Post Op Pain Management Case Study - Answer key/guide SKINNY reasoning PDF

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Answer key/guide for Post Op Pain Management Case Study for Sheila Dalton with COPD...

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Post-op Pain Management Case Study: Day of Surgery 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? RELEVANT Data from Present Problem: 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

Clinical Significance: 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.

RELEVANT Data from Social History: She lives alone and has no nearby relatives

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. Clinical Significance: 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: T: 100.2 F/ 37.9 C (oral) P: 110 (regular) R: 24 BP: 98/50 O2 sat: 88% 4 liters per n/c

P-Q-R-S-T- Pain Assessment (5th VS): Provoking/Palliative: Movement/lying still Quality: Ache Region/Radiation: Lumbar-incisional Severity: 6/10 – gradually increasing Timing: Continuous since arrival from PACU

What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Temperature of 100.2

Pulse of 110 BPM Respirations of 24 and 88% oxygen sat on 4 L

Clinical Significance: 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.

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. 98/50 Blood pressure This is significantly lower than her baseline; could be indicative of oversedation or due to blood loss. Pain 6/10 and continuous at incision site, provoked by movement.

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: RESP:

CARDIAC:

NEURO: GI: GU: SKIN:

Appears uncomfortable, body tense, frequent grimacing – last used PCA 10 minutes ago Breath sounds clear with equal aeration ant/post but diminished bilaterally, non-labored respiratory effort, occasional moist-nonproductive cough Pale-pink, warm and dry, no edema, heart sounds regular – S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks Alert and oriented to person, place, time, and situation (x4) Abdomen soft/non-tender, bowel sounds hypoactive and audible per auscultation in all 4 quadrants, c/o nausea Foley catheter secured, urine clear/yellow, 100 ml the past two hours 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: Patient is uncomfortable, tense, and clearly in pain despite use of PCA

Clinical Significance: 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.

Diminished bilateral lung sounds and occasional moist non-productive cough

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

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.

Complaints of nausea

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): WBC (4.5-11.0 mm3 ) Hgb (12-16 g/dl) Platelets (150-450x103 µl) Neutrophil% (42-72) Band forms (3-5%)

Current:

High/Low/WNL?

Prior:

11.8 10.4 220

High Low WNL

7.2 15.2 258

85 1

High Low

68 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: Worsening

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.

Hgb

A low hemoglobin level Worsening indicates a significant loss in red blood cells and blood volume. I would notify the provider and possibly give the patient a blood transfusion.

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 Current: High/Low/WNL? Prior: Panel (BMP): Sodium (135-145 134 Low 136 mEq/L) Potassium (3.5-5.0 3.8 WNL 3.9 mEq/L) Glucose (70-110 148 High 98 mg/dl) BUN (7-25 mg/dl) 20 WNL 22 Creatinine (0.6-1.2 0.9 WNL 1.1 mg/dl) What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab(s):

Clinical Significance:

Sodium

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.

TREND: Improve/Worsening/Stable: Worsening

Glucose

Ms. Dalton’s blood glucose is Worsening (This should be elevated. This could be due to monitored closely in order to pain and emotional stress. An create an observable trend elevated blood sugar could and monitor significance) delay healing and increase the chances for surgical-site infection. Lab Planning – Creating a Plan of Care with a PRIORITY Lab: Lab:

Normal Value:

Why Relevant?

Hemoglobin

12-16 g/dl

Value: 10.4

Critical Value: 20 g/dl

The patient’s hemoglobin is below the normal level; it is crucial that this be monitored closely.

Nursing Assessments/Interventions Required: 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.

Pharmacology: Home Med:

Classification:

Atenolol

Beta Blocker (Antidysrhythmic)

Mechanism of Action (in own words): Atenolol lowers the response rate of nerve impulses to the heart, thereby slowing down the heart rate and lowering the blood pressure. Blood and oxygen volume travelling to the heart are increased.

Nursing Considerations: Lowers blood pressure and heart rate.

Lisinopril

Angiotensin Converting Enzyme Inhibitor

Citalopram

Selective Serotonin Reuptake Inhibitor

Hydrocodone/ acetaminophen

Narcotic Analgesic

Aspirin

Salicylate

Lisinopril blocks the mechanisms that cause blood vessels to tighten, thereby relaxing the blood vessels. This, in turn, increases blood and oxygen supply to the heart and lowers blood pressure. Citalopram increases the levels of the hormone, serotonin, in the brain by inhibiting the reuptake of it in the nerves. The brain can transmit messages more efficiently with more available serotonin. Hydrocodone/acetami nophen binds to opioid receptors, decreasing pain sensation, and inhibits COX enzymes, reducing the compounds that promote inflammation, pain, and fever. Aspirin affects the clotting cascade by inhibiting clot promoting compounds and promoting clot inhibiting compounds.

Lowers blood pressure.

