Case Study - Sickle Cell Anemia

Case Study-Sickle Cell Anemia Mark is a 14-year-old patient diagnosed with Sickle Cell Anemia. He is the youngest of 3 children and lives with his mother and two older siblings. Additionally, his grandmother, aunt and 2 cousins live in the household. Mark recently returned from a football training camp held in the mountains. He began to experience severe pain that was uncontrolled at home. His mother contacted the sickle cell clinic and was advised to bring Mark to the hospital. 1. Based on this information, what lab work should the nurse anticipate? I would anticipate that they would do a complete blood test on Mark to see his co2 and his RBC’s. They might also do a blood culture under the microscope to see what his blood cells are looking like at the moment to see how many of them are sickled. 2. What is the nurses’ primary concern based on the patient symptoms? The nurse’s primary concern based on the patients’ symptoms is that they will go into a sickle cell crisis. The drastic change in o2 could have caused his cells to start to sickle and is causing him pain. You would want to keep and eye on his o2 saturation and try to control his pain. 1 Mark is admitted to the hospital later that afternoon. His lab results are reported as: WBC 11.5 Hgb 4.0 g/dL RBC 3.04 MCV 65.30 femotoliter MCH 21.33 picograms/cell MCHC 30 gm/dL pH 7.4 PaO2 60 mmHg SaO2 85% RA PaCO2 50 HCO3 24 Mark’s admitting VS are recorded as: HR 88 BP 100/64 RR 24 Temp 100.8 F Pain 10/10 1. What should the nurse suspect is the cause of the altered lab results? The result of the altered lab results would be because of the sickle shape of the red blood cells. Because they are this shape that means that it cannot carry oxygen around the body. This results in increased co2 and lower o2 in the blood. This is also why the rbc’s is reading low. 2. What are the implications for the patient related to the lab results? The implications related to the lab results would be that since he came from a place with low o2 to a place with high o2 so his body went into a sickle cell crisis. 2 3. What is concerning to the nurse regarding the vital signs? What are the implications of the altered vital signs? His bp is low compared to what it should be, this could be because he does not have as many rbcs circulating through his system. His rr is also high. This is because he is in pain from the sickling of his rbcs and because his bp is low. Mark is started on IV antibiotic therapy and is started on a Dilaudid PCA. Additionally, he has D51/2NS infusing at 150 ml/hr. 1. What is the rationale for administering IV antibiotics? What antibiotics are typically prescribed for someone in Sickle Cell Crisis? They use the antibiotics prophylactically to help prevent pneumonia from occurring whilst they are having an sickle cell crisis. The antibiotic they typically use is penicillin. 2. What is the rationale for administering IVF at the 150 ml/hr (2 times the maintenance for this patient? They administer 2 times the maintenance for this patient because they are in excruitiating pain and they require a higher amount of pain medication to break through the pain. 3. What is the rationale for administering Dilaudid through a PCA? What are the anticipated side effects? They administer the dilaudid through a pca because the patient is in constant pain, so while using the pca, hopefully the patient will know when to administer the medication so that their pain in under control. You want to monitor for respiratory depression since this is an opiod and it is being used on the pca. 3 Mark’s mother reports to the nurse that Mark isn’t “acting right” and looks like “one side of his mouth won’t move.” 1. What should the nurse assess first? What is the rationale? The nurse should assess if mark is having a stroke. You want to rule this out right away because if he is having a stroke you want to give him a clot buster but there is only a certain amount of time you can give them the drug before it will not work anymore so we want to rule this out as soon as possible. So we want to do a neurological assessment on him and get an mri. 2. Based on the assessment what actions should the nurse take next? The nurse should get a mri or ct to assess for a stroke and should deifnityly contact the health care provider to notify them of what is happening. We would want to give his o2 via nasal cannula as well. The physician suspects the patient may have experienced a stroke. An order for a brain MRI is placed and the nurse must prepare the patient for the procedure.  What information should the nurse obtain from Mark prior to the MRI? We want to know if he has a history of bleeding disorders, or if he is allergic to the dye they give you for a contrast mri. Because to identity a stroke they need to use contrast. So we want to make sure that he is not allergic. We also want to get consent from mark, which in this case will be from his mother.  What patient education should be provided to Mark and his mother? You should educate mark about what will happen when he gets to the mri, how he needs to lay for the mri and that they will be injecting contrast into his iv and it might feel a little bit weird. You also want to tell him what they mri will show us and what he is going to get the mri for so that he is not freaked out by not knowing what is going on. 4     What assessment of Mark should the nurse conduct before, during and after the MRI? Before a. Make sure he has no metal on him; pacemaker, staples from a surgery or prosthetics b. Remove all jewelry from the body c. Assess for allergy of contrast or iodine During a. Lie very still b. Assess if he starts to freak out and panics c. Vital signs After a. Monitor for adverse reactions of the contrast b. Vital signs c. Look ast results Results of the brain MRI conclude that Mark experienced a mild stroke. Occupational Therapy has been consulted and will work with Mark daily. Additionally the following lab results have been reported: WBC 10.8 RBC 3.0 Hgb 3.5 g/dL pH 7.4 PaO2 63 mmHg SaO2 82% RA PaCO2 49 HCO3 24 1. What are the implications of Mark’s current lab results? He is starting to go into respiratory acidosis because he is breathing very quickly and he is not ble to exchange his o2 so his co2 is raising. 