breathing
...
It
is imperative that I get her up and moving as soon as possible in order
to improve GI function
...
If ordered, I
could offer her Zofran or possibly some sprite and saltines in order to
calm her stomach
...
5–11
...
8
10
...
2
15
...
5–5
...
6–1
...

Worsening
A low hemoglobin level indicates a significant loss in Worsening
red blood cells and blood volume
...

A percentage of band forms indicates a low number of
immature neutrophils
...

Current:
134
3
...
9

High/Low/WNL?

Prior:
136
3
...
1

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
TREND:
RELEVANT Lab(s):
Clinical Significance:
Sodium
Glucose

Ms
...
An intervention would be to give her a
solution of saline
...
Dalton’s blood glucose is elevated
...
An elevated blood sugar could delay
healing and increase the chances for surgical-site infection
...
4

12-16
g/dl
Critica
l
Value:
20 g/dl

The patient’s hemoglobin An intervention could be follow up lab draws or a blood
is below the normal level; transfusion to raise her red blood cell count
...
Dalton’s vital signs for significant
monitored closely
...


SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
Clinical Reasoning Begins…
1
...
What is the underlying cause/pathophysiology of this primary problem?

The underlying cause of acute pain is Ms
...
Her low oxygen saturation is likely due to a build-up of secretions and bronchial spasms which can be
attributed to her history of COPD along with shallow respirations and the use of accessory breathing muscles due to
pain
...
1–0
...
1–0
...
9% NS 100 mL/hour IV

Clear liquids/advance diet as
tolerated

Apply lumbar orthotic brace
when up in chair or ambulating

•
•

Will decrease pain level/keep pain under control
...

The patient will have no pain
Will keep the patient comfortable
...

The patient will lab values will
Will expand patient’s lungs, decreasing pain
become normal
level and need for high levels of oxygen
Will keep the patient hydrated and balance
electrolytes
Will keep patient from being nauseated by
advancing too quickly after surgery and increase
fluid intake
Will decrease patient pain level and increase
mobility
Will allow for a trend and continued monitoring
of patient’s laboratory values
Will allow for a trend and continued monitoring
of the patient’s abnormal CBC levels
...
Hydromorphone PCA
2
...
Ondansetron (Zofran) 4
mg IV push every 4 hours
prn nausea
4
...
Incentive spirometer (IS)
6
...
Clear liquids/advance diet
as tolerated

Order of Priority:
Continuous pulse oximetry,
Titrate O2 to keep sat >90%,
Incentive spirometer, Clear
liquids, advance diet as
tolerated

Rationale:
ABC’s Airway, breathing, and circulation, as well as nutrition
and fluids

Medication Dosage Calculation:
Medication/Dose:

Mechanism of Action:

Ondansetron

It's a serotonin antagonist,
meaning its mechanism of
action is blocking the
serotonin receptors in the
CTZ
...


4 mg IV push
(4mg/2 mL vial)

Volume/time frame to
Safely Administer:

IV Push:
Volume every 15
sec?

Nursing Assessment/Considerations:
Assess dizziness and drowsiness that might
affect gait, balance, and other functional
activities
...


Collaborative Care: Nursing
3
...
nutrition, fluids, and elimination
...
What interventions will you initiate based on this priority?
Nursing Priority: Nursing Interventions:
Rationale:
Impaired gas
exchange

Expected Outcome:

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
ABCs

5
...

effort, including the use of accessory Rapid and shallow breathing patterns
muscles, nasal flaring, and abnormal and hypoventilation affect gas
breathing patterns
...

Increased respiratory rate, use of
accessory muscles, nasal flaring,
abdominal breathing, and a look of
panic in the patient’s eyes may be seen
with hypoxia
...
What is the worst possible/most likely complication to anticipate?

The patient becomes dehydrated and or stops breathing due to low O2 stats
...
What nursing assessments will identify this complication EARLY if it develops?

The trend of values going down, skin turgor, and respiratory assessments
8
...
What psychosocial needs will this patient and/or family likely have that will need to be addressed?

Ms
...
Since her family is not present or involved in her life, Ms
...

10
...
Dalton does not have close family members nearby, she will rely on the nursing staff for many of her
psychosocial needs
...


Evaluation:
Evaluate your patient’s response to nursing and medical interventions during your shift
...


One Hour Later…
You recognized the need to increase the hydromorphone PCA and have increased the bolus dose to 0
...
You have instructed her to use the PCA as frequently as needed, placed cold
packs to her incision prn, provided clear liquids with the instructions to take it slow and call the nurse if she feels any
nausea
...


