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Done by: nursing institutes fourms
Evaluated by: prince of nursing
Patient’s Demographic data:
Name of patient: xxxx
Age: 23 years
Address: xxxx
Religion: Muslim
Marital status: Single
Level of education: class 11
Occupation: Doesn’t work
Nationality: xxxxx
Data of hospitalization: xx-xx-xxxx
Duration of hospitalization: 2 days
Health History
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The patient came to the hospital because
she complaints of severe joint pain’ pain in
the arms, back and complete fatigue.
Vital signs:
BP:120/70mmHg
Temperature:37C
RR:20 per min
P:80 bate/ min
Medical Data:
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Diagnosis
SCD with VOC with pain upper limb and
lower limb.
Past medical History
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The patient doesn’t have any significant
illness but she has known case of SCD since
she was child.
Definition of the disease:
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Sickle cell anaemia is the most severe from of
sickle cell disease. It is severe haemolytic
anaemia that results from inheritance of the
sickle haemoglobin gene. When the oxygen level
in venous blood is low it to causes change in
RBC containing haemoglobin HBS. Loses its
round, biconcave disk shape, deformed and
sickle shaped. The abnormal HGB turns RBCs
in to sickle shaped. This decrease the oxygen
carrying capacity of the RBC. If deformed RBC
obstructs blood flow to tissue, ischemia or
infarction results. Sickling crises are intermittent
because RBC can revert to normal shape if it
takes adequate oxygen.
Etiology Of Sickle-cell Disease
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According to books:
1.
Genetic factor.
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Increase destruction of RBC.
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Nutritional deficiency.
Infection.
Cardiac dysfunction.
Impaired production of RBC.
Undergoing anesthesia with out
proper oxygenation.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Climbing to high altitude.
Excessive exercising
Pulmonary dysfunction.
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In the patient:
Genetic factors
Nutrional deficiency
Clinical Manifestations
According to books:
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Jaundice , pale.
Dysrhythmias and heart
failure.
Sudden change in temperature.
There is sever pain in various
part of the body.
Loss of appetite.
Weakness.
Fever.
Clinical Manifestation
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According to books:
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.Ischemic necrosis or hypoxic
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damage.
Bone pain: painful and
swollen large joints.
Cardiomegaly
Splenomegaly.
Decreased splenic function
Clinical manifestation:
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In the patient
Pale
Decrease in hgb 9 QIDC
Loss of appetite
Weakness
Sudden change in temperature .Increase when she has pain
37.5C.
Severe pain in various part of body. L and R lower and
upper limbs. Pain score 8.
PATHOPHYSIOLOGY
Abnormal hemoglobin turns in to sickle shaped
↓
Decrease oxygen carrying capacity of the RBCs
↓
The deformed RBCs obstruct blood flow to tissue
↓
Vaso occlusive crisis
↓
Hypoxia
↓
Joint pain and organ infraction
Blood investigation:
Name
WBC
NEU
LYF
MONO
ESO
BASO
RBC
HGB
Result
11.9 k/ul
4.3 k/ul
5.89 k/ul
1.02 k/ul
3.98 k/ul
0.247 k/ul
3.44 k/ul
9.13 QIDC
Normal
4.0 – 11.0
2.0- 7.5
1.5- 4.5
0.2- 0.8
0.0- 0.4
0.0- 0.2
3.8- 5.8
12.0- 15.0
Result
normal
normal
high
normal
high
normal
normal
low
Pharmacology:
Name of drug
Classification
Route
Dose
Frequency
Tramadol
Tramal
Centrally
acting
analgesic
Oral
500mg/cap
OD
Mefenamic
Non steroidal Oral
Acid.Ponstan anti
inflammatory
drugs
Folic acid
Folic acid
Vitamin
supplement
Oral
Paracetamol
Antipyretic
Analgesic
Oral
Dextrose
Isotonic
solution
IM/IV
injection
500mg/tab OD
5mg/tab
OD
1000mg/tab OD
50mg
OD
Non pharmacologic:
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Massage
Heat application
Tramadol:
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Action:
Bind to mu- opioid receptors and inhibits
the reuptake of norepinphrine and serotonin
causes many effects similar to the opioids,
dizziness, somuolence, nausea,
constipation but does not have the
respiratory depressant effects.
