Post-op Pain Management Case Study: Day of Surgery History of Present Problem: Sheila Dalton is a 52-year-old woman who has a history of chronic low back
... [Show More] 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 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%. 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: EBL of 675 mL 2500 mL of Lactated Ringers Pain 2/10 and increases with movement Posterior spinal fusion of L4-S1 0.2 mg/hr hydromorphone PCA and 0.1 mg of IV bolus Chronic low back pain History of COPD On 4L of oxygen EBL > 500 mL is an emergency and requires immediate intervention. This combined with 2500 mL Lactated Ringers will significantly lower Ms. Dalton’s Hgb level. Because Lactated Ringers is an isotonic solution, I would be concerned about fluid/electrolyte imbalance as well. Pain level, even at a low level should continue to be monitored post-op. Because her pain is affected by movement, I would administer pain medication about 30 minutes prior to activity. I would also make sure that she has assistance when getting up. Hydromorphone (dilaudid) is an opioid narcotic. Although this dose is standard and acceptable, Ms. Dalton should be monitored for mild signs and symptoms of oversedation, which includes altered mental status and altered consciousness. Her history of chronic back pain and posterior spinal fusion would indicate a need for positioning after surgery. I would also be [Show Less]