SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE STUDY: STUDENT POST-OP PAIN MANAGEMENT, Exams of Health sciences

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SHEILA DALTON, 52 YEARS UNFOLDING REASONING CASE STUDY:

STUDENT POST-OP PAIN MANAGEMENT 1 & 2: CARDIAC ARREST-

EXPERT VERSION 2024-2025.

Post-op Pain Management: Day of Surgery

(1/2)

Sheila Dalton, 52 years old

Primary Concept

Pain

Interrelated Concepts (In order of emphasis)

1. Gas Exchange
2. Glucose Regulation
3. Perfusion
4. Inflammation
5. Clinical Judgment
6. Patient Education
7. Communication
8. Collaboration

© 2024 Keith Rischer/www.KeithRN.com

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 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 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 is RELEVANT and has 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.

• Pain level, even at a low level should continue to be

monitored post-op.

• Ms. Dalton should be monitored for mild signs and symptoms

of oversedation, which include 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 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

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?

(Which medication treats which condition? Draw lines to connect.)

PMH: Home Meds: Pharm. Classification: Expected Outcome:

• Low back pain with

lumbar compression

fracture

1. Citalopram 40 mg

daily

Antidepressant

Narcotic

Narcotic

Alleviate depression

symptoms

Alleviate pain

2. Oxycontin SR 40 mg bid
   3. Oxycodone 10 mg every

4 hours prn

4. Fluticasone/salmeterol

250/50 diskus 1 puff

every 12 hours

5. Sildenafil 20 mg tid

• Depression

• COPD

Bronchodilator

Vasodilator

Alleviate SOB

• Pulmonary hypertension
• 2 ppd smoker x 32 years

One disease process often influences the development of other illnesses. Based on your knowledge of

pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in her life?

- Circle what PMH problem likely started FIRST. - Underline what PMH problem(s) FOLLOWED as domino(s).

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) P rovoking/Palliative: Movement/lying still

P: 110 (regular) Q uality: Ache

R: 24

R egion/Radiation:

Lumbar-incisional

BP : 98/50 S everity: 6/10-gradually increasing

O2 sat: 88% 4 liters per n/c T iming: Continuous since arrival from PACU

What VS data is RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT VS Data: Clinical Significance:

Temperature of 100.

Pulse of 110 BPM

Respirations of 24 and

88% oxygen sat

on 4 L

98/50 Blood pressure

Pain 6/10 and continuous

at incision site, provoked

by movement.

• Temperature is elevated and could signify a possible infection.
• Ms. I would continue to monitor for a change in temperature. Elevated pulse

could signify pain/distress.

• 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.
• 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 is 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 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

Lab Results:

Complete Blood Count (CBC): Current: High/Low/WNL? Prior:

WBC (4.5–11.0 mm 3) 11.8 7.

Hgb (12–16 g/dL) 10.4 15.

Platelets (150–450 x10 3 /μl) 220 258

Neutrophil % (42–72) 85 68

Band forms (3–5%) 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:

WBC

Hgb

Neutrophil %

Band Forms

• A high white blood cell count could indicate

an infection.

• A low hemoglobin level indicates a significant loss

in red blood cells and blood volume.

• A high neutrophil % indicates a response to a

bacterial infection.

Worsening

Worsening

Worsening

Stable

• 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.

Basic Metabolic Panel (BMP): Current: High/Low/WNL? Prior:

Sodium (135–145 mEq/L) 134 136

Potassium (3.5–5.0 mEq/L) 3.8 3.

Glucose (70–110 mg/dL) 148 98

BUN (7–25 mg/dl) 20 22

Creatinine (0.6–1.2 mg/dL) 0.9 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)

Lab Planning–Creating a Plan of Care with a PRIORITY Lab:

Lab: Normal

Value:

Why Relevant? Nursing Assessments/Interventions Required:

Hemoglobin

Value:

12-

g/dl

Critica

l

Value:

20 g/dl

The patient’s hemoglobin

is below the normal

level; it is crucial that this

be monitored closely.

An intervention could be follow up lab draws or a blood

transfusion to raise her red blood cell count. I would also

continue to monitor Ms. Dalton’s vital signs for significant

changes.

Clinical Reasoning Begins…

1. What is the primary problem that your patient is most likely presenting with?

She is having Acute pain and low oxygen saturation

2. What is the underlying cause/pathophysiology of this primary problem?

The underlying cause of acute pain is Ms. Dalton’s posterior spinal fusion of L4-S1, some pain is expected during

recovery. 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.