Tramadol:
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Possible side effects:
CNS: Headache, fatigue.
CV: Tachycardia, angina pectoris.
CHF: hypotintion in salt or volume depleted pt.
Dermatologic: rash
GI: glupset, dirrhea.
GU: renal insufficiency, renal failure, polyuria,
oliguria.
Others: cough, dizziness, malaise and dry mouth.
Tramadol
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Nurse’s Responsibilities:
Administer once a day at same time each
day.
Mefenamic Acid [ponstan ]:
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Action:
Anti inflammatory, analgesic and
antipyretic activities related to inhibition of
prostaglandin synthesis exact mechanisms
of action are not know.
Possible side effects:
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CNS: headache, dizziness, insomnia, fatigue, tiredness
and ophthalmic effect.
Dermatologic: rash, sweating, dry mucous membrane and
stomatitis.
GI: nausea, dyspepsia, GI pain, dirrhea, vomiting and
constipation.
GU: dysuria and renal impairment.
Hematologic: bleeding, platelets inhebition with higher
doses and neutropenia.
Respiratory: dyspnea, hemoptysis, rhinitis.
Perepheral edema: anaphylactic shock..
Nurse’s responsibilities:
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Give with milk or food to decrease GI
upset.
Arrange for periodic ophthalmologic
examinations during long term therapy.
Folic Acid:
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Action:
Required for nucleoprotein synthesis and
maintenance of normal erythropoiesis.
Possible side effects:
Hypersensitivity.
Local pain and discomfort at injection site.
Nurse’s Responsibility:
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Administer orally if it all possible with severe GI
malabsorpation or very severe disease give IM,
IV or subcutaneously.
Test using schilling test and serum vitamin B12
levels to rule out pernicious anemia apy may
mask signs of pernicious anemia while the
neurologic deterioration continues.
Paracetamol:
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Action:
Inhibits the synthesis of prostaglandins in
the CNS and peripherally blocks pain
impulse generation.
Artipyresis from inhibition of
hypothalamus heat regulating centre.
Possible Side Effects:
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Endocrine and metabolic:
May increase chloride, uric acid and
glucose.
Hematologic:Anemia, blood dyscrasia.
Hepatic: may increase bilirubin.
Renal: nephrotoxiaty with over dosage.
NURSING CARE PLAN
Diagnosis:Pain related to tissue hypoxia due to
agglutination of sickled cell within the small blood vessels as
manifested by pt said ‘’I have sever arms and back pain’’. Pt
looks tired.
 Goals:To relieve pain or decrease in intensity of pain.
Nursing
Intervention
Rational
Use pts subjective
Provides baseline for
description of pain and
assessing change in the
pain rating on a pain scale pain level and evaluating
to guide the use of
interventions.
analgesic agents.
Sever:8
Intervention
Rational
Use of these strategies along
Teach pt relaxation
with analgesia produce more
techniques, breathing
exercises and distraction effective pain relief.
Heat increase blood flow to an
to rease pain.
affected area and it provide
Apply warm compresses some analgesia and more
to affected area.
comfort.
Encourage pt to reduce Hard activity can aggravate
the sickling process.
hard activity.
Cold can aggravate the
Instruct pt to avoid
sickling process because
cold environment.
vasoconstriction slows the blood
flow.This aggravate pain.
Intervention
Distraction
which
involves focusing the pt
attention on something
other the pain.
Rational
To
reduce the perception of pain
by stimulating control
system,resulting in fewer painful
stimuli being transmitted to the
pain.
Analgesics are more effective if
Administer balanced
analgesics as prescribed to administered early in pain cycle.
use of analgesics will provide
promote optimal pain
greater pain relief with fewer side
relief
effects.
Intervention
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Instruct pt and
family about
potential side
effect of analgesics,
their prevention
and management.
Rational
Anticipating
and preventing
side effects enable the pt to
continue analgesia without
interruption because of side
effects.
Intervention
Rational
Start IV fluid therapy
To dilute blood and
as prescribed (Dextrose).
reduce the pain.
