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ARREST

Post-op Pain Management: Cardiac Arrest
(2/2)

Sheila Dalton, 52 years old

Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)

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

SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
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KeithRN
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She had a posterior spinal
fusion of L4-S1 earlier today
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She was started on a
hydromorphone patient-controlled analgesia (PCA) with IV bolus dose that is 0
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2 mg/hour
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She was having
increased pain despite using the PCA every 10 minutes
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1 mg to 0
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Current VS:
T: 99
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7 C (oral)
P: 78
R: 12
BP: 92/48
O2 sat: 89% room air 4 liters n/c


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• history of smoking
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S1 Pain from 6/10-2/10 Hydromorphone
• Recently patient had surgery to help with their chronic lower back
PCA 0
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Ondansetron
• The patient is now taking hydromorphone (Dilaudid) to manage the
pain
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• Since the patient had a fusion at the L4-S1 it is important to make sure
the patient does not perform any significant bending or twisting but
remains able to promote lung expansion and keep airway patent
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Since the patient is at risk of respiratory
depression due to medication it is important to make sure oxygen
equipment is available and the appropriate size for the patient
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Five
minutes later she puts the call light on again
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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
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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

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

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
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Mouth full of emesis, drooling Chunks of
undigested food in mouth No palpable
• Since there is no radial pulse it is possible there is cardiac involvement
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per minute Does not arouse/awaken to
• Since the patient is unresponsive there has been a disruption with
vigorous physical stimuli
getting oxygen to the patient’s brain
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• The patient will need to be set up to an ECG, get ABGs drawn, lung
function test, chest xray and possibly intubated
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O2 76% 4L n/c Px 2/10
• The patient is only taking 4 breaths per minute, bradypnea, and oxygen saturation is
76% on 4L n/c which are symptoms of respiratory depression, along with cyanosis,
lethargy and confusion
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The patient is hypotensive which can be due to a
decrease in cardiovascular function, aspiration, or postoperative complications

Clinical Reasoning Begins…
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What is the underlying cause/pathophysiology of the primary problem?

The patient is most likely experiencing respiratory arrest related to the amount of
hydromorphone she is taking through the PCA
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The depressive effects of opioids can lead to
hypoventilation by interfering with the CNS and respiratory effort
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SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE
STUDY:STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC
ARREST
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What interventions will you initiate based on this priority?
Nursing Interventions:
Rationale:
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Assess airway for patency
Auscultate lungs for adventitious sounds
Assess RR, rhythm, quality, presence
Assess LOC
Assess VS (HR, BP, temp); pulse oximetry
Assess emesis for color consistency and
amount Perform suctioning and roll to the
side to clear emesis from mouth
Assess skin color, moisture, temperature
Monitor ECG
Assess for chest pain
Call HCP Initiate MONA if recommended
by the physician

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5
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Fever may develop in response to retained
secretions or atelectasis of may be a
manifestation of an infectious or
inflammatory process
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Tachycardia, bradycardia, and ectopic beats
can further compromise cardiac output

Expected Outcome:
Airway become patent after
clearing the emesis with a
side swipe, turning to side,
and suctioning Respiratory
status improves with the
administration of humidified
oxygen via nasal canula
Improve circulation status
by monitoring hemodynamic
function and providing
oxygen Improve
cardiopulmonary function

What body system(s) will you most thoroughly assess based on the primary/priority concern?

Cardio and respiratory
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What nursing assessments will identify this complication EARLY if it develops?
Assessing vital signs, ECG monitoring, oxygenation saturation, monitoring airway clearance, cardiac focused assessment, and
respiratory focused assessment
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The following
rhythm is displayed:
Cardiac Telemetry Strip:

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

Interpretation:

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

Clinical Significance:
Ventricular fibrillation is the most common dysrhythmia associated with cardiac arrest
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It is important for the new nurse to understand the most common ACLS algorithms as it is relevant to clinical practice
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Nurses who are BLS certified can have an active part in the code such as chest compressions; pulse check; bag
ventilation; and vital sign checks
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So many
times, nurses who are not ACLS certified will not even do those things that are taught in the BLS certification course
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Every crash cart has a simple 1-2 page form that documents the code and is self-explanatory
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Once the code team arrives, the role of the primary nurse is to contact physician, family, and pastoral
care to update on patient status and assist with care

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