Collaborative Care-Medical Management

Care Provider Orders: Rationale: Expected Outcome:

Hydromorphone PCA–

Settings:

*Bolus: 0.1–0.3 mg every 10”

*Continuous: 0.1–0.3 mg

*Max every 4 hours: 6 mg

Continuous pulse

oximetry

Ondansetron 4 mg IV push

every 4 hours prn nausea

Titrate O2 to keep sat >90%

Incentive spirometer (IS) 5–

10x every hour while awake

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.

• Will monitor patient oxygen saturation and

need for high levels of oxygen.

• Will keep the patient comfortable.
• Will keep patient oxygen saturation

at acceptable levels.

• Will expand patient’s lungs, decreasing

pain 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.

The patient oxygen saturation

will increase

The patient will have no pain

The patient nutritional balance

will be normal

The patient will lab values

will become normal

PRIORITY Setting: Which Orders Do You Implement First and Why?

Care Provider Orders: Order of Priority: Rationale:

1. Hydromorphone PCA
2. Continuous pulse oximetry
3. Ondansetron (Zofran) 4

mg IV push every 4

hours prn nausea

4. Titrate O2 to

keep sat >90%

5. Incentive spirometer (IS)
6. Apply lumbar orthotic

brace when up in chair

or ambulating

7. Clear liquids/advance diet

Continuous pulse oximetry,

Titrate O2 to keep sat

90%, Incentive spirometer,

Clear liquids, advance diet

as tolerated

ABC’s Airway, breathing, and circulation, as well as

nutrition and fluids

as tolerated

Medication Dosage Calculation:

Medication/Dose: Mechanism of Action: Volume/time frame to

Safely Administer:

Nursing Assessment/Considerations:

Ondansetron

4 mg IV push

(4mg/2 mL

vial)

It's a serotonin antagonist,

meaning its mechanism of

action is blocking the

serotonin receptors in the

CTZ. This reduces the

communication to the

vomiting center in the brain

and decreases nausea and

vomiting the patient

experiences.

IV Push:

Volume every

15 sec?

Assess dizziness and drowsiness that might

affect gait, balance, and other functional

activities. Report balance problems and

functional limitations to the physician and

nursing staff and caution the patient and

family/caregivers to guard against falls and

trauma.

Collaborative Care: Nursing

3. What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY)

Airway, breathing, and circulation. nutrition, fluids, and elimination. pain and comfort

4. What interventions will you initiate based on this priority?

Nursing Priority:

Impaired gas

exchange

Nursing Interventions: Rationale: Expected Outcome:

ABCs Incentive spirometer, oxygen therapy,

pulmonary hygiene, frequent vital sign

measurement

Assess respiratory rate, depth, and

effort, including the use of

accessory muscles, nasal flaring,

and abnormal breathing patterns.

These are the most important

priorities according to Maslow’s

hierarchy of needs and ultimately

affect patient welfare the most.

Rapid and shallow breathing patterns

and hypoventilation affect gas

exchange (Gosselink & Stam, 2005).

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.

Patient will require less

oxygen and increase lung

expansion as time

progresses post-op

5. What body system(s) will you most thoroughly assess based on the primary/priority concern?

Respiratory and fluids and nutrition

6. What is the worst possible/most likely complication to anticipate?

The patient becomes dehydrated and or stops breathing due to low O2 stats.

7. What nursing assessments will identify this complication EARLY if it develops?

The trend of values going down, skin turgor, and respiratory assessments

8. What nursing interventions will you initiate if this complication develops?

Call a code/ rapid response team and initiate airway

9. What psychosocial needs will this patient and/or family likely have that will need to be addressed?

Ms. Dalton’s priority psychosocial needs will likely be security needs, love and belonging needs, self-esteem needs,

and self-actualization needs. Since her family is not present or involved in her life, Ms. Dalton will rely on the

healthcare staff for these needs.

10. How can the nurse address these psychosocial needs?

Since Ms. Dalton does not have close family members nearby, she will rely on the nursing staff for many of her

psychosocial needs. I can address these by ensuring her safety and involvement in her care, initiating hourly

rounding and educating her about each step of her care, treating her with respect and dignity, and promoting her

independence.

Evaluation:

Evaluate your patient’s response to nursing and medical interventions during your shift. All physician orders have been

implemented that are listed under medical management.

One Hour Later…

You recognized the need to increase the hydromorphone PCA and have increased the bolus dose to 0.2 mg per physician

order shortly after Sheila arrived to the unit. 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. You had her sit up in the chair with the brace and instructed her in proper technique to use the incentive

spirometer (IS).

