Running head: PAIN CASE STUDY
1
Pain Case Study
Mina Rose Hassanshahi
Carrington College
Medical Surgical Nursing N243
Professor Nancy Smith
October 21, 2021
, PAIN CASE STUDY
2
Step #1: THINK Like a Nurse by Recognizing
RELEVANCE and
PRIORITIES
Four Principles of Clinical Reasoning:
1. Identify and interpret RELEVANT clinical data.
2. TREND relevant clinical data to determine current status (stable vs. unstable).
3. Grasp the “essence” of the current clinical situation.
4. Determine nursing PRIORITY and plan of care.
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.
RELEVANT Data from Present Problem: Clinical Significance:
Chronic low back pain Ms. Dalton’s history of chronic low back pain along with her surgery
would require repositioning post operation. This will promote patien
Posterior spinal fusion of L4-S1 safety and avoid potential nosocomial infections from bedsores.
EBL 675mL Due to EBL of 675mL, pt received 2500 mL Lactated Ringers to
maintain fluids. According to the text (Lewis, 2017), it is critical to
monitor a patient for “anemia resulting from acute blood loss most
0.2mg/hr hydrophorphone PCA and 0.1 mg likely includes administration of blood products” for the
postoperative patient. Additionally, the text states that “In the clinica
of IV bolus unit, postoperative fluid and electrolyte imbalances are contributing
factors to heart problems…fluid status directly affects cardiac
output” and that “Fluid retention during postoperative days 1 to 3
can result from the stress response, which maintains both blood
2500mL of Lactated Ringers volume and BP.” Chapter 30 describes manifestations of acute blood
loss of 500mL-1000mL (~20% volume loss), can result in
tachycardia with exercise and slight postural hypotension.
Pain 2/10 increased with movement
Hydromorphone (Dilaudid) is a schedule II controlled substance
© 2016 Keith Rischer/www.KeithRN.com
1
Pain Case Study
Mina Rose Hassanshahi
Carrington College
Medical Surgical Nursing N243
Professor Nancy Smith
October 21, 2021
, PAIN CASE STUDY
2
Step #1: THINK Like a Nurse by Recognizing
RELEVANCE and
PRIORITIES
Four Principles of Clinical Reasoning:
1. Identify and interpret RELEVANT clinical data.
2. TREND relevant clinical data to determine current status (stable vs. unstable).
3. Grasp the “essence” of the current clinical situation.
4. Determine nursing PRIORITY and plan of care.
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.
RELEVANT Data from Present Problem: Clinical Significance:
Chronic low back pain Ms. Dalton’s history of chronic low back pain along with her surgery
would require repositioning post operation. This will promote patien
Posterior spinal fusion of L4-S1 safety and avoid potential nosocomial infections from bedsores.
EBL 675mL Due to EBL of 675mL, pt received 2500 mL Lactated Ringers to
maintain fluids. According to the text (Lewis, 2017), it is critical to
monitor a patient for “anemia resulting from acute blood loss most
0.2mg/hr hydrophorphone PCA and 0.1 mg likely includes administration of blood products” for the
postoperative patient. Additionally, the text states that “In the clinica
of IV bolus unit, postoperative fluid and electrolyte imbalances are contributing
factors to heart problems…fluid status directly affects cardiac
output” and that “Fluid retention during postoperative days 1 to 3
can result from the stress response, which maintains both blood
2500mL of Lactated Ringers volume and BP.” Chapter 30 describes manifestations of acute blood
loss of 500mL-1000mL (~20% volume loss), can result in
tachycardia with exercise and slight postural hypotension.
Pain 2/10 increased with movement
Hydromorphone (Dilaudid) is a schedule II controlled substance
© 2016 Keith Rischer/www.KeithRN.com