Anti-depressant, anti-anxiety

Pain, inflammation, fever relief

Anticoagulant

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

Developing Nursing Thinking by Identifying Clinical RELATIONSHIPS 1. What is the RELATIONSHIP of the past medical history and current medications? (Which medication treats which condition? Draw lines to connect) Past Medical History (PHM): ● Low back pain with lumbar compression fracture ● Depression ● COPD ● Hypertension ● 2 ppd smoker x 32 years

Home Meds: Acetaminophen/hydrocodone 1-2 tabs every 4 hours prn pain Citalopram 40 mg daily Atenolol 50 mg daily Lisinopril 40 mg daily Aspirin 81 mg daily

2. Is there a RELATIONSHIP between any disease in PMH that may have contributed to the development of the current problem?  (Which disease likely developed FIRST and then began a “domino effect?”) PMH: ● Low back pain with lumbar compression fracture ● Depression ● COPD ● Hypertension ● 2 ppd smoker x 32 years

What Came FIRST: 2 ppd smoker x 32 years What then Followed: COPD, hypertension, and depression

3. What is the RELATIONSHIP between the primary care provider’s orders and primary problem? Care Provider Orders:

How it Will Resolve Primary Problem/Nursing Priority:

Hydromorphone PCA – Settings: *Bolus: 0.1-0.3 mg every 10 min *Continuous: 0.1-0.3 mg *Max every 4 hours: 6 mg

Will decrease pain level/keep pain under control.

Continuous pulse oximetry

Will monitor patient oxygen saturation and need for high levels of oxygen.

Ondansetron 4 mg IV push every 4 hours prn nausea

Will keep patient comfortable.

Titrate O2 to keep sat >90%

Will keep patient oxygen saturation at acceptable levels.

Incentive spirometer (IS) 5-10x every hours while awake

Will expand patient’s lungs, decreasing pain level and need for high levels of oxygen

0.9% NS 100 ml/hour IV

Will keep patient hydrated and balance electrolytes

Clear liquids/advance diet as tolerated

Apply lumbar orthotic brace when up in chair or ambulating

Will keep patient from being nauseated by advancing too quickly after surgery and increase fluid intake Will decrease patient pain level and increase mobility

Basic metabolic panel (BMP) in morning

Will allow for a trend and continued monitoring of patient’s laboratory values

Complete blood count (CBC) in morning

Will allow for a trend and continued monitoring of patient’s abnormal CBC levels.

Developing Nursing Thinking by Identifying Clinical PRIORITIES 1. Which orders do you implement first and why? Care Provider Orders: 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%

Order of Priority: 1. Continuous pulse oximetry, Titrate O2 to keep sat >90%, Incentive spirometer, Clear liquids, advance diet as tolerated

Rationale: According to Maslow’s hierarchy of needs, physical and biological needs are most important. Airway, breathing, and circulation, as well as nutrition and fluids would fit into this

5. Incentive spirometer (IS) 6. Apply lumbar orthotic brace when up in chair or ambulating 7. Clear liquids/advance diet as tolerated

2. Hydromorphone PCA, Zofran 4 mg IV push every 4 hours PRN, Apply lumbar orthotic brace when up in chair or ambulating

category and would therefore be a top priority. Next important are safety and psychological needs. This would include pain, comfort, and nausea control. Although important, these needs are not as important as physical and biological needs.

2. What nursing priority(ies) will guide your plan of care? (If more than one – list in order of PRIORITY) i. Airway, breathing, and circulation ii. nutrition, fluids, and elimination iii. pain and comfort 3. What interventions will you initiate based on this priority? Nursing Priority:

Nursing Interventions: Incentive spirometer, oxygen therapy, pulmonary hygiene, frequent vital sign measurement

Rationale:

Expected Outcome:

These are the most important priorities according to Maslow’s hierarchy of needs and ultimately affect patient welfare the most.

Patient will require less oxygen and increase lung expansion as time progresses post-op

Nutrition, fluids, elimination

Encourage fluid intake, encourage activity, IV fluid therapy, toileting schedule, bladder scanning, advance diet as tolerated

According to Maslow’s hierarchy of needs, these are second priority but still require adequate attention.

Pain and comfort

Patient’s pain level and vital signs will continue to be monitored. Increase activity level and

According to Maslow’s hierarchy of needs, these are next in priority and

Patient will eliminate within one shift post op and output >30 mL of fluid. Patient will maintain balanced fluid/electrolyte status. Patient will advance to solid diet. Patient’s will be up and walking within the first shift after surgery. Patient’s pain will be under

ABCs

reposition at minimum every two hours. Administer pain medication or Zofran as needed for comfort.

require attention for control, and patient patient welfare. will be comfortable as much as able.

4. What are the PRIORITY psychosocial needs that 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. 5. 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. 6. What educational/discharge PRIORITIES will be needed to develop a teaching plan for this patient and/or family? Medication teaching, pain management education, and possible referrals to a rehabilitation, TCU, or skilled nursing facility to aid her with her ADLs. Caring & 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 I do to engage myself with this patient’s experience, and show that he/she matters to me as a person? I can take the time to empathize and listen to what Ms. Dalton has to say and present open-ended questions in order to allow the patient to speak freely about her emotions and feelings. I can also use her preferences, beliefs, and past experiences to create a 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 and transfer what is learned to improve nursing thinking and patient care in the future. 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 int...