Brittany Long v Sim CP

CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) Sickle cell anemia is the most homozygous and most common form of sickle cell disease. The clinical features of SCA are primarily the result of (1) obstruction caused by the sickled RBCs with other cells, (2) vascular inflammation, and (3) increased RBC destruction. The abnormal adhesion, entanglement, and enmeshing of rigid sickle shaped cells accompanied by inflammatory process intermittently blocks the microcirculation causing vasoocclusion. The resultant absence of blood flow to adjacent tissues causes local hypoxia, leading tissue ischemia and infarction (cellular death). DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) CBC Results: Hb: 10; HCT: 29; Reticulocytes: 5.5. CBCs determine the number and average size of RBCs in the body as well as how much hemoglobin they contain, both of which are often low in those with sickle cell disease yet there will be increased platelet count and elevated erythrocyte sedimentation rate. CMP and BMP: Creatinine: 0; Cl-; 113; BUN: 30.3. The CMP and BMP provides information on glucose levels, the balance of electrolytes and fluid as well as the health of the kidneys and liver PATIENT INFORMATION Patient: Brittany Long Gender: Female DOB: 12/10/2015 Allergies: No known allergies Immunizations: Up to date Adm Dx: Sickle Cell Anemia ANTICIPATED PHYSICAL FINDINGS -Anemia -Periodic Episodes of Pain -Dactylitis (Swelling of hands and feet) -Frequent Infections -Delayed Growth or Puberty -Vision Problems -SOB, fatigue -Pallor, pale mucous membranes -Jaundice -Hands and feet cool to touch -Dizziness -Headache Adm On: 3/28/2021 ANTICIPATED NURSING INTERVENTIONS -Promote rest to minimize energy loss -Administer O2 as prescribed if hypoxia is present -Provide hydration therapy while maintaining fluid and electrolyte balance -Monitor I&Os -Give oral fluids -Electrolyte replacement -Analgesia for pain -Treat and prevent infection with antibiotics, frequent hand hygiene, vaccines if not up to date -Monitor and report laboratory results vSim ISBAR ACTIVITY WORKSHEET INTRODUCTION Catherine Espinosa, RN, Pediatric Unit Your name, position (RN), unit you are working on SITUATION PatientÕs name, age, speciÞc reason for visit BACKGROUND PatientÕs primary diagnosis, date of admission, current orders for patient ASSESSMENT Current pertinent assessment data using headto toe approach, pertinent diagnostics, vital signs RECOMMENDATION Brittany Long is a 5-year-old African American female admitted on 3/28/2021 from the emergency department during the night with the diagnosis of sickle cell anemia. She is accompanied by her mother, Janet Long who states that the patient has been complaining of right lower leg pain over the last 2 days. Sickle Cell Anemia, 3/28/2021. The patient has no known allergies. Brittany Long has a hx of sickle cell disease disease, diagnosed at 6 months old, and has been prescribed regular folic acid supplement. She was brought into the emergency department during the night by her mother, Janet Long who stated that the patient has been complaining of right lower leg pain over the last 2 days. Brittany rated her pain as a 5 on the FACES Scale and did not want anyone to touch her leg during assessment. She has not had an appetite in the last 24 hours but has taken small amounts of oral fluids. She has had pain crises before, mostly managed at home with acetaminophen and ibuprofen. She has been hospitalized twice, once at age 4 years for a vaso-occlusive crisis episode and once at age 3 years for a fever. Brittany was given oral pain medication in the emergency department at 6:00 AM. She is asleep but is responsive when awakened. She has been taking small amounts of oral fluids and continues to receive intravenous maintenance fluids at 52 mL/hr. When examined this morning, her blood pressure was 101/70 and her temperature was 37.4¡C (99¡F). She now rates her pain as a 3. Current orders for the patient include: VS q 4 hrs, continuous pulse oximetry