Patient Conference Report History of events leading to admission: 58 year-old male came into the ER with complaints of pain

on R hip (Trochanter area) since Monday without adequate pain relief . He denys recent injury to affected area. Patient states he has had this type of pain before due to his sickle cell type SC condition. Patient has adequate range of motion able to ambulate without problems pain intensifies with ambulation. Gait steady without the need of assistive devices. Family has a history of hypertension, breast cancer, sickle cell. Patient states I have two sisters and three brothers which all have hypertension and sickle cell anemia. Diagnosis: Sickle cell anemia crisis. Past Medical History: Sickle cell, HTN, RE avascular necrosis of hip. Past Surgical History: Retinal repair detachment right eye, partial repair detachment left eye. Pertinent Lab Results: CBC with differential, CMP, urinalysis, ESR.RDW 20.0, WBC 15.57, glucose 119, BUN 6,prot total 8.8,bilirubin 1.6, AST 48, Sed rate 7 (normal) Pertinent Diagnostic Tests: Urine analysis, X-Ray right hip.(no change since last x-ray six years ago). Lists of Medications: Levaquin 500mg, Ambien 10 mg, Norvasc, percocet 325 mg, hydrochlorothiazide 25 mg, N/S 1000 ml with KCL 10 meq at 100 ml/hr, Demerol IV 25 mg. O2 3 L per nasal canal. Allergies: NKDA DNR status: Full code Vital Signs: T 98 P 58 R 20 B/P 141/78 SaO2 99 with O2 O2 3 liters

List 3 pertinent medications given by you on your shift. Include actions, side effects, and nursing considerations: Name: Action: Percocet

Inhibits ascending pain pathways in CNS, increases pain threshold, alters pain perception( Mosbys, 2011 pg. 853). Side Effects: Drowsiness, dizziness, confusion, headache, sedation, euphoria, fatigue, abnormal dreams/thoughts, hallucinations, palpitations, bradycardia, change in BP, tinnitus, blurred vision, miosis, diplopia, nausea, vomiting, anorexia, constipation, cramps, gastritis, dyspepsia, bililary spasms, increased urinary output, dysuria, urinary retention, rash, urticaria, bruising, flushing, diaphoresis, pruritus, respiratory depression( Mosbys, 2011 pg. 853). Nursing I &O ratio check for decreasing output may indicate urinary retention. Central Considerations: nervous system changes dizziness, drowsiness, hallucinations, euphoria, LLC, pupil reaction, allergic reactions at, respiratory dysfunction. A assess for pain intensity, location, time characteristics, meet for pain medications by pain sedation scoring physical dependence, biliary status constipation(Mosbys, 2011 pg. 853). 1

Name: Action:

Norvasc

Inhibits calcium ion influx across cell membrane during cardiac depolarization, produces relaxation of ordinary vascular smooth muscle and peripheral vascular smooth muscle, dilates coronary vascular arteries, increases myocardial O2 delivery in patients with vasospastic angina(Mosbys, 2011 pg. 134). Side Effects: Headache, dizziness, asthenia, anxiety, depression, insomnia, paresthesia, somnolence, peripheral edema, bradycardia, hypotension, palpitations, syncope, chest pain, nausea, commenting, diarrhea,*upset, constipation, flatulence, anorexia, gingival hyperplasia, dyspepsia, dysphagia, nocturia, polyuria, sexual difficulties, rash, pruritus, urticaria, hair loss, fleshing, muscle cramps, cough, weight gain, tinnitus, epistaxis( Mosbys, 2011 pg. 134). Nursing Assess cardiac status B/P, pulse, respirations, ECG, acute in MI after calcium Considerations: channel blockers in obstructive CAD is severe, I&O ratio, weight daily, and China intensity, location, or ration of pain. Evaluate therapeutic response decreased anginal pain, decreased B/P, increased exercise tolerance( Mosbys, 2011 pg. 134).

Name: Action:

Demerol

Depresses pain and calls and mission at the spinal cord level by interacting with opioid receptors(Mosbys, 2011 pg.715). Side Effects Drowsiness, dizziness, confusion, headache, the patient, or yet, increased intracranial pressure, seizures, serotonin syndrome, palpitations, ready cardiac, hypo tension, change in BP, tachycardia, tinnitus, blurred vision, miosis, diplopia, depressed corneal reflex, nausea, vomiting, anorexia, constipation, cramps, biliary spasms, paralytic ileus, urinary retention, dysuria, rash, urticaria, bruising, flushing, diaphoresis, pruritus, respiratory depression, anaphylaxis(Mosbys, 2011 pg. 715). Nursing Assess pain location, type, character, give before pain becomes extreme, reassessed Considerations: after 5 to 10min IV. Renal function prior to initiating therapy poor renal function can lead to accumulation of toxic metabolite and seizures. Assess I&O ratio check for decreasing year-end output may indicate urinary retention, constipation, increase fluids, give stimulant laxatives if needed. Assess for dizziness, drowsiness, hallucinations, euphoria, LOC, pupil reactions, allergic reactions, rash, rested or if this function, depression character, rate, rhythm notify physcian if respirations are less than 12(Mosbys, 2011 pg. 715).

