Post-op Pain Management: Cardiac Arrest
(2/2)
Sheila Dalton, 52 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of
... [Show More] emphasis)
1. Gas Exchange
2. Acid-Base Balance
3. Fluid and Electrolyte Balance
4. Clinical Judgment
5. Patient Education
6. Communication
7. Collaboration
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. She had a posterior spinal fusion of L4-S1 earlier today. Her 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 that is 0.2 mg and continuous rate of 0.2 mg/hour. The nurse reported that her nausea has improved after receiving ondansetron IV four hours ago. She was having increased pain despite using the PCA every 10 minutes. Her pain has decreased from 6/10 to 2/10 since the PCA bolus was increased from 0.1 mg to 0.2 mg of hydromorphone IV one hour ago.
Current VS:
T: 99.8 F/37.7 C (oral)
P: 78
R: 12
BP: 92/48
O2 sat: 89% room air 4 liters n/c
.
What data from the history is RELEVANT and has clinical significance to the nurse?
RELEVANT Data from History: Clinical Significance:
History of chronic low back pain COPD
2/10 pain that increases with movement Needs spinal infusion of L4-S1 today
Risk for respiratory obstruction during surgery and 02 insufficiency Due to lack of movement puts pt at risk for pressure sores.
Your shift continues…
Thirty minutes later she is feeling more nauseated, and you administer ondansetron 4 mg IV push prn. Five minutes later she puts the call light on again. You are not able to respond immediately because you are helping your other patient get on the commode. 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. When you arrive in her room you observe the following…
Patient Care Begins:
Current Assessment:
GENERAL APPEARANCE: Lethargic, unresponsive, ashen pale in color
RESP: Minimal spontaneous respiratory effort present. 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
CARDIAC: 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.
Calculate pulse rate: /minute
NEURO: Unresponsive, does not arouse or awaken to vigorous physical stimuli
GI: Not assessed
GU: Not assessed
SKIN: Not assessed
© 2016 Keith Rischer/www.KeithRN.com
What assessment data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data: Clinical Significance:
GENERAL
APPEARANCE: Lethargic, unresponsive, ashen pale in color
RESP: Minimal spontaneous respiratory effort present, her mouth is full of liquid emesis with chunks of undigested food that is drooling out the side of her mouth.
CARDIAC: 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 Ashen pale color shows the pt is experiencing a decrease of oxygen and blood flow.
Lack of respiratory effort from decreased oxygen which can be from emesis containing chunks of undigested food clogging her airway.
Her pulse rate is only 24 BPM which means she is bradycardic and in cardiac arrest.
Current VS: [Show Less]