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 a posterior spinal fusion
... [Show More] 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
careful to log roll them and be cautious not to twist her back.
Her previous history of COPD combined with her need for this much oxygen increases a priority for incentive spirometry, postural drainage, and percussion in order to clear the airways of mucus and secretions and promote lung expansion. I would want to continue monitoring her oxygen saturation so that it stays above 90% as well.
RELEVANT Data from Social History: Clinical Significance:
She lives alone and has no nearby relatives This indicates a lack of support system; she may need additional assistance upon d/c from the hospital. The patient could be at increased risk for falls due to living alone, chronic pain, and need for oxygen.
Possible referral needed to skilled nursing
facility or TCU upon discharge
Developing Nursing Thinking by Identifying Significance of Clinical Data
Patient Care Begins – Arrives from PACU to Surgical Floor
Current VS: P-Q-R-S-T- Pain Assessment (5th VS):
T: 100.2 F/ 37.9 C (oral) Provoking/Palliative: Movement/lying still
P: 110 (regular) Quality: Ache
R: 24 Region/Radiation: Lumbar-incisional
BP: 98/50 Severity: 6/10 – gradually increasing
O2 sat: 88% 4 liters per n/c Timing: Continuous since arrival from
PACU
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
Temperature of 100.2
Pulse of 110 BPM
Respirations of 24 and 88% oxygen sat on 4 L Temperature is elevated and could signify a possible infection. Ms. Dalton should begin pain medication and use of an incentive spirometer to lower temperature. I would continue to monitor for a change in temperature.
Elevated pulse could signify pain/distress.
98/50 Blood pressure
Pain 6/10 and continuous at incision site, provoked by movement. High respiratory rate and low oxygen sat could signify respiratory distress or pain. High respirations could signify that she is using accessory muscles to breathe. Low oxygen saturation could indicate shallow breathing. I would use pulmonary toileting techniques as well as the incentive spirometer to clear the airway of mucus and expand the lungs.
This is significantly lower than her baseline; could be indicative of oversedation or due to blood loss.
Ms. Dalton’s pain level is significant and should be treated and monitored.
Her vital signs (including pain) should be continually monitored post-op.
Current Assessment:
GENERAL
APPEARANCE: Appears uncomfortable, body tense, frequent grimacing – last used
PCA 10 minutes ago
RESP: Breath sounds clear with equal aeration ant/post but diminished bilaterally, non-labored respiratory effort, occasional
moist-nonproductive cough
CARDIAC: Pale-pink, warm and dry, no edema, heart sounds regular – S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial
landmarks
NEURO: Alert and oriented to person, place, time, and situation (x4)
GI: Abdomen soft/non-tender, bowel sounds hypoactive and audible
per auscultation in all 4 quadrants, c/o nausea
GU: Foley catheter secured, urine clear/yellow, 100 ml the past two
hours
SKIN: Skin integrity intact, skin turgor elastic, no tenting, dressing in
place with no drainage noted
What assessment data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data: Clinical Significance:
Patient is uncomfortable, tense, and clearly in pain despite use of PCA
Diminished bilateral lung sounds and occasional moist non-productive cough
Hypoactive bowel sounds
Complaints of nausea The patient requires another intervention for pain. I could see if any other medication could be given and do so. If not, I would consider taking her for a walk or assisting her in changing positions. I could help her find a movie to watch or a magazine to read in order to aid in distraction. I could also offer essential oils to aid in relaxation.
It is common for COPD patients to develop diminished lung sounds during flare-ups. This is due to increased secretions and bronchial spasms obstructing the airway.The occasional moist non-productive cough is likely due to her history of COPD as well. The patient may need a bronchodilator to open up her bronchi and aid in breathing.
Hypoactive bowel sounds could mean that the patient is constipated. It is imperative that I get her up and moving as soon as possible in order to improve GI function.
The patient is in discomfort due to complaints of nausea. If ordered, I could offer her Zofran or possibly some sprite and saltines in order to calm her stomach. I could also offer essential oils to aid on nausea and relaxation.
Developing Nursing Thinking through APPLICATION of the Sciences
Fluid & Electrolytes/Lab/Diagnostic Results:
Complete Blood
Count (CBC): Current: High/Low/WNL? Prior:
WBC (4.5-11.0 mm3) 11.8 High 7.2
Hgb (12-16 g/dl) 10.4 Low 15.2
Platelets
(150-450x103 µl) 220 WNL 258
Neutrophil% (42-72) 85 High 68
Band forms (3-5%) 1 Low 1
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
WBC A high white blood cell count could indicate an infection.
This is something that should be brought to the provider’s attention as soon as possible. I would continue to monitor for other signs of infection. Worsening
Hgb A low hemoglobin level indicates a significant loss in red blood cells and blood volume. I would notify the provider and possibly give the patient a blood transfusion. Worsening
Neutrophil % A high neutrophil % indicates a response to a bacterial infection. Worsening
Band Forms A percentage of band forms indicates a low number of immature neutrophils. This is something to monitor, as an increase in this number signifies the body trying to fight off a large infection. Stable
Basic Metabolic
Panel (BMP): Current: High/Low/WNL? Prior:
Sodium (135-145
mEq/L) 134 Low 136
Potassium (3.5-5.0
mEq/L) 3.8 WNL 3.9
Glucose (70-110
mg/dl) 148 High 98
BUN (7-25 mg/dl) 20 WNL 22
Creatinine (0.6-1.2
mg/dl) 0.9 WNL 1.1
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
Sodium
Glucose Ms. Dalton’s hyponatremia is probably due to receiving too many fluids in the ER. An intervention would be to give her a solution of saline.
Ms. Dalton’s blood glucose is elevated. This could be due to pain and emotional stress. An elevated blood sugar could delay healing and increase the chances for surgical-site infection. Worsening
Worsening (This should be monitored closely in order to create an observable trend and monitor significance) [Show Less]