Current VS: Most Recent: Current PQRST:

T: 99.6 F/37.6 C (oral) T: 100.2 F/37.9 C (oral) P rovoking/Palliative: Movement/minimize movement

P: 82 ( regular) P: 110 ( regular) Q uality: Ache

R: 16 R: 24 R egion/Radiation: Incisional

BP: 110/62 BP: 98/50 S everity: 2/

O2 sat: 92% 2 liters

per n/c

O2 sat: 88% 4 liters per

n/c

T iming:

Continuous

Current

Assessment:

GENERAL

APPEARANCE:

Resting comfortably, appears in no acute distress, appears to be sleeping but arouses easily

when awakened

RESP: Breath sounds clear with equal aeration but remain diminished bilaterally, non-labored

respiratory effort, IS volume 750 mL initially–currently 1250 mL

CARDIAC: Pink, warm and dry, no edema, heart sounds regular with no abnormal beats, 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 audible per auscultation in all 4 quadrants

GU: Foley catheter, urine clear/yellow, 250 mL u/o the past 2 hours

SKIN: Skin integrity intact, no drainage present on dressing

1. What clinical data is RELEVANT that must be recognized as clinically significant?

RELEVANT VS Data: Clinical Significance:

T: 100.2 F/37.9 C (oral)

The vitals may be high because of the recent surgery. The patient does

not seem to be in distress. Blood pressures in little low can be

indicated of blood loss through surgery and oxygen level is low but is

receiving oxygen because of surgery. The patient needs pain

medication because of the pain level

P: 110 ( regular)

R: 24

BP: 98/

O2 sat: 88% 4 liters per

n/c

Pain 2/

RELEVANT Assessment Data: Clinical Significance:

Breath sounds clear with equal aeration

but remains diminished bilaterally,

non- labored

respiratory effort, IS volume 750 mL

initially–currently 1250 mL

the patient remains diminished bilaterally non-labored because of recent

surgery and because of a history of COPD.

2. 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.

3. 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. start

4. 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.

It is now the end of your shift. Effective and concise handoffs are essential to excellent care

and if not done well can adversely impact the care of this patient. You have done an excellent

job to this point, now finish strong and give the following SBAR report to the nurse who will

be caring for this patient:

S ituation:

Name/age: Sheila Dalton, 52 y/o

BRIEF summary of primary problem: 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 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.

Day of admission/post-op #:

B ackground:

RELEVANT past medical history: history of chronic low back pain and COPD.

T: 100.2 F/37.9 C (oral)

P: 110 ( regular)

A

R: 24

BP

ss

:

e

s

sm

/5 0

ent:

M

O

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r a

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c :

e 8

n 8

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vit

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s

it

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g

r

n

s

s:

per

n/c

RELEVANT body system nursing assessment data:

Resting comfortably, appears in no acute distress, appears to be sleeping but arouses easily when awakened.

Breath sounds clear with equal aeration but remains diminished bilaterally, non-

labored respiratory effort, IS volume 750 mL initially–currently 1250 mL

INTERPRETATION of current clinical

status (stable/unstable/worsening): Stable

R ecommendation:

Suggestions to advance plan of care: no current recommendations

Education Priorities/Discharge Planning

1. 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?

Medication teaching, pain management education, and possible referrals to a rehabilitation, TCU, or skilled nursing

facility to aid her with her ADLs.

Caring and the “Art” of Nursing

1. What is the patient likely experiencing/feeling right now in this situation?

Ms. Dalton is likely worried about what will happen after she discharges from the hospital and how difficult her

recovery will be. 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. She is also likely scared that she will continue to have pain despite the

surgery.

2. What can you do to engage yourself with this patient’s experience and show that she matters to you as a person?

I can take the time to empathize and listen to what Ms. Dalton has to say and present open-ended questions to allow

the patient to speak freely about her emotions and feelings. I can also use her preferences, beliefs, and past

experiences to create personal and individualized care. 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.

Use Reflection to THINK Like a Nurse

Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an

intervention in the moment as the events are unfolding to make a correct clinical judgment.

1. What did I learn from this scenario?

This scenario assisted me in learning how to organize and understand the full aspect of care for a post-operational

patient. 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. In this scenario, I was able to promote my own independence by applying

knowledge that I have learned about the nursing process, individualized patient care, pain-relief, and peri-operational

care. Overall, I felt that this scenario allowed for knowledge expansion and affirmation.

2. 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. This experience will help me in the future when

developing plans for patient care, especially in the post-operational setting. 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.

© 2016 Keith Rischer/www.KeithRN.com

Post-op Pain Management: Cardiac Arrest

(2/2)

Sheila Dalton, 52 years old

Primary Concept

Perfusion

Interrelated Concepts (In order of emphasis)

© 2016 Keith Rischer/www.KeithRN.com