Current VS:
T: 99
...
6 C (oral)
P: 82 (regular)
R: 16
BP: 110/62
O2 sat: 92% 2 liters
per n/c

Most Recent:

Current PQRST:
T: 100
...
9 C (oral)
Provoking/Palliative:
P: 110 (regular)
Quality:
R: 24
Region/Radiation:
BP: 98/50
Severity:
O2 sat: 88% 4 liters per Timing:

Movement/minimize movement
Ache
Incisional
2/10
Continuous

n/c

Current
Assessment:
GENERAL
APPEARANCE:
RESP:

Resting comfortably, appears in no acute distress, appears to be sleeping but arouses easily
when awakened
Breath sounds clear with equal aeration but remain diminished bilaterally, non-labored
respiratory effort, IS volume 750 mL initially–currently 1250 mL

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
CARDIAC:
NEURO:
GI:

Pink, warm and dry, no edema, heart sounds regular with no abnormal beats, pulses strong,
equal with palpation at radial/pedal/post-tibial landmarks
Alert and oriented to person, place, time, and situation (x4)
Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
GU:
SKIN:

Foley catheter, urine clear/yellow, 250 mL u/o the past 2 hours
Skin integrity intact, no drainage present on dressing

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
1
...
2 F/37
...
The patient does
P: 110 (regular)
not seem to be in distress
...
The patient needs pain medication because
O2 sat: 88% 4 liters per
of the pain level
n/c
Pain 2/10

RELEVANT Assessment Data:

Clinical Significance:

Breath sounds clear with equal aeration the patient remains diminished bilaterally non-labored because of recent
but remains diminished bilaterally, non- surgery and because of a history of COPD
...
Has the status improved or not as expected to this point?

No, the patient status has not improved it increased just a little bit will call the doctor as soon as possible
...
Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?

Yes, my plan is clearly needed to be modified after this evaluation assessment because it seems to be that the
interventions are not working
...
Based on your current evaluation, what are your nursing priorities and plan of care?

This is a respiration and circulation system that need further evaluation
...
Effective and concise handoffs are essential to excellent care and
if not done well can adversely impact the care of this patient
...

She had a posterior spinal fusion of L4-S1 today
...
Pain is currently controlled at 2/10 and increases with movement
...

T: 100
...
9 C (oral)
P: 110 (regular)
R: 24
ssessment:
BP:
98/50
Most
recent
vital
signs:per
O2 sat:
88%
4 liters
n/c

A

RELEVANT body system nursing assessment data:

Resting comfortably, appears in no acute distress, appears to be sleeping but arouses easily when awakened
...
What will be the most important discharge/education priorities you will reinforce with Sheila about her
medical condition to prevent future readmission with the same problem?

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
Medication teaching, pain management education, and possible referrals to a rehabilitation, TCU, or skilled nursing
facility to aid her with her ADLs
...


What is the patient likely experiencing/feeling right now in this situation?

Ms
...
This combined with her lack of support system is probably putting a lot of strain on her, as she
could lose some independence for a while
...


2
...
Dalton has to say and present open-ended questions to allow
the patient to speak freely about her emotions and feelings
...
By doing this, I can open the door for an open and respectful
relationship in which the patient feels involved and engaged in her care and recovery
...

1
...
I was able to use all of my resources, prior knowledge, and developing nurse intuition in order to make
inferences about my patient’s care
...
Overall, I felt that this scenario allowed for knowledge expansion and affirmation
...


How can I use what has been learned from this scenario to improve patient care in the future?

I can use my knowledge from this scenario to view the entire aspect of a patient’s care and consider all of their needs based on
past medical history, subjective data, objective data, and acute needs
...
I can also use the knowledge that I learned from this
scenario to develop individualized care based on a patient’s social and medical history
...
KeithRN
...
KeithRN
...

2
...

4
...

6
...


Gas Exchange
Acid-Base Balance
Fluid and Electrolyte Balance
Clinical Judgment
Patient Education
Communication
Collaboration

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST

© 2016 Keith Rischer/www
...
com

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
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
...
Her pain is currently controlled at 2/10 and increases with movement
...
2 mg and continuous rate of 0
...

The nurse reported that her nausea has improved after receiving ondansetron IV four hours ago
...
Her pain has decreased from 6/10 to 2/10 since the PCA bolus
was increased from 0
...
2 mg of hydromorphone IV one hour ago
...
8 F/37
...