Assess the following systems Neurological: Patient alert and orientated X 3, pupils pinpoint, memory intact, absence of seizures, gait steady without the use of assistive devices, gross motor coordination intact, hand grasp strong/equal, foot presses and pulls strong and equal, speech clear, no visual disturbances. Cardiovascular: S1&S2 present, BP 141/78,P 58,R 20,denies chest pain, edema absent, skin warm to dry, capillary Refill <3 sec. pedal pulses non-palpable, no JVD noted. Respiratory: Breath sounds clear and equal in all lobes, respirations regular and non-labored w/o use of accessory muscles. Mucous membranes pink. Chest excursion, symmetrical and trachea midline no cough present,O2 sat 99% with oxygen running at 3 liters . Musculoskeletal: Pain R hip 8, active range of motion of all extremities, patient independent of all ADLs, good muscle strength, gait steady without use of assistive devices. Patient completed sponge bath without complications with minimal assistance. Gastrointestinal: Bowel sounds active X4, abdomen soft, non-distended, non-tender, tolerates fluid, regular diet, patient consumed 100% of breakfast, 35% of lunch stated did not enjoy lunch as well, absence of nausea, vomiting, cramping and diarrhea. Patient is continent of bowel. Patient reports last BM yesterday without complications. Patient tolerated meals without complications. Genitourinary: Patient continent of bladder, urine was slightly hazey, no unusual odor, bladder non-distended, denies burning and discomfort while urinating. Tolerates oral liquids well. Patient voided 4x normal amount.

Integumentary: T 98,skin turgor normal ,mucous membranes moist, intact without breakdown, no rash, redness or blanching. IV site intact without irritation or redness. Patients lower extremities very dry, no skin breakdown noted. No bruising or skin tears noted.

Nursing Care Plan Student: Margaret olivero Date: 3/2/11 Clients initials: LW Age: 58 Diagnosis: Sickle cell anemia crisis. Diagnosis Definition: A sickle cell crisis occurs when the sickled cells become stuck in larger blood vessels of the body, obstructing blood flow and causing severe pain. Symptoms vary depending upon where circulation is blocked by the sickle red blood cells. Commonly during a sickle cell crisis, circulation to the chest, abdomen, bones, joints, bone marrow, brain, or penis may be compromised. With circulation obstructed, tissue hypoxia occurs, causing severe pain. Patients in a sickle cell crisis often have a fever, either because infection precipitated the crisis or as part of the inflammatory response to tissue hypoxia(Linton,2007 pg. 584). Instructor: Mrs. Roberts Facility: Town & Country

ASSESSMENT

NURSING DIAGN OSIS PROBLEM

GOAL

IMPLEMENTATION & EVALUATION

Interventions & Rationales GOAL MET, NOT MET, PARTIALLY MET

DATA COLLECT ION

SUBJECTIVE DATA:

GOAL/TIME FRAME

DX: Acute pain

Patient states My hip has been hurting since Monday I have sickle cell disease SC type I have two sisters three brothers who also have sickle cell disease RELATED TO: pain level at 8 Sickle cell crisis. I would like to have some prune juice Pain level is at a AS EVIDENCED 6-7 after BY: medication Patient states he administration.

GOAL: The patient will have a pain level of 5 or below by the end of the shift.

has had sickle cell disease since he was nine years old and has experienced a crisis before

OBJECTIVE DATA:

HCT 43.2, PLT336, SEGs 65, lymphs 28, HGG 14.4, WBC 15.57, RDW 20.0, glucose 119, BUN 6, AST 48,Bilirubin 1.64,prot total 8.8, urinalysis slightly hazey 1+ A trace A

Cultural/Psychosocial Concerns: Patient has a history of alcohol use.

1. Monitor patients vital signs and comfort level. Allows for appropriate interventions.( Liefer, 2007) 2.Assess patients knowledge to chronic disease process. Gives you a baseline of the patients knowledge of disease to begin teaching. 3.Assess patients pain level prior to pain medication administration and 30 min. after pain medication administration. Allows evaluation of effectiveness of pain management efforts ( Liefer, 2007). 4. Monitor patients oral intake. Sufficient oral intake decreases pain level. ( Liefer, 2007). 5.Instruct patient to report signs or symptoms of infection promptly. Infection can lead to sickle cell crisis. (Liefer, 2007). 6.Administer o2 as ordered by physician 3liters. Decreases tissue hypoxia which will decrease pain levels(Liefer, 2007).

Goal partially met AS EVIDENCED BY: Patient

originally came in with a pain scale of 10 patients states pain level has been between a 6-7 with pain medication. Safety: 1.Orient patient to room and surroundings. 2.Orient patient to call bell and leave within reach. 3. Instruct patient to call for assistance if dizziness occurs with ambulation. Education: 1.Teach patient to make position changes slowly. 2.Teach patient to prevent sickle cell crisis to maintain good hydration and avoid smoking, alcohol beverages, and high altitudes. 3.Teach patient signs and symptoms of dehydration.

Reference page Linton. (2007) . Introduction to medical-surgical nursing. St .Louis, Missouri: Elsevier Mosby. Skidmore-Roth, L. (2011). Mosbys nursing drug reference. St. Louis Missouri: Elsevier Mosby.

Margaret Olivero Med-Surg care plan Town & Country Acute pain 3/2/11 Related to sickle cell crisis

Mrs. Roberts