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
... [Show More] 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:
EBL of 675 mL
2500 mL of LR administered during surgery
Pain is currently controlled at 2/10
Hydromorphone PCA with bolus dose of 0.1 mg and continuous hourly rate of 0.2 mg
Requiring 4 liters per n/c to keep sat >90% An EBL >500 mL is a clinical RED FLAG that requires increased vigilance by the nurse. How will this impact any repeat Hgb? In the post-op period, loss of blood (depending on amount) will lower Hgb. IV fluids given during surgery and PACU can cause a DILUTIONAL effect and lower the Hgb as well — think Kool-Aid with too much water!
LR is an ISOTONIC solution; 2–3 liters is typical for a surgical case, so this is not unexpected. Any isotonic solution does not stay in the intra- vascular space. Up to three quarters will go into the interstitial space in just hours. For any recent surgical patient, the nurse must intentionally note the EBL and the amount of IV fluids given to see if there is a need to anticipate any potential/possible fluid balance concerns.
Pain level, even if normal, is ALWAYS RELEVANT. Level of pain must be closely monitored–especially EARLY post-op to identify TREND.
Hydromorphone is a potent synthetic opioid narcotic. This dosage is WNL. The crucial nursing assessments for any narcotic, especially those with a continuous drip, include altered level of consciousness (LOC) and new onset of confusion, which are the EARLIEST signs of over-sedation. Assess for them!
LATE signs of narcotic over-sedation are respiratory depression with severe lethargy or somnolence. The nurse must assess for mild signs of altered mental status BEFORE respiratory depression occurs!
Be sure to reinforce proper use of the PCA pump and explain that she is also receiving a continuous infusion in addition to the demand dosing.
Her COPD history and her need for this much O2 post-op make it clear that pulmonary toileting and IS usage will be a high nursing priority! [Show Less]