What data from the history is RELEVANT and has clinical significance to the nurse?
RELEVANT Data from History:
Clinical Significance:
52 years old Hx of chronic low back pain
• Patient has a history of COPD
...
However this patient has not disclosed this
Hx of COPD Posterior spinal fusion of L4information, it is something that should be asked when taking a history
...
2mg Nausea 4 hours ago
pain
...
Dilaudid can have adverse effects of CNS depression, respiratory
distress, nausea, etc
...

• Since the patient is nauseous, making sure the room is stocked with
suction equipment is essential
...


Your shift continues…
Thirty minutes later she is feeling more nauseated, and you administer ondansetron 4 mg IV push prn
...
You are not able to respond immediately because you are helping
your other patient get on the commode
...
When you arrive in her room you observe the
following…

Patient Care Begins:
Current Assessment:

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
GENERAL
APPEARANCE:
RESP:

Lethargic, unresponsive, ashen pale in color
Minimal spontaneous respiratory effort present
...

Calculate pulse rate:
/minute
Unresponsive, does not arouse or awaken to vigorous physical stimuli
Not assessed
Not assessed
Not assessed

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
What assessment data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data:
Clinical Significance:
Lethargic, unresponsive, ashen pale color
• The patient has been unattended for several minutes, meaning you are
Minimal spontaneous respiratory effort
unaware for how long the patient has been in this state of
unresponsiveness and with an airway obstruction most likely
...

The carotid pulse is very low meaning the ability for the heart to pump
radial pulse Palpable carotid pulse 24 beats
is very significantly poor
...
In this case it is priority to call a
code for assistance, clear the patient’s airway, supply oxygenation, and
regain cardiovascular function
...


Current VS:
T: not assessed
P: 24
R: 4
BP: 72/40
O2 sat: 76% 4 liters n/c
What VS data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
Pulse 24 RR 4 BP 72/40
• The patient had poor cardiac perfusion and an ineffective breathing pattern
...

• The patient should be on more oxygen and possibly switched to a nonrebreather mask
in order to get more on inhalation
...
What is the primary problem that your patient is most likely presenting with?

Respiratory arrest – ineffective breathing pattern, airway obstruction, decreased cardiac output
2
...
Respiratory failure can occur due to many factors in the postoperative
period including COPD complications and drug overdose
...
Pain may also interfere with the patient’s ability to
deep breath and cough
...
What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY)
Ineffective airway clearance Ineffective breathing pattern Decreased cardiac output

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
4
...


RR and rhythm are early warning signs of
impending respiratory difficulties Suctioning
is performed
when the patient is unable to clear secretions
themselves Clearing the obstruction from the
airway allows for air to get to lungs
Decreased sounds may be indicative of a
major airway obstruction Tachycardia and
HTN may be related to increased work of
breathing due to hypoxia
...

Low cardiac output can further reduce
myocardial perfusion Cardiac dysrhythmias
may occur from low perfusion, acidosis, or
hypoxia
...
What is the worst possible/most likely complication to anticipate?

Cardiac arrest or death
7
...
What nursing interventions will you initiate if this complication develops?
Call code and assistance, initiate CPR if unresponsive, check ECG,

A crash cart is brought into the room, and the patient is placed on the cardiac monitor/defibrillator
...
It is a rapid, disorganized ventricular
rhythm that causes ineffective quivering of the ventricle

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
Medical Management: Rationale for Treatment & Expected Outcomes
I recognize that most students/new nurses have not had ACLS training or exposure to this certification in nursing school
...
If
and when ACLS certification as a registered nurse is taken, this case study will have provided practice of this essential
skill! Please recognize that doing this case study does not qualify for ACLS interventions in practice! You must be
officially certified to actually intervene with these measures in a code
...
Nurses should feel that they can work within their scope and certification
...

But there is a place for a nurse who is not ACLS certified during a code that is an important role…the RECORDER
...
Though this role should
ultimately be done by a certified ACLS nurse when one arrives, until then begin documentation and remain present in the
room so that you as the primary nurse can communicate to the code team and physician the patient’s story and what led
up to the code
...

Care Provider Orders:

ACLS Priorities:
• ABCs & Check
responsiveness
• Activate
emergency
response system
and AED
• Circulation
• Defibrillation
• Disability

Rationale:
Expected Outcome:
ensure a patent airway and adequate ventilation Patient is Ventilation is improved and
not able to spontaneously breathe on own and is
respiratory rate is within normal
unresponsive – we must help the patient breathe A
limits of 12-20 breaths per minute
...

ET tube and in the proper position of the trachea ABGs
Patient cardiovascular function is
assess ventilation and oxygenation
stable and respiratory function
stable
...

1:10,000
1 mg/10 mL IV/IO Both beta 1 and 2 receptors
every 3-5” push are affected producing
bronchodilation
...