and O2 to keep O2 >94%; Encourage PO fluids. IV fluids at D5 1/2 NS at 52 mL/hr. Medication includes: Codeine elixir 8 mg PO every 4 hrs. Acetaminophen elixir 240 mg PO q 6 hrs (15 mg/kg/dose). Ibuprofen elixir 160 mg PO at 0900 and then q 6 hrs (10 mg/kg/dose) Docusate sodium 100 mg PO every day (liquid per home dose). Morphine Sulfate 2 mg IV (0.15 mg/ kg/dose) x 1. Labs: Daily CBC and BMP. The child answered 3 on the FACES pain scale with a range of 0 to 5 There is no obvious airway obstruction. obstruction The right lower leg is warm 5.There to touch. There is normal elasticity of the skin. She is breathing at 24 breaths per minute and the chest is moving equally. She looks slightly pale and her skin is cool. The mucous membranes show no signs of dehydration. The HR and rhythm are regular without murmurs. There are normal bowel sounds. The pulse is strong, 120 per minute and regular. Current VS are as followed: HR 120, BP: 109/74/ SpO2 99% on 2L Nasal Cannula. Recommendations that I have for this patient would be to administer Any orders or recommendations you mayhave for this patient analgesic for pain and promote rest. I would also continue the O2 as prescribed to maintain SpO2 levels above 94%. I would encourage fluids and also monitor I&O to assess for any S&S of hypervolemia. I would also encourage the patient to eat to maintain her nutrition and to monitor her VS. PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Folic Acid CLASSIFICATION: Red blood cell formation, healthy cell growth and function; Prevention of birth defects PROTOTYPE: Folic Acid SAFE DOSE OR DOSE RANGE, SAFE ROUTE PO (Children >2 yr): 1 mg/day. Brittany Long was prescribed a regular folic acid supplement. The case did not say the exact dose to which she was prescibed PURPOSE FOR TAKING THIS MEDICATION Red blood cell formation, healthy cell growth and function; Prevention of birth defects; Treats folate deficiency PATIENT EDUCATION WHILE TAKING THIS MEDICATION Take folic acid exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor. Take the missed dose as soon as you remember it. However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not take a double dose to make up for a missed one. Folic acid may cause side effects. If patient experiences any of the following symptoms, call the doctor immediately: skin rash, itching, redness, difficulty breathing. Tell doctor and pharmacist if the patient is allergic to folic acid or any other drugs and what prescription and nonprescription medications the patient taking, especially phenytoin (Dilantin) and vitamins. PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Codeine CLASSIFICATION: Therapeutic: allergy, cold, and cough remedies, antitussives, opiod analgesics; Pharmacologic: opiod agonists PROTOTYPE: Antitussive SAFE DOSE OR DOSE RANGE, SAFE ROUTE PO (Children 2-5 yr): Analgesic: 0.5-1 mg/kg q 4-6 hr (up to 4 times daily) as needed. PatientÕs dose is: Codeine elixir 8 mg PO q 4 hrs. The patient weighs 16 kg so the safe dose range is 8-16mg/kg. The prescribed dose is within the recommended limits. The maximum dose the patient can have within 24 hrs is 60 mg PURPOSE FOR TAKING THIS MEDICATION Decreased severity of pain. Can also be used for suppression of cough reflex and relief of diarrhea. PATIENT EDUCATION WHILE TAKING THIS MEDICATION May cause drowsiness and dizziness. Advise patient and caretaker that patient may need assistance when ambulating. Advise patient and caretaker that patient should change positions slowly to minimize orthostatic hypotension Advise patient that good oral hygiene, frequent mouth rinses, and sugarless gum or candy may decrease dry mouth PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Acetaminophen CLASSIFICATION: Therapeutic: antipyretics, nonopiod analgesics PROTOTYPE: Acetaminophen SAFE DOSE OR DOSE RANGE, SAFE ROUTE PO (Children 1-12 yr): 10-15 mg/kg/dose q 6 hr as needed (not to exceed 5 doses/24 hr). PatientÕs Dose: Acetaminophen elixir 240 mg PO q 6 hr (15 mg/kg/dose). The total dose within 