Transcript Health history

Done by: nursing institutes fourms
Evaluated by: prince of nursing
Health history
Present history:
She has sever pain in her left leg. A nurse
give her sedative, so she sleeps all the times.
She looked pallor and borning. Temp:37.
pulse:88bits\min.Bp:120\80mmhg.
Rr:20min
Past history: she has not any medical
history.
Definition
All sickle cell disorder due to inherited •
of agene for a structurally abnormal of
the Hgb chain. The beta globin sublint
of the adult Hgb chain is structurally
abnormal and is called (Hbs). People
with homezygous Hbs have sickle cell
disease of varying severity.
Pathophysiology
When celluar oxygen tension •
decreases, RbC distor itself into sickle
shape. Sickled cells increase viscosity
of the blood, slowing circulation and
causing increased celluar hypoxia and
plugging of the circulation to the organs
infracts cao occur in central nervous
system eyes, lungs, liver, spllen, kidney,
joints and bone.
Etiology:
According to books •
Having parents
hetrezygous for Hbs
Being black and African
ancestry.
Cell sickling evolved
because it confers
abiologic advantage
malatial infection.
In patien •
Her parents carried •
gentic trait
Clinical manifistations:
Accordinng to books: •
1-growth and development are delyed.
2- the person susceptible to infections.
3-pain crises
4-aplastice crises
5-sequestration crisis
6- acute chest syndrom
Investigations condurted:
CBC:all normal except
*Hgb:8.58g\Dl (Normal 12-15) decrease
*Hct:26,6% (normal 36-46) ) decrease
*Mcv:57.3fl (normal 74-95) decrease
*Mch: 18.3 (normal 26-32) decrease
Reticoulocyte count: 4.6%
(Normal 0.2-2) increase
Treatment :
Pharmacological: Folic acid(folic acid) –
Mefenamic acid (NSAIDs)Parcetamol(analesic) –
Tramadol(centrally action analgesic)Diclofenac(antinflammatory agert) Morphine Sulphat(nacrotic agonist
analegescis)
Nonpharmacological
Physiacl and occupational
therapy,physiotherapy inculd (the use
of heat,massage and
exercise),behavioral
intervention(inculding distraction and
relaxtion)and support group .
Nursing care plan:
Nursing diagnosis: pain related to •
intravascular sickling with localized
stasis and occlusion . Mainfasted by:
Subjective data: patient said ((I have •
pain in my left leg ))
Objective data:lookes tired-facial •
experessions.
.Goals: to relief\control of pain •
Nursing order:
*Assess repots of pain inculding
location,duration and intensity(scaleof 0-10).
Rational: provide for assessing changes in pain
level
*Apply local massage gently to affected areas.
Rational: helps reduce muscle tension .
*Administer balanced analegesicsas
prescribed to promote optimal pain relief.
Cont’d
Rational: analegesicses are more effective if
administeres early in pain cycle. Stimultuneous
use of analgesics that work on different portions
of the nocipetive system will provide greater
pain relief with fewer side effects.
* Instarcut patinet and family about potential
side effects of analgesics and their
prevention and management.
Rational: anticipating and preventing side effect
the patient to continue analgesia with out
interruption because of side effects.
Outcomes:
1-reports relief of pain.
2- identifies effective pain relief
strategies.
3- experiences minimal side effects of
analgesids without interraption to
treat side effect.
Nuring diagnosis :
High risk for imparied skin integrity
realted to imparied circulation and
altered sensation.
Goals: to maintenance of skin integrity.
Nursing order:
* Inspect skin \pressure points regularly for •
redness,provide gentle massage.
Rational: poor circulation may predioscpe to •
rapid skin breakdown
*Reposition ferquently,even when sitting in chair. •
Rational: prevents prolonged tissue pressue where •
circulation is alresdy compromised,reducing risk of
tissue trauma.
*Keep skin dry and clean linens dry \wrinkle free. •
Rational: moist, contaminted areas provide excellent •
media for growth pathogenic organisms
Outcomes
Maintains skin intergrity. •
Prevent dermal ischemic injury.
Absence of infection
Discharge plan
She leave has been given from 30\9\06
to 6\10\06. Her Hgb was maintained:
7,99gm. She is in stable condition
and it’s improved. Discharge
medication given (paracetmol,folic
acid and tradamol)
Advice given :
*Teach the patient to avoid exacerbation of
the disease proces by doing the following:
1-avoiding strenuous exercise.
2-avoiding cold temperatures and swimming
in cold water.
3-avoiding medications that cause
vasoconstriction.
4-avoiding high altitudes
2- promote good general health by
teaching the patint to do the following:
a-obtain yearly immunizations for prevention of
pneumonia.
b-eat awell balanced diet ,inculding foodshigh in
iron
C- drink plenty of fluids.
3- support the prevents of achild with sickle cell
disease.
A-allow for verbalization of possible feeling guit
over having the disease to child
B- moniter the need for information on coping with
a chronically ill child
The end