Question

Case Study #7 H.M. is a 15-year-old African American adolescent who was diagnosed with sickle cell disease three years ago. H.M. presents to the emergency department with pain related to sickle cell crisis.

Subjective Data

Pain level is an 8/10

location = bilateral legs,

described as deep muscle pain Student in 10th grade,

honor roll student On the track team Lives with mother and father

Objective Data Vital signs:

T= 99.3

P= 80

R= 18

BP= 140/68

Weight: 140 lbs

HT: 5 feet, 6 inches

Questions (10 points total)

1. What other assessments should be included for this patient? (2 points) general examination, local examination,

2. What type of pain is this patient experiencing? (2 points)

3. What standards of assessing pain will be applied to this patient’s plan of care? (2 points)

4. What teaching should the nurse consider from the problems list? (2 points)

5. What interventions should be included in the plan of care for this patient? (2 points)

Answer 1

Sickle cell anemia is a disease caused by genetic mutation, in which the red blood cell normal round shape has been changed to sickle or crescent moon shape. This shape obstructs the easy flow of RBC making it sticky and rigid. The sickle cells get stuck to the walls of the blood vessels, blocking the normal flow of blood. The area of the body where the block happens, and the blood flow to the area get obstructed, the area will present with severe pain.

When the sickled RBC block the blood vessels, causing pain, of varying intensity and frequency (acute pain lasting for hours to days depending on people), it is called Sickle cell crisis.

1. Assessment

HM presents with Pain level is an 8/10, described as deep muscle pain.

The main symptoms of sickle cell crisis include,

• Anemia
• Pain
• Breathing problems
• Yellowishness of the extremities (Jaundice)
• Painful swellings of hands and feet
• Frequent infections
• Painful erections in male
• Delayed Growth and development

In the case of HM, pain in both the legs present, temperature is 99.3 degree F.

• Assess for any Breathing problems, because lack of proper oxygenation can lead to breathing difficulties. Also since the temperature is above normal, he is at risk for infection too.
• Check for signs and symptoms of anemia.
• Assess for jaundice, as the destruction of RBC happen in 10-20 days than the normal 120 days.
• Assess the growth and development of the child as he is an adolescent and whether it is normal.

2. The type of pain:

The patients with sickle cell disease will have deformed RBC. The sickle shaped RBC get stuck to the walls of the blood vessel, blocking the blood flow to the body part. This causes necrotizing pain in that area where blood flow is absent.

The pain may be mild to severe depending on the extent of obstructed blood flow, and it may happen regularly in some patients, but not so frequently in some. The pain may last a few hours in some, but may prolong for a few days in others.

In this case, HM was experiencing severe pain, that also deep muscular type pain.

3. Standards of pain assessment:

The verbally administered numerical pain scale has to be administered to the patient to assess the level of pain. The patient experiences severe pain, and every shift the pain has to be assessed by the nurse.

Proper analgesic medications as per the prescription has to be administered, and the effectiveness in pain reduction has to be reassessed using pain scale.

• Numerical rating scale assesses the pain on a scale of 0-10 score. A score of zero is no pain , 0-5 is mild pain and 5-10 is severe or worst pain experienced
• Brief pain inventory(BPI) can also be used for assessing this type of pain. In this it is a series of questions in a questionnaire to assess the pain.

4. Patient and family teaching:

The patient and family have to be taught on the management of crisis at home. Provide teaching on the self care, pain medications, and preventing infections.

• Drink plenty of fluids to loosen the blood , and increase the fluid intake when the pain starts.
• Manage the pain using medicines like Acetaminophen or Ibuprofen.
• Hot bath, massage and heating pad can be used for local relief.
• Physiotherapy can be done mildly, without causing over stress.
• Remain stress free by relaxation and meditation.
• Wear warm clothes and when in Ac rooms
• Don’t smoke or avoid alcohol intake
• Avoid swimming in cold water
• Wash hands often
• Avoid visiting sick people, and avoid being around people who are sick
• Administer vaccines and medications on time.

5. Interventions :

Pain management:

• Administer pain medications as per the prescription
• Provide rest and heat pads and calm environment to rest
• Provide relaxation like music therapy
• Assist with activities of daily living like going to toilet etc.

Managing Anemia:

• Check for anemia, and inform the physician if blood Hb is low.
• Administer blood transfusion, if prescribed
• Administer plenty of fluids, orally.
• Maintain intake output chart

Preventing infection:

• Maintain strict asepsis while caring the patient
• Teach patient and family to follow proper hand washing
• Check and record vital signs every 6 hourly
• Administer antibiotics prescribed (preventive purpose)

Reduce anxiety:

• Provide a calm and comfortable resting
• Teach deep breathing and relaxation exercise
• Help the patient and family to ventilate their feelings and answer the queries.
• Explain how they can manage the crisis pain at home