24 hrs for this patient would be 960 mg. The patientÕs weight is 16 kg so the safe dose range for this patient is 160 mg-240 mg. The patientÕs prescribed dose is within the safe recommended range. PURPOSE FOR TAKING THIS MEDICATION Analgesia. Antipyresis. PATIENT EDUCATION WHILE TAKING THIS MEDICATION Explain purpose of medication to patient and caregiver. Recommended dosage of 10-15 mg/kg every 4-6 hours as needed and no more than 5 doses per 24-hour period. Anything greater than 5 doses may lead to hepatotoxicity, renal, or cardiac damage. Children should not take it longer than 5 days unless directed by HCP. Notify HCP if rash occurs and to discontinue medication Caution caregiver to check labels on all OTC products and to advise caregiver/patient taking more than one product containing acetaminophen at a time to prevent toxicity. PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Ibuprofen CLASSIFICATION: Therapeutic: antipyretic, antirheumatics, nonopiod analgesics, nonsteroidal antiinflammatory agents; Pharmacologic: nonopiod analgesics PROTOTYPE: Aspirin SAFE DOSE OR DOSE RANGE, SAFE ROUTE PO (Infants and Children): Analgesic: 4-10 mg/kg/dose every 6-8 hr. PatientÕs Dose: Ibuprofen elixir 160 mg PO at 0900 and then q 6 hrs (15 mg/kg/dose). The total dose within 24 hrs for this patient would be (160+15+15) 190 mg. The patientÕs weight is 16 kg so the safe dose range for this patient is 64-160 mg. The initial dose is within the recommended range but the added subsequent doses are not so the added 15 mg for the patient is unsafe. PURPOSE FOR TAKING THIS MEDICATION Decreased pain and inflammation. Reduction of fever. PATIENT EDUCATION WHILE TAKING THIS MEDICATION Teach parents and caregivers to calculate and measure doses accurately and to use measuring device supplied with product Advise parent, caregiver, and patient to consult HCP if rash, itching, visual disturbances, tinnitus, weight gain, edema, epigastric pain, dyspepsia, black stools, hematemesis, persistent headache, or influenza like syndrome (chills, fever, muscle aches, pain) occurs Advise parents/caregivers not to administer ibuprofen to children who may be dehydrated (can occur with vomiting, diarrhea, or poor fluid intake); dehydration increases risk of renal dysfunction PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Docusate sodium CLASSIFICATION: Therapeutic: laxatives; Pharmacological: stool softeners PROTOTYPE: Docusate sodium SAFE DOSE OR DOSE RANGE, SAFE ROUTE PO (Children 3-6 yr): 20-60 mg in 1-4 divided doses. PatientÕs Dose: Docusate sodium 100 mg PO q (liquid, per home dose). The total dose within 24 hrs for this patient would be 60 mg. The prescribed dose of 100 mg may be too high for the child. PURPOSE FOR TAKING THIS MEDICATION Softening and passage of stool. PATIENT EDUCATION WHILE TAKING THIS MEDICATION Advise caregiver and patient that laxatives should be given for short-term therapy. Long-term therapy may cause electrolyte imbalance and dependence. Advise caregiver and patient that laxatives should not be used when abdominal pain, fever, or N&V is present. Encourage other forms of bowel regulation such as increasing fiber in the diet, fluid intake (6-8 glasses a day) and increasing mobility. PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Morphine CLASSIFICATION: Therapeutic: opioid analgesics; Pharmacologic: Opioid agonists PROTOTYPE: Opium SAFE DOSE OR DOSE RANGE, SAFE ROUTE IV, Subcut (Children > 1 mo): Continuous infusion, sickle cell or cancer pain: 0.02-2.6mg/kg/hr. PatientÕs Dose: Morphine sulfate 2 mg IV (0.15 mg/kg/dose) x 1. The total amount for 24 hrs is 0.48-62.4 mg. The patient weighs 16 kg so the dosage range for this patient would be 0.32 mg to 41.6 mg/kg/hr. The patientÕs dose of 2 mg falls within the recommended range. PURPOSE FOR TAKING THIS MEDICATION Decrease severity of pain PATIENT EDUCATION WHILE TAKING THIS MEDICATION Caution caretaker and patient that medication may cause drowsiness and dizziness and to use assistance when ambulating. Advise