Question

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 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? 

Answer 1

Question no 1 relevant data and it's clinical significance from history of present illness

relevant data from history of present illness

1) Had history of low back ache and COPD

It's clinical significance , - can have exacerbations of COPD

2 )underwent surgery today

Clinical significance- pain can occur

3) blood loss occured

Clinical significance- reduction in blood components has occured which might lead to perfusion insufficiently

Subpart of question no 1 )

Relevant data from social history

1)she is divorced and estranged from children

Clinical significance- she might not be able to look after by herself even after discarge ,so proper follow up should be made

Question no 2)relevant data from vital signs and it's clinical significance

Relevant data

1 ) Temperature -101.2

Clinical significance- there is a risk for infection present in the patient

2)spo2 is below 90 even after oxygen administration

Clinical significance- insufficiently of oxygen in body can develop

3) BP-98/50

Clinical significance-risk for hypotension seen , increase in fluid intake should be initiated.

4 ) 6/10 pain seen

Clinical significance- need for analgesic administration seen

Question no 3 ) relevant data from assesment and it's clinical significance

Relevant data

1)Appears uncomfortable

Clinical significance- position should be adjusted

2) appears tensed

Clinical significance- anxiety still present ,should be reassured

3 )grimacing seen

Clinical significance - pain not reduced

4) diminished breath sounds posteriorly

Clinical significance- might have secretion on posterior lobes

5)folleys catheter present

Clinical significance - should be checked for infection and fluid intake should be increased

Question no 4) relevant lab results and it's clinical significance

Relevant lab results

1)WBC  

Clinical significance- elevation in WBC might be due to infections process

Trends- worsening

2)hemoglobin

Clinical significance-reduced Hb can lead to anemia , change in diet should be initiated

Trends - worsening

3) neutrophils

Clinical significance- increased neurophils might be due to bacterial infection

Trends - worsening

4) band form

Clinical significance- high risk for infection due to reduced band form

Trends - stable

Question no 5)

Relevant lab data it's clinical significance and trends

Relevant data

1) sodium

Clinical significance- further reduction can lead to hypotension

Trends- worsening

2)glucose

Clinical significance- increase serum glucose level indicates diabetes

Trends - worsening

Question no 6) lab planing

Hemoglobin

Normal value- ( 12-16 mg/ dl)

Critical value - <6 mg / dl

Why relevant - It causes the body to make too many red blood cells, causing the blood to be thicker than usual. This can lead to clots, heart attacks, and strokes. It is a serious  lifelong condition that can be fatal if it is not treated.

Nursing interventions- having diet which helps to increase Hb , blood transfusion etc can be done .

Question no 6)

Pharmacology

1) Atenolol

Classification-Atenolol belongs to a betablockers

Mechanism of action - It works by blocking the action of hormones like epinephrine, on the heart and blood vessels. This lowers the heart rate, BP and. strain on the heart.

Nursing consideration- vitals should be checked

Heart rate should be monitored closely

2) lisinopril-

Classification- Lisinopril belongs to ACE inhibitor

Mechanism of action - it is an angiotensin converting enzyme inhibitor prevention the conversation of angiotensin 1 to 2 .it thereby reduces hypertension

Nursing consideration- check the vitals

Check the BP of the patient before administration

3 ) not visible

4) acetaminophen- Acetaminophen belongs to NSAIDS and antipyretic

Mechanism of action- The exact mechanism of action is not know ,but it  reduce the secretion of prostaglandins in the brain. Prostaglandins are chemicals that begins inflammation and helps to raise body temperature.

Nursing consideration- check the vitals

Check for any kidney injury before administration

5)Aspirin  

Classification-NSAIDS

MECHANISM OF ACTION-Aspirin causes so many effects in the body, like the reduction of inflammation, analgesia, the blocking of clotting, and the reduction of temperature. Much of this occurs due to decrease in the production of prostaglandins as well as TXA2.

Nursing consideration - check vitals of the patient

Check if she had any surgery recently

Question no 7)

Primary problem - COPD

Cause of COPD- smoking ,female gender