Sickle cell disease - Research Proposal Example

?Sickle Cell Disease: The Various Nursing Intervention Approaches to Decrease Pain among Patients in Kendall Regional Hospital In-Patient Section -Abstract Pain is one of the most important characteristic of sickle cell disease. While prevalent to certain race origins, the treatment of, control and reduction of pain among SCD patients has become an integral approach towards delivery of equitable health care services. The patients with SCD has been identified to be mainly from marginalized groups – poor and ethnic minorities. Pain treatment among SCD patients reflects not only the access and availability of health care but also prevailing practices and knowledge about the disease, its prognosis and pathology. This paper will determine the various methods employed in nursing interventions for the treatment, control, and reduction of pain among SCD patients in a Kendall Regional Hospital in-patient section from January 2009 to January 2010. It will also determine the immediate effect of employing such methods. By determining these methods and their frequency of use, it will be able to highlight available options for the underserved patients as well as provide an understanding to best practices, knowledge about the control of pain on SCD patients, what, and how or why a certain method is most or least frequently used. -Introduction Sickle cell disease or SCD has been seen as one of the diseases identified with minority groups or those with less access to health care services. SCD is a genetic disorder with autosomal recessive pattern of inheritance (Pelehach, 1995; Routhieaux, Sarcone, Stegenga, 2005) caused by a single-based mutation of adenine to thiamine resulting in a substitution of valine for glutamine at the 6th codon of the ? globin chain and is usually found from people of African-American, Middle Eastern, African, Afro-Caribbean, Indian or Mediterranean descent (McMahon, Callaghan, O'Brien, and Smith, 2002, 183) This condition usually results in haemoglobin with increased blood viscosity, dehydration, acidosis, or infection polymerise with less deformable red cells (McMahon et al, 2002). The symptoms of SCD which results to vascular occlusion are painful hand-foot syndromes, cerebrovascular occlusions, chest syndromes, and splenic sequestration resulting to splenic atrophy. It is characterized by the failure of the spleen to function optimally even in the first months of birth that usually leads to overwhelming pneumococcal infection, usually at 20% mortality rate for patients under 5 years old (Overturf, 1999). Since access to health care is seen as one of the main problems for SCD patients, it becomes important to identify ways to mitigate its most immediate or important effect on patient which is pain described as chronic, acute or both. Pain management is an important element of care for SCD patients. It is with the related goal to identify pain treatment, control or reduction that this study will proceed. Quality of life is an overarching goal for patients even with those genetic disorders. Pain reduction is usually related to increased patient satisfaction and improved quality of life even in conditions of disease and chronic pain. Chronic pain has been reported by people with SCD even when they now have chances of living a longer life. Use of pain relieving, controlling and treatment method for patients with SCD is then important for the determination of quality delivery of health care services. Various methods are employed in HMO settings to treat SCD patients in reducing, controlling, and treating pain. These are influenced by the pain assessor, patient access, affordability, availability, knowledge and orientation of administrator, and other factors that may be present during prescription or administration. This research will identify the methods used at Kendall Regional Hospital in-patient section, their frequency of use, what is the most popular method preferred, and determine the immediate effect of employing such methods. -Purpose of the study The purpose of this study is to identify the pain reduction methods used during care for patients with SCD at Kendall Regional Hospital in-patient section for the period January 2009 to January 2010. Sickle cell disease is characterized by painful experiences of patients of all ages. The study will identify and chronicle the methods used in reducing or removing pain among SCD patients during the period January 2009 to January 2010 at the Kendall Regional Hospital in-patient section as well as determine the immediate effect of employing such methods. The findings will aid patients and care providers to determine which best will fit their requirement or need as well as inform them of available options as well as best practices. -Specific aims The specific aim of this study is to identify the ways to reduce pain occurrences and pain experience for SCD patients undergoing treatment and nursing care. Daily experiences of pain were reported by patients with SCD. In the reduction of pain, nurses may implement preferred or better options of pain reduction to patients that translate to improved care delivery. Research questions( 2 questions) 1. What nursing interventions and methods were implemented for patients with SCD to reduce incidences and patient experiences of pain? 2. How often were these methods used for SCD patients during the period under study? 3. What are the most immediate effect of employing each method? Hypotheses 1. The various nursing interventions methods employed during the pain management of sickle cell disease patients at the hospital include use of injectable and oral, mixed methods, Recidivism Model Project, Day Hospital, use of NSAIDs, Hydroxyurea, diomorphine, and self-hypnosis. 2. Such methods were seen to help manage and reduce pain experienced by SCD patients. Significance of the problem The problem about pain experiences of patients with SCD is common. Reduction of pain in the delivery of care leads to improved condition as well as patient satisfaction. Patient-centeredness of health care delivery is an integrated approach towards a holistic patient-health-care provider relationship. The findings of this study will add to the knowledge about available options, rationale for preferences by both patients and health care providers, and provision of best practices towards the treatment and control of pain among SCD patients. Review of literature Sickle Cell Disease Also called sickle-cell anemia, SCD is a disorder ad inherited abnormalities of the ? haemoglobin that results to polymerization and sickling of the red blood cells (Steinberg and Brugnara, 2003). Its irregular shape disables the cells to deliver adequate oxygen to the tissues. This damages the tissue and results to pain. The pain has been described as unpredictable, varied, acute, chronic, or acute and chronic (Elander, Lusher, Bevan, and Telfer, 2003). Adegbola (2009) suggested that there had not been an identified method to manage pain for SCD patients adequately. SCD is one of the first diseases identified as based on genetics. It is a monogenic hemoglobinopathy of which the primary dysfunction has been the formation of abnormal beta chains in the haemoglobin molecule. The haemoglobin S or HbS results from the single-based substitution on the gene tasked at encoding human ?-globin subunit of which ?6 glutamic acid is replaced by valine (Bunn, 1997). The HbS when deoxygenized form polymers that cause sickled red-cells and damages the membrane. Other sickle cells adhere to endothelial cells that result to vaso-occlusion and crippling pain and organ damage (Schubert, 2005). Herrick (1910) was the first to identify the sickle-shaped cells in the blood smear of a student with pulmonary symptoms and although molecular and cell biology have provided more modern understanding of SCD, no definite cure and enough understanding has advanced the SCD pathology. And as already highlighted, chronic pain management for patients with SCD is still insufficient (Kutlar, 2005). The