CONCEPT MAP
_ PCA, other pain meds
_Incentive spirometer use
_provide powerade (orange)
_O2 while sleeping
_ambulate as tolerated
_assess vital signs q4h
_provide smoking cessation info
_ assess feet and hands for color, circulation, temp, pain, swelling
_assess peripheral pulses
_assess for pain
_admin pain meds, SC meds
_assess pts level of knowledge about disease(s)
_provide printed materials about SC disease
_discuss materials with pt
_ listen to concerns, questions, fears
_ pt will rpt satisfaction with pain control measures
_ infection will not spread during shift
_ No s/s of ineffective tissue perfusion during shift
_Pt will list 5 facts about SC crisis by end of shift
Pain r/t SCA AEB pt report, VS
Infection (pneumonia) r/t SC crisis AEB dec lung
sounds, ele WBC, cough, sob, dec O2 sats, fever
Male, mid-twenties, in for SC crisis,
pneumonia, possible PE. Hospital day 11.
Back pain, rt foot pain, general achy feeling.
Fatigued, yellow sclerae, lungs clear, dim
upper left, left sided weakness, numbness r/t
Arnold-Chiari malformation. Quiet, no
visitors during day. Slept for a good part of
the day, ambulated off floor x1. Pain
controlled with PCA dilaudid .4 q 8 min.,
methadone, benadryl, ibuprofin.
Sickle cell anemia is the most severe form of an
autosomal recessive disorder where the person has
inherited HbS from each parent. SC crisis occurs when
the RBCs change from a squished disc shape into a sickle
shape. The misshapen cells get stuck in the capillaries,
causing occlusion, vasospasm leading to tissue injury and
hypoxia. Tissue ischemia, infarction and necrosis can
eventually result as a result of lack of O2 and circulation.
With repeated episodes of sickling, all body organs are
impacted, esp spleen, lungs, kidneys, heart and brain
leading to autosplenectomy, Pulmonary HT, pneumonia,
hematuria, renal failure, CHF and CVA.
Lucretia Shafer PLU SN 10/09/06
Risk for altered tissue perfusion, peripheral r/t SC crisis
AEB pain, swelling, dec cap refill, dusky, cool skin
Ineffective mgt of therapeutic regimen r/t knowledge
deficits, complexity of illness AEB frequency of episodes,
smoking habit, I dont know why it happens
Sickle Cell Crisis
Incidence: 1:350 to 500 live births predominant
in African Americans
Severe deep, achy pain esp joints
and hand and feet; fatigu;, jaundice
(yellow sclerae); chronic anemia;
cholelithiasis; pale mucous memb.;
priapism, painful swelling of hands
and feet is often the first symptom
The abnormal RBCs sickle most
commonly when triggered by low O2 in
the blood (hypoxia)bacterial
infection, high altitude, stress, surgery,
blood loss, dehydration, acidosis, low
body temp.
*Blood smear may show sickled cells
*Electrophoresis of hemoglobin (shows
presence of abnormal hemoglobin)
*CBC
--dec Hb/Hct, iron,
--inc reticulocytes, bilirubin
*Skeletal x-rays (bone and joint deformities
and flattening)
*DNA testing (costly) only needed once
Pneumoniaesp prone to infection because the spleen doesnt
phagocytize foreign substances. Pneumonia is the most common
infection with SSA
Gilberts Syndromea benign, common mild liver disorder in
which the liver lacks proper level of the enzyme that processes bilirubin-can lead to jaundice. Affects 3% to 10% of US pop.
Arnold-Chiari Malformationa rare malformation of the
area where the brain and the spinal cord meet causing part of the
cerebellum to protrude out through the foramen magnum into the
spinal canal. This impedes the flow of CSF to and from the brain
causing it to accumulate in the empty spaces of the brain and spinal
cord. It may be present at birth but often it manifests itself at puberty
or later. Symptoms include headaches, esp those c/b suddenly coughing,
sneezing or straining; neck pain; unsteady gait; vomiting; swallowing
difficulties and slurred speech. Dx is made by MRI. Tx is surgery if
symptoms are worsening, to relieve the crowding of the cerebellum.
Medical Diagnosis
Patients Story
Pathophysiology
Diagnostic Workup
Clinical Manifestation
Nursing Diagnosis
Etiology & Risk Factors
Expected Outcome
Secondary Diagnosis
_Nursing Interventions
Patients Medications:
Dilaudid
Methadone
Ibuprofen
Folic Acid
Benadryl
Hydroxyurea
Atenolol
Discharge Planning:
References:
1. Lewis, S. M., Heitkemper, M. M., &
Dirksen, S. R. (2004). Medicalsurgical nursing: Assessment and
management of clinical problems
(6th ed.). St. Louis: Mosby.
2. MayoClinic.com (2006). Chiari
malformation. Retrieved October 9,
2006 from http://mayo clinic.com
/health/chiari-malformation/
AN00506.
3. MayoClinic.com (2006). Gilberts
syndrome. Retrieved October 9,
2006 from http://mayo clinic.com
/health/gilberts-syndrome/
AN00506.