Evaluation:
Report that pain is relieved promptly and
lower discomfort.
Identifies effective pain relief strategies.
Use pain medication as prescribed .
Experiences minimal side effects of
analgesia.
Nursing Diagnosis: Altered nutrition less than body
requirement related to loss of appetite, nausea and vomiting
Goals: improve nutritional statues
Intervention
Rational
Assess dietary intake and
Identifies nutritional
nutritional status through diet intake and adequacy of
history,wieght measurement
nutritional state.
and labortary data.
Provides calories for
Provide diet high in
energy.
carbohydrates.
Intervention
Encourage pt to provide oral
hygiene before meals and
provide pleasant environment
for meals at meals time.
Provide attractive meals and
an aesthetically pleasing
setting at meal time.
Rational
Promotes positive
environment and increased
appetite, reduces unpleasant
taste.
Promotes appetite and sense
of well-being.
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EVALUATION
Exhibits improve nutritional status by
increasing weight and improve laboratory
data.
States rationale for dietary modification
Identifies foods high in carbohydrates.
Report improved appetite.
Nursing Diagnosis:
Activity intolerance related to illness as manifested by
pain, loss appetite and patient looks pale.
GOAL:
Encourage power.
Nursing Intervention
Increase
Rationale
pt’s ability to
To make the pt
use normal coping
cooperative with her
resources of physical
treatment.
strength, psychological
stamina and positive self
esteem.
To forget the illness.
Encourage the pt to read
different books.
Out come Criteria:
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Expresses improved sense of control.
Participates in goal setting and in planning
and implementing daily activity.
Participates indecisions about care.
Nursing Diagnosis:
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Knowledge deficient regarding sickle crisis
prevention related to lack of exposure/ recall,
information misinterprtation and unfamiliarity
with resources as manifested by in adequate
nutrition in take and regular admition in the
hospital.
Goal:
Verbalizes understanding of disease process and
therapeutic needs, initiates behaviours/ lifestyle
changes.
Nursing Intervention
Rationale
Review
Provides
disease process
and treatment needs.
Assess pt knowledge of
precipitating factors, e.g.:
Cold environmental
temperatures, failure to
dress warmly when
engaging in winter
activities: wearing tight,
restrictive clothing:
stressful situation.
knowledge base
on which pt can make
informed choices.
Causes peripheral
vasoconstriction, which
may result in sludinr of the
circulation, increased
sickling, and
mayprecipitate avasoocclusive crisis.
Nursing Intervention
Rational
Encourage
Prevents
ROM exercise and
regular physical activity with a
balance between rest and activity
Review pt’s current diet,
reinforcing the importance of
diet including liver, green leafy
vegetables, citrus fruits, and
wheat germ. Provide necessary
instruction regarding
supplementary vitamins like
folic acid.
bone
demineralization and may
reduce risk of fractures. Aids in
maintaining level of resistance
and decreases oxygen needs.
To increased demands placed
on bone marrow and folic acid
supplements are frequently
ordered to prevent plastic
crisis.
Out come Criteria:
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Increases knowledge about disease process.
Identifies situations and factors that can
precipitate sickle cell crisis.
Describes the importance of warmth,
adequate hydration, and prevention of
infection in preventing crisis.
Discharge Plan:
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xxxx 23years old. She is from Nizwa. She
came to NH because she complaints from
arms and back pain. She was very tired,
weakness, looks pale, fever. Her
temperature 37.5C. BP 120/80mmHg. P
70bate/min. RR 20per/ min.
Health Education:
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Exercise regularly but not so much that became really
tired.
When do exercise, drink a lots of water.
Drink at least 8 glasses of water a day, specially during
warm weather.
Avoid stress .
Treat any infection as soon as it occurs.
Wear warm clothes out side in cold weather. And don’t
swim in cold water.
Tell the doctor if might has as sleep problem like snoring
or some time during sleep- apnea.
If has any another medical condition like diabetes get
treatment and control the condition.
Take food that including liver, green leafy vegetables,
citrus fruits and wheat germ and regarding supplementary
vitamins such as folic acid.