Student-Pain Management-1-2- Skinny Reasoning PDF

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ATI Learning Stacks, templates used for drug medication....

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Clinical Assignment Group Names: Amy Vang, Brittani Fierson, Miranda and Brady

SKINNY Reasoning

Part I: Recognizing RELEVANT Clinical Data 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 are RELEVANT and have clinical significance to the nurse? RELEVANT Data from Present Problem: History of low backache and copd Underwent surgery today Blood loss occured

RELEVANT Data from Social History: Pt is divorces and estranged from children

Clinical Significance: Can exacerbations of copd Pain can occur Reduction in blood components has occurred which might lead to perfusion insufficiently Clinical Significance: Pt might not be able to take care of herself even after discharged, so proper follow up should be made

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)

Provoking/Palliative:

Movement/lying still

P: 110 (regular)

Quality:

Ache

R: 24

Region/Radiation:

Lumbar-incisional

BP: 98/50

Severity:

6/10-gradually increasing

O2 sat: 88% 4 liters per n/c

Timing:

Continuous since arrival from PACU

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

Clinical Significance:

Clinical Assignment Group Names: Amy Vang, Brittani Fierson, Miranda and Brady

Temperature of 101.2 Spo2 is below 90 even after oxygen administration BP 98/50 6/10 Pain seen

There is a risk for infection Insufficiently of oxygen in body can develop Risk for hypotension seen, increase in develop Need for analgesia administration seen

© 2018 Keith Rischer/www.KeithRN.com

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 are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Appears uncomfortable Appears tense Grimacing seen Diminished breath sounds posteriorly Foley catheter present

Clinical Significance: Position should be adjusted Anxiety still present, should be reassured Pain not reduced Might have secretion on posterior lobes Should be checked for infection and fluid intake should be increased

Diagnostic Results: Basic Metabolic Panel (BMP) Na

K

Gluc.

Creat.

Clinical Assignment Group Names: Amy Vang, Brittani Fierson, Miranda and Brady

Current: Most Recent:

134

3.8

148

0.9

136

3.9

98

1.1

Complete Blood Count (CBC)

Current: Most Recent:

WBC

HGB

PLTs

% Neuts

11.8

10.4

220

85

7.2

14.2

258

68

What data must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Diagnostic Data:

WBC Hemoglobin Neutrophils Band form

Clinical Significance:

Elevation in WBC might be due to infections process Reduced Hb can lead to anemia, change in diet should be initiated Increased neutrophils might be due to bacterial infection High risk for infection due to reduced band form

TREND: Improve/Worsening/Stable: Worsening Worsening Worsening Stable

© 2018 Keith Rischer/www.KeithRN.com

Part II: Put it All Together to THINK Like a Nurse! 1. After interpreting relevant clinical data, what is the primary problem? (Management of Care/Physiologic Adaptation)

Problem: DKA

Pathophysiology in OWN Words: Study of the physiology of disease

Collaborative Care: Medical Management 2. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies)

Clinical Assignment Group Names: Amy Vang, Brittani Fierson, Miranda and Brady

Medical Management: 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%

Rationale:

Expected Outcome:

addressing O2 sat is extremely important, as the body tissue and organs need oxygen to work well. Low oxygen can be harmful to busy organs like the brain.

Help to treat their pain by self-administering a dose of analgesics. helps client maintain a more constant level of relief requiring less medication for pain. effective on acute pain related to surgery

monitoring oxygen levels give the nurse information about how well oxygen is being sent to parts of the body

monitor the patient oxygen saturation value of all hemoglobin binding sites, allowing the nurse to know how well oxygen is being sent to parts of the body, such as body tissue and organs.

will control the client's pain and keep it at a low level.

it will expand collapse alveoli so client can take in more oxygen

Incentive spirometer (IS) 5–10x every hour while awake

will help with nausea

0.9% NS 100 mL/hour IV

ambulating as soon as possible will prevent respiratory, circulatory, urinary, and GI complications. it also prevents muscle weakness

Clear liquids/advance diet as tolerated

will alleviate symptoms of nausea and vomiting caused by surgery anesthesia. help to increase the amount of oxygen in the lungs due to COPD and blood loss.This will increase the amount that makes it into the blood. this will help to expand collapsed alveoli

this will be done when the client can tolerate foods and fluids.

Apply lumbar orthotic brace when up in chair or ambulating

This will help the client replace fluid and electrolytes lost either before or during surgery. This will help the nurse see if the client can tolerate clear liquids with no nausea, then the diet can progress to full liquids and then regular diet. this will let the nurse to know that gastrointestinal functioning is normal.

a lumbar orthotic brace will provide support to the spine when ambulating or up in chair.

© 2018 Keith Rischer/www.KeithRN.com

Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY: PRIORITY Nursing Interventions:

Clear airways by excreting mucus Rationale:

Expected Outcome:

Clinical Assignment Group Names: Amy Vang, Brittani Fierson, Miranda and Brady Administer pain medication as needed

Giving pain medication will lower pain level

Pt should no longer feel as much pain

dx acute pain dx risk for loneliness

4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity/Basic Care and Comfort)

Psychosocial PRIORITIES: PRIORITY Nursing Interventions: CARING/COMFORT: How can you engage and show that this pt. matters to you?

Rationale: Let the patient know you are here to listen and to help whatever concerns they need.

Expected Outcome: Will make the patient more comfortable with their feelings.

Physical comfort measures:

EMOTIONAL SUPPORT: Principles to develop a therapeutic relationship

Provide information about agencies that can help with home care

Encourage the patient to recognize available support And encourage the patient to reach out to a friend.

SPIRITUAL CARE/SUPPORT:

Educate the patient the use of spiritual resources as desired

religious practices may provide strength and inspiration

5. What educational/discharge priorities need to be addressed to promote health and wellness for this patient and/or family? (Health Promotion and Maintenance) Provide information about agencies that can help with home care and encourage patients to reach out to a friend. Encourage the patient to recognize available support. Educate the patient the use of spiritual resources as desired, religious practices may provide strength and inspiration. Also provide a care plan for the patient, follow up on the patient.

Clinical Assignment Group Names: Amy Vang, Brittani Fierson, Miranda and Brady

© 2018 Keith Rischer/www.KeithRN.com...