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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

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