Question

Post-op Pain Management: Day of Surgery (1/2) History of Present Problem: Sheila Dalton is a 52-ver-old woman who has a history of chronic low back pain and COPD. She had a posterior spinal fusion of L4S1 today. She had an estimated blood loss (EBL) 675 ml during surgery and received 2500 mL of Lactated Ringers (LR) Paimis 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 sin post-anesthesia care unit (PACUP 88 R20 BP 122/76 requires 4 liters pernic to keep herO2 sat 90 percent. You are the usereceiving 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 sheis estranged Whar data from the histories are RELEVANTO e clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Signif RELEVANT Data from Social History: Clinic Developing Nurse 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 7/879 Coral) Provoking Palliative Movement lying shill P. 110 regalar) Quality Ache RO24 Region Radios Lombar indir 9 0 Severity: 6/10-gradually increasing 02 sat: 88% 4 litersparne Timing Continuous since arrival from PACU Whar vs data are RELEVANT and must be recepted as clinically significar by the n RELEVANT VS Data: Clinical significance e

Answer 1

Relevant data from the present problem:

1. Posterior spinal fusion surgery

2. History of COPD

3. Usage of patient controlled analgesia

Clinical Significance:

1. Patient movement post surgery is to be minimal. It will take 3 to 6 months to heal.

2. Patient is on Oxygen therapy and since patient has a past history of COPD, need to check the O2 saturation limit meticulously.

3. Since the patient is on PCA, education need to be given on the usage of the same. Overdose should be avoided and well explained to the patient.

Relevant data from social history:

1. Lives alone

Clinical significance:

1. Since the surgery is a major one it will take 3 to 6 months to cure. So she cannot drive by herself. Also should not involve in hard work. She need to take help from home care support. Also mental rehabilitation to be given if she needs it.

Relevant Vs data:

1. Hypotension

2. Tachycardia

3. Pain 6/ 10

Clinical significance:

1. The patient had excess blood loss leading to hypovolemic shock. CBC, blood electrolyte measurement can be ordered. BP need to be restored by IV fluids or medications. Blood transfusion can be given if necessary

2. PCA to be started more efficiently.

Relevant assessment data:

1. Grimace expression

2. Mild post operative urine retention

Clinical significance;

1. PCA to be efficiently used.

2. Urine output to be monitored.

Relevant Labs:

1. Reduced Hb levels

Clinical significance:

Patient may go to shock and she is anemic.