Done by: nursing institutes fourms

Evaluated by: prince of nursing

Patient’s Demographic data:Name of patient: xxxxAge: 23 yearsAddress: xxxxReligion: MuslimMarital status: SingleLevel of education: class 11Occupation: Doesn’t workNationality: xxxxxData of hospitalization: xx-xx-xxxxDuration of hospitalization: 2 days

Health History

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: Diagnosis SCD with VOC with pain upper limb and

lower limb.

Past medical History The patient doesn’t have any significant

illness but she has known case of SCD since she was child.

Definition of the disease: 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 According to books:

1. Genetic factor.2. Increase destruction of

RBC.3. Nutritional deficiency.4. Infection.5. Cardiac dysfunction.6. Impaired production of

RBC.7. Undergoing anesthesia

with out proper oxygenation.

8. Climbing to high altitude.9. Excessive exercising 10. Pulmonary dysfunction.

In the patient: Genetic factors Nutrional deficiency

Clinical ManifestationsAccording to books:

• 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 According to books: .Ischemic necrosis

or hypoxic damage. Bone pain: painful

and swollen large joints.

Cardiomegaly Splenomegaly. Decreased splenic

function

Clinical manifestation:

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:NameResultNormalResult

WBC11.9 k/ul4.0 – 11.0normal

NEU4.3 k/ul2.0- 7.5normal

LYF5.89 k/ul1.5- 4.5high

MONO1.02 k/ul0.2- 0.8normal

ESO3.98 k/ul0.0- 0.4high

BASO0.247 k/ul0.0- 0.2normal

RBC3.44 k/ul3.8- 5.8normal

HGB9.13 QIDC12.0- 15.0low

Pharmacology:Name of drugClassificationRouteDoseFrequency

Tramadol

Tramal

Centrally acting analgesic

Oral500mg/capOD

Mefenamic Acid.Ponstan

Non steroidal anti inflammatory drugs

Oral500mg/tabOD

Folic acidFolic acid

Vitamin supplement

Oral5mg/tabOD

ParacetamolAntipyretic

Analgesic

Oral1000mg/tabOD

DextroseIsotonic solution

IM/IV injection

50mgOD

Non pharmacologic: Massage Heat application

Tramadol: 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: 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 Nurse’s Responsibilities: Administer once a day at same time each

day.

Mefenamic Acid [ponstan ]: Action: Anti inflammatory, analgesic and

antipyretic activities related to inhibition of prostaglandin synthesis exact mechanisms of action are not know.

Possible side effects:

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: Give with milk or food to decrease GI

upset. Arrange for periodic ophthalmologic

examinations during long term therapy.

Folic Acid: Action: Required for nucleoprotein synthesis and

maintenance of normal erythropoiesis. Possible side effects: Hypersensitivity. Local pain and discomfort at injection site.

Nurse’s Responsibility: 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: 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: 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 PLANNursing 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.

InterventionRationalUse pts subjective description of pain and pain rating on a pain scale to guide the use of analgesic agents.

Sever:8

Provides baseline for assessing change in the pain level and evaluating interventions.

InterventionRationalTeach pt relaxation techniques, breathing exercises and distraction to rease pain.Apply warm compresses to affected area.Encourage pt to reduce hard activity. Instruct pt to avoid cold environment.

Use of these strategies along with analgesia produce more effective pain relief.Heat increase blood flow to an affected area and it provide some analgesia and more comfort.Hard activity can aggravate the sickling process.Cold can aggravate the sickling process because vasoconstriction slows the blood flow.This aggravate pain.

InterventionRational

Distraction which involves focusing the pt attention on something other the pain.

Administer balanced analgesics as prescribed to promote optimal pain relief

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 administered early in pain cycle. use of analgesics will provide greater pain relief with fewer side effects.

InterventionRational

Instruct pt and family about potential side effect of analgesics, their prevention and management.

Anticipating and preventing side effects enable the pt to continue analgesia without interruption because of side effects.

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.

InterventionRationalStart IV fluid therapy as prescribed (Dextrose).

To dilute blood and reduce the pain.

Nursing Diagnosis: Altered nutrition less than body requirement related to loss of appetite, nausea and vomiting

Goals: improve nutritional statues

InterventionRationalAssess dietary intake and nutritional status through diet history,wieght measurement and labortary data.Provide diet high in carbohydrates.

Identifies nutritional intake and adequacy of nutritional state.Provides calories for energy.

InterventionRationalEncourage 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.

Promotes positive environment and increased appetite, reduces unpleasant taste.Promotes appetite and sense of well-being..

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.

hydration.Give him written instructions.Regarding the minimum amount of fluid required each day.

Instruct him to avoid strenuous physical activity.

Teach him to avoid undue emotional stress.

Instruct him to avoid areas of low oxygen concentration.

Nursing Diagnosis:Activity intolerance related to illness as manifested by pain, loss appetite and patient looks pale.

GOAL:Encourage power.

Nursing InterventionRationale

Increase pt’s ability to use normal coping resources of physical strength, psychological stamina and positive self esteem.Encourage the pt to read different books.

To make the pt cooperative with her treatment.

To forget the illness.

Out come Criteria: Expresses improved sense of control. Participates in goal setting and in planning

and implementing daily activity. Participates indecisions about care.

Nursing Diagnosis: 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 InterventionRationale

Review 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.

Provides knowledge base on which pt can make informed choices.Causes peripheral vasoconstriction, which may result in sludinr of the circulation, increased sickling, and mayprecipitate avaso- occlusive crisis.

Nursing InterventionRationalEncourage ROM exercise and regular physical activity with a balance between rest and activityReview 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.

Prevents 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: 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: 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: 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.