Acute Sickle Cell Crisis

Nursing Care Plan DIAGNOSIS: Acute sickle cell crisis ASSESSMENT Nursing Diagnosis: Priority #1 Acute pain r/t intravascular sickling statis AEB patient reporting throbbing pain on scale of 8/10. Subjective Data: Reports “Throbbing pain” Objective Data: Guarding on right lower extremity Diaphoresis Facial grimacing V/s taken as follows BP 148/78 T-99% SPO2 95% Pulse 96 RR 20 Medication Morphine 4MG IV Q4 PRN PLAN Priority:1 Goal: Patient shall verbalize relief or control of pain thoughtout this shift. Outcome Criteria: Client will1. Identify pain intensity on a pain scale and rate the pain consistently by end of shift. 2.Identify factors that increase the pain by end of shift. 3. Experience comfort from a reduction in the level of pain or relief from pain by end shift. INTERVENTIONS EVALUATION The nurse will: Outcome #1 a. Acknowledge the patient's pain, and accept responses to the pain. (Matthie & Jenerette, 2015) Priority Goal Evaluation: b.Instruct the patient to notify the caregiver of all episodes of pain. Criterion 2: Goal met Pt was able to identifies factors that exacerbates pain. Outcome #2 a. Explore complementary therapies with the patient, such as massage therapy, relaxation therapy, and guided imagery. b. Allow alternative pain treatments from the patient's culture, as appropriate. Outcome #3 a. Administer medications, as prescribed, and monitor for effect. b. Provide supplemental oxygen, as ordered. Criterion 1:Goal in progress Patient reports pain on a scale of 4/10 Criterion 3 Goal met: The patient experiences comfort from a reduction in the level of pain or relief from pain. ASSESSMENT Nursing Diagnosis: Priority #2 Activity Intolerance related to verbal report of fatigue or weakness as evidence by imbalance between oxygen supply and demand. Subjective Data: Patient states she has been “so weak and just plain tried” for the past week. Objective Data: Restlessness Skin is pale and cool to the touch PLAN Priority: Goal: Improve on activity tolerance. Outcome Criteria: Client will1. Pt will demonstrate two breathing techniques to use during dyspneic episodes within 12 hours. (Tanabe et al., 2019 p 31) 2. Maintain a respiratory rate of 12-20 breaths per minute throughout hospitalization (Tanabe et al., 2019 p 31) 3. Pt will verbalized two ways on how to prevent anxiety. INTERVENTIONS The Nurse: a) The nurse will ambulate with the patient in the hallway approximately 300 feet and assess for any signs of fatigue during ambulation before discharge. b). The nurse will verbalize and provide printed education material on 4 signs and symptoms of anemia by discharge. c). The nurse will demonstrate and verbalized 4 energy conserving techniques within 12 hours. EVALUATION Priority Goal Evaluation: Criterion :1 Goal Met PT demonstrate two breathing techniques to use during dyspneic episodes within 12 hours. Criterion :2 on going Pt respiratory rate was below 20 breaths per minute throughout this shift. Criterion 3 Goal met. PT verbalized two ways on how to prevent anxiety. ASSESSMENT Nursing Diagnosis: Priority #3 Deficient Knowledge unfamiliarity with resources AEB patient reporting that he tries to sleep when in pain. Subjective Data: Patients states that he sleeps when in pain. Pt states “they do not care about my pain” (BrennanCook et al., 2018) Objective Data: Flat affect. PLAN Priority:3 Goal: Outcome Criteria: Client will1. Verbalize understanding of therapeutic needs before end of day. 2. Verbalize understanding of disease process, including symptoms of crisis, potential complications before the end of shift. 3. Participate in continued medical follow-up before end of this shift. Medication Ceftriaxone: 2000 mcg IV, once daily. INTERVENTIONS EVALUATION The Nurse Will: 1.Review disease process and treatment needs. Priority Goal Evaluation: 2. Address Stressful situations Criterion 2. Goal met Patient understand the disease process . 3. Assist patient to strengthen coping abilities: deal appropriately with anxiety, get adequate information, use relaxation techniques. Criterion 1:Goal met. Patients reports understanding of therapeutic needs Criterion 3.Goal not met Patient is reluctant on asking about pain management when in pain.