Epinephrine

Volume/time frame to
Safely Administer:
10 mL syringe

Administer each 1 mg
(10 mL) IV Push:
Volume every 15 sec?
2
...
Monitor
pulmonary function tests Observe for
paradoxical bronchospasm (wheezing) –
withhold if occurs notify HCP Observe for
rebound bronchospasm and tolerance after 3
treatments Monitor ECG, chest pain, HR
>110, and HTN; hemodynamic parameters
May increase blood glucose and decrease
potassium Monitor for hypovolemia, nasal
congestion, and signs of overdose Monitor
IV site for infiltration, phlebitis, or allergic
reaction

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST

Medication/Dose:

Mechanism of Action:

Volume/time frame to
Safely Administer:

Nursing Assessment/Considerations:

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
Amiodarone
300 mg IV push
150 mg/3 mL vial

Blocks potassium chloride,
leading to a prolongation of
action potential duration

ECG monitoring, heart rate, and rhythm
while taking medication Monitor ECG for
IV Push:
PR prolongation, QRS widening, T-wave
Volume every 15 sec? reduction and widening, and U waves, QT
prolongation with worsening arrythmias
Assess for pulmonary toxicity
(rales/crackles, decreased breath sounds,
fatigue, dyspnea, wheezing, fever, hypoxia)
Assess IV access for adverse reactions
Monitor patient for signs and symptoms of
ARDS Monitor BP for hypotension Assess
for neurotoxicity (ataxia, tremors, weakness,
tingling, numbness) Assess any
abnormalities in vision Assess for thyroid
dysfunction and liver function If rash
appears assess for SJS and toxic epidermal
necrolysis Maximum dose in 24 hours is
2
...
The patient has cardiac rhythm back
however it is tachycardic, therefore we need to try to return it to a beat between 60-100
...
Provide oxygen to help decrease the
workload on the heart
...


The in-house physician running the code orders a stat ABG right after she is successfully
resuscitated and is now intubated
...
35–7
...
15
64
78
22
90%
100%

High/Low/WNL?
low
low
high
WNL
low
WNL

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
pH 7
...

Usually patients with COPD will not develop symptoms of hypercapnia due to

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
the prolongation of CO2 accumulation and compensation of the renal system
having time to work
...
These values help assess the functionality of the
lungs and kidneys

Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
Lab:

pH
Value:

7
...

Monitor ventilation and oxygenation levels
Analyzing the ABGs allows us to
7
...
45
2
...
Reduce any bronchospasm or inflammation
Anything
perfuse the body and remove
4
...

Acidosis can occur rapidly or
over time
...
1 F/37
...
Is pale/pink, coarse crackles/rhonchi scattered in both lung fields even
after suctioning
...
effort
...
Strong femoral pulse
...
Heart rate regular–S1S2
...
Responds to pain stimuli by bringing both hands toward the source of
pain
Abdomen soft, non-tender with active bowel sounds
Foley placed, 30 mL clear, yellow urine present in bag
Surgical incision intact, no redness, drainage, or dehiscence present

1
...
1 P 128 regular R ambu bag 20 BP
• Patient was unable to breath on own spontaneously therefore was
128/88 O2 92% on 100% O2
intubated and has been breathing via the assistance of an ambu bag
...

• The pulse is elevated which can occur after ventricular fibrillation
...

• The patient temperature is elevated which could be due to infectious
process or inflammatory response to the trauma the lungs and heart
have endured
...
Due to
the aspiration the patient is at risk of pneumonia and possibly
endocarditis
...
The response to
painful stimuli may be reflexivity
...

There are peripheral pulses that were absent prior
...

The patient now has a foley placed to assist with fluid output
...
Monitor kidney function, urine amount, color, consistency,
and labs
...

This is also a source of infection as well, monitoring for signs and
symptoms of a CAUTI are important, and hygiene and peri care should
be performed daily
...
There is presence of fluid and
secretions throughout the lungs, providing humidified oxygen will help
loosen the secretion and suction will hopefully remove as much as

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
possible
...

2
...

3
...
My focus will be to maintain a clear airway by
monitoring secretions and listening to the lung function, as well as, improving breathing pattern
...

4
...


SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
Think ABC’s…
A: AIRWAY–Maintain placement and integrity of endotracheal tube

B: BREATHING–Impaired gas exchange

C: CIRCULATION–Maintain adequate blood pressure and stable cardiac rhythm (impaired tissue perfusion)

TEN minutes post-resuscitation:
Medical Management: Rationale for Treatment & Expected Outcomes:
Care Provider Orders:

ACLS Priorities:
• ABCs &
responsiveness
• Disability; alert,
voice, painful,
unresponsive
• Exposure for visual
assessment
• Signs and symptoms
• Allergies
Medications
• Past illnesses

Medication/Dose:

Rationale:
Expected Outcome:
o ensure a patent airway and adequate ventilation
❖ Ventilation is improved
and respiratory rate is
Patient is not able to spontaneously breath on own
within normal limits of
and is unresponsive – we must help the patient
12-20 breaths per minute
...
Patient
proper position of the trachea ABGs assess
cardiovascular function is
ventilation and oxygenation Understanding the
stable and respiratory
cause of the primary problem Gathering as much
function stable
...
02 mg IV
push every 2
minutes
0
...
1 to 0
...
Provide oxygen,
resuscitation, and ventilation

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
The room is now ready and it is now time to transfer to ICU
...
You
have done an excellent job to this point, now finish strong and give the following SBAR report
to the nurse who will be caring for this patient:

Situation:
Name/age: : Sheila Dalton, 52 y/o

BRIEF summary of primary problem:

Patient came in for spinal surgery and has been in postoperative care focusing on managing pain and nausea
...
Patient experienced ventricular fibrillation
...
Cardiac rhythm was returned to sinus tachycardia
...
Patient was taking Dilaudid for post-op pain and Zofran for increasing
nausea
...
The patient was taking hydromorphone 0
...
Pt had a fusion of L4-S1
...


Assessment:
Most recent vital signs:

T 99
...
15 pO2 64 pCO2 78 O2 sat 90%
INTERPRETATION of current clinical status (stable/unstable/worsening): Stable

Recommendation:

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
Suggestions to advance plan of care: Monitor ABCs and LOC, continue oxygenation, assess cardiovascular function
...

Heart size normal
...
35–7
...
29
102
48
23
100%
100%

Prior:
7
...
29
pO2 102 (slightly high)
pCO2 48

•

•
•

Complete Blood Count (CBC):
WBC (4
...
0 mm 3)
Hgb (12–16 g/dL)
Platelets (150-450 x103/µl)
Neutrophil % (42–72)

Patients’ acute respiratory acidosis is
improving, hypoxemia has been
effectively reversed, and CO2 is
normalizing
...

It is important to continue to monitor
these values with mechanical
ventilation as over ventilating a patient
can create complications and create
another imbalance of CO2
...
9
10
...
8
11
...
2 (low)
Platelets 148 (low)
Neutrophils 85% (high)

• Hgb worsening
Hgb has been lowered
...

• Platelets have decreased in amount
which can affect the patient’s ability to
clot or bleed
...
It is
important to monitor the platelet count over
time, understand the duration and if it decreases
Basic Metabolic Panel (BMP):
Sodium (135–145 mEq/L)
Potassium (3
...
0 mEq/L)
CO2 (Bicarb) (21–31 mmol/L)
Glucose (70–110 mg/dL)
Creatinine (0
...
2 mg/dL)
Misc:
Lactate (<2
...
1
20
152
1
...
9

High/Low/WNL?

Prior:
140
3
...
1
N/a

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
TREND: Improve/Worsening/Stable:
Hgb 10
...
There was less
oxygen being circulated throughout the
blood since the lungs were not
working/pulmonary function and
circulation was decreased
...
The amiodarone that was
given to the patient several times prior
to the MI can have adverse effects of
coagulation abnormalities
...
The QRS and T wave mimic the same direction
...


Education Priorities/Discharge Planning
1
...


SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
2
...


SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
Caring and the “Art” of Nursing
1
...
This scenario is a critical life-threatening event that can end
very poorly if not acted on as soon as possible
...


2
...
Telling the patient when you are in the room, telling them what you
are doing every step of the way, providing therapeutic touch when necessary, and continuing patient daily care and
hygiene will make them feel like they matter
...

1
...
I was able to use all my resources, prior knowledge, and developing nurse intuition in order to make
inferences about my patient’s care
...
Overall, I felt that this scenario allowed for knowledge expansion and affirmation
...
What would I do differently (if applicable) in this situation to prevent this outcome?

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
I would have been more on top of the patient’s pain management and persistent about pain assessments
...
How can I use what has been learned from this situation to improve patient care in the future?
I can use my knowledge from this scenario to view the entire aspect of a patient’s care and consider all of their needs based on
past medical history, subjective data, objective data, and acute needs
...
I can also use the knowledge that I learned from this
scenario to develop individualized care based on a patient’s social and medical history

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