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Clinical Presentation: Pain Control Post Surgery

A 68-year-old woman was admitted to the clinical unit following a total abdominal hysterectomy for fibroids. The postanesthesia care unit (PACU) nurse reports to the unit admitting nurse that the patient had a prolonged stay in the PACU because her pain was difficult to control, and she required a total of 2 mg of intravenous (IV) hydromorphone titrated in 0.5-mg doses to achieve satisfactory relief of pain. IV patient-controlled analgesia (PCA) was initiated in the PACU with a prescription that allows the patient to self-administer a 0.2-mg hydromorphone bolus dose every 8 minutes as needed, with no basal rate (continuous infusion) of drug. The patient's husband and daughter are present in the room on admission.

The patient opens her eyes and acknowledges the nurse's request to assist with her transfer from the stretcher to the bed. During transfer to the bed, the patient moans and says that her abdomen hurts, and rates the pain intensity as an 8 on a scale of 0-10. Once settled in bed, she rates her pain as 7 and says that she is mildly nauseated then falls quickly back to sleep.

Admission Assessment

An abdominal dressing is dry and intact. A Foley catheter is draining clear, light yellow urine. An IV PCA is piggybacked into a maintenance IV that is infusing at 100 mL/hr. The PCA pump programming is verified to be correct. The PCA history reveals that the patient has pressed the PCA button 3 times since PCA was initiated, and the last time was 10 minutes ago.

The nurse who admits the patient to the clinical unit obtains the following information on initial assessment.

Vital signs. Findings include:

• Ear temperature: 98.1 °F.
• Pulse: 80 beats/minute.
• Respirations: 18 breaths/minute; room air; quiet, regular, shallow respirations; breath sounds equal and clear. Nail beds and general skin color are pink.
• Blood pressure: 112/72 mm Hg.
• General appearance: overweight with disproportionately large neck; recorded body mass index is 29 kg/m².

The husband and daughter both express concern about the degree of pain that the patient is experiencing and request that the nurse give her additional pain medication.