patient and caretaker that patient should change positions slowly to minimize orthostatic hypotension Emphasize the importance of aggressive prevention of constipation with the use of morphine Initials: B.L. Diagnosis: Sickle HCP: N/A cell disease Isolation: No Fall Risk: Yes Age: 5 yo Length of Stay: M/F: F Code Status: Unknown IV Type: D5 1/2 NS Location: Left forearm Consults: N/A Transfer: No Since 3/28/2021 Fluid/Rate: 52 mL/hr Allergies: Critical Labs: Hb, HCT, Creatinine, Cl-, BUN Other Services: Obtaining CBC and BMP. Consults Needed: Hematologist Pediatric Cardiologist Pediatrician Dietician No known allergies Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: Brittany Long is a 5-year-old African American female admitted on 3/28/2021 with a history and diagnosis of sickle cell disease who was brought into the hospital by her mother, Janet Long because the patient complaining of right lower leg pain over the last 2 days. Health History/Comorbities (that relate to this hospitalization): Brittany Long has a hx of sickle cell disease, diagnosed at 6 months old, and has been prescribed regular folic acid supplement. She has had pain crises before, mostly managed at home with acetaminophen and ibuprofen. She has been hospitalized twice, once at age 4 years for a vaso-occlusive crisis episode and once at age 3 years for a fever. Shift Goals/ Patient Education Needs: 1. Treat patientÕs leg pain and keep the childÕs pain at a 1 or lower 2. Monitor I&O and prevent hypervolemia 3. Promote rest to decrease O2 consumption 4. Educate parent and caregiver about sickle cell anemia and what they can do at home to prevent exacerbations of the Path to Discharge: Promoting rest, adequate oxygenation and hydration, providing IV therapy while maintaining fluid and electrolyte balance. Prevent infection. VS within patientÕs limits. Laboratory results within patientÕs normal limits. Patient will no longer feel pain. Path to Death or Injury: Sickle cell disease is exacerbated leading to increased destruction of RBC. Vaso-occlusive crisis, sequestration which can lead to hypovolemic shock, aplastic crisis, acute chest syndrome Alerts: What are you on alert for with this patient? (Signs & Symptoms) 1. Vaso-occlusive crisis which can manifest as severe pain and swollen joints Management of Care: What needs to be done for this Patient Today? 1. Treat and relieve pain 2. Sequestration which can manifest itself in enlarged spleen or liver (splenomeagly or /and hepatomeagly) and reduced blood 2. Provide adequate hydration volume which can lead to hypovolemic shock. 3. Promote rest 3. Hypoxia which can result for lower RR and from decreased saturated pulse ox 4. Provide patient and caregiver education about disease process and how to treat and manage it. 5. Monitor VS What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1. Assess for pain and swollen joints focusing on the hands and feet 6. Encourage oral fluids and adequate nutrition Priorities for Managing the PatientÕs Care Today 1. Keeping O2 saturation >94% 2. Monitoring VS and labs 3. Keeping patientÕs pain at a minimum of 1 or lower. 2. Assess BP and S&S of hypotension, splenomeagly, hepatomeagly, bruising, excessive bleeding 4. Promoting rest and assistance out of bed if needed. 3. Assess respirations, pulse ox, and HR What aspects of the patient care can be Delegated and who can do it? List Complications may occur related to dx, procedure, comorbidities: 1. Stroke 2. Acute chest syndrome 3. Septicemia What nursing or medical interventions may prevent the above Alert or complications? 1. Blood transfusions are usually performed monthly to prevent a stroke 2. Blood transfusion, take antibiotics as prescribed 3. Prevent infection by use of aseptic and clean technique wherever appropriate 4. Monitor for abnormal behavior, seizures, weakness, visual changes, vomiting, and headache Washing the patient, providing patient adequate hygiene, obtaining VS, monitoring I&O, assisting the patient to the BR can be delegated to the UAP