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Nursing Management
THE PATIENT IN SICKLE CELL CRISIS
ASSESSMENT
Health History:
Miss Olivia smith is a 22 year-old African American who was diagnosed with
sickle cell anemia 7 years ago she is small and appears younger than her stated
age she was admitted through the emergency department with chest pain and
dyspnea. She reports no sensory or motor impairments. She works as an assistant
in a daycare center for children. No unusual stressors are identified at this
time, but she does take a few beers if socializing on weekends miss smith lives
with her mother, who has accompanied her to the hospital.
Physical Examination:
vital signs: temperature, 99,4°
F orally; pulse, 110; respiration, 28; blood pressure, 136/92 patient is
dyspnea and anxious. Breath sounds are dimisnished on the left side. Oral
mucous membranes are dry and sticky. Arms and legs are disproportionately long
joints are enlarged.
GOALS AND
OUTCOME
NURSING
DIAGNOSIS - CRITERIA -
INTERVENTIONS
Acute
pain related to sickle cell crisis the patient, will state that she is
comfortable and will appear more relaxed give prescribed analgesics and assess
effects.
Anxiety
related to pain and hospitalization the patient will have less anxiety as
evidenced by calm demeanor and verbalizations. Be calm, offer reassurance, and
respond promptly to request. Encourage mother to stay with her until she is
more comfortable.
Impaired
gas exchange related to altered oxygen carrying capacity of blood cells,
possible pulmonary embolus the patient’s respiratory status will improve as
evidenced as evidenced by rate of 12-20, dyspnea, decreased restlessness.
Elevate head of bed. Administer oxygen as ordered. Allow rest until condition
improves. Monitor vital signs for increasing hypoxia: increased restlessness,
dyspnea confusion report signs and symptoms of worsening condition to
physician.
Fluid
volume deficit related to inadequate fluid intake or excess loss due to
activity in extreme heat the patient will maintain adequate hydration as
evidenced by good tissue turgor, moist mucous membranes, urine specific gravity
of 1.01-1.03 administer intravenous fluids as ordered monitor fluid intake and
output weigh daily.
High
risk for injury related to effects of anemia the patient will remain free of
injury during hospitalization when patient is able to resume activities, assist
with standing and walking in case the becomes dizzy have her move slowly from
lying to sitting to standing positions allow for rest between activities.
Provide extra blankets if chilly administer blood transfusions as prescribed.
Knowledge
deficit of disease process and self-care the patient will acknowledge aspects
of self-care, including measure to reduce the risk of complications. Assess
what patient knows, reinforce and provide additional verbal and written
information, include:
1.
Pathophysiology
2.
Common stressors that can
trigger crisis: infection dehydration hypoxia high altitudes strenuous
activity.
3.
Avoidance of smoking
because it constricts blood vessels
4.
Need to drink 4-6 liters of
nonalcoholic beverages daily to reduce risk of thrombosis
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