2. What should the nurse anticipate is the next intervention regarding Mark’s hemoglobin? They should anticipate a blood transfusion so that he is able to get his hemoglobin us and get more o2 flowing through his blood. 5 The physician determines that Mark needs a blood transfusion. The order states that 1 unit of PRBCs are to be infused over 4 hours. 1. What must occur prior to Mark receiving his blood transfusion?   Blood typing to see what kind of blood he needs and so he does not have a reaction Vital signs to get a baseline before the transfusion begins Consent for the procedure         2. What are the signs/symptoms of a transfusion reaction? When are the symptoms most likely to manifest? Fever Rash/ pruritis Angioedema Phlebitis Anaphylaxis Increased respiratory rate Increased bp Symtpms are most likely to manifest during the first 15 minutes.  3. What is the protocol when a transfusion reaction occurs?     Stop the infusion Disconnect iv tubing Give epi, Benadryl, steroids,o2 Send tubing and blood to pharmacy to get examined for contamination. Mark’s blood is obtained from the blood bank. It contains 375mL of PRBCs. After double-checking the blood with another nurse at the bedside and verifying the right patient is receiving the right blood, the nurse proceeds to hang the PRBCs. 1. What rate should the IV infusion pump be set to infuse? It should be set to infuse 94mL/hour since there are 375 mL to be infused over 4 hours. 2. When should vital signs be taken? Every 15 minutes for the first hour then every hour until its complete then 30 after the transfusion. 6 3. What should the nurse tell Mark and his mother to report during the transfusion?        Swelling of mouth Itching Redness Fever Feeling warm Trouble breathing] Increased heart rate 4. What should the nurse anticipate being ordered at the completion of the transfusion? I would anticipate a complete blood count to be ordered after the blood transfusion to see if his hemoglobin and hematrocrit were increased and helped with the blood transfusion. Mark tolerates the blood transfusion without signs or symptoms of a transfusion reaction. He reports feeling “ a little bit better” and is now reporting his pain is well controlled with the PCA. His current labs are: WBC 11.2 RBC 4.5 Hgb 7.8 g/dL PaO2 70 O2 sats 88% 1. What are the implications of Mark’s lab results? His hgb is still a little low but his rbcs are in the normal range now. I think that after a little bit the rbcs will be able more around more and the hemoglobin should go up after they circulate a little bit. After 7 days in the hospital, Mark is ready to be discharged. 1. What patient education should be included in Mark’s discharge teaching? You should include to be careful when traveling as it could trigger a sickle cell crisis due to the cold or the high altitudes. You also want to encourage him to be carful whilst playing sports as that is also another trigger. Since he had a minor stroke you want to maybe think about putting him on some blood thinner to prevent this from happening again and also inform them of some of the things to look for in a stroke if it does happen again so that they are able to identify it. 7 Write a nursing care plan for Mark. Choose one Actual Nursing Diagnosis and one Potential Nursing Diagnosis. You must include 2 patient goals for each nursing diagnosis. You must include 3 nursing interventions for each patient goal. Include the rationale for each nursing intervention. You must determine how you will evaluate whether or not the patient goal was met.   Acute pain r/t intravascular sickling with localized occlusion and infarction aeb facial grimacing, guarding of affected areas, pain described as throbbing, headache and joint and abdominal pain. o Patient shall verbalize relief or control of pain  Discuss what pain relief measures were effective in the past, this will help in increasing the effectiveness of pain relief and stablishing individual treatment.  Teach and discuss alternative pain relief measures, relaxation techniques, guided imagery, and breathing techniques, this may help with the pain if pharmacological control is not enough.  Observe nonverbal pain cues such as gait, positioning, and facial grimacing, this may aid in evaluation of pain and effectiveness of therapy since pain is unique to each patient.  Patient will rate pain less than a 4 out of 10 on a # scale. o Demonstrate relaxed body posture, and be able to sleep appropriately  Provide support and carefully affected extremities, this helps to reduce edema, discomfort and risk of injury.  Plan activities during peak analgesic effect, this maximizes movement f joints which enhances mobility.  Apply warm moist compresses to affected joints and other painful areas, this with increase vasodilation and circulation and help relieve some pain so they can relax.  Patient will sleep for at least 8 hours at night Risk for fluid volume deficit r/t increased fluid needs due to hypermetabolic state, fever, or inflammatory process. o Obtain normal urine output  Maintain accurate intake and output and weigh daily to make sure that they are not losing to much fluid due to vomiting and diarrhea  Not urine characteristics like urine specific gravity to know if the kidneys are not working properly due to poor circulation  Encourage drinking water during commercials do help with dehydration  Patient will have an output of at least 30mL per hour o Maintain a temperature below 100.4  Use antipyretics such as acetaminophen to bring down fever and decrease fluid consumption through the body 8   Drink lots of fluids to cool down the body and brink the fever down Use a fan to help cool down the body and decrease metabolic rate from sweating.  Patient will maintain a fever below100.4 for at least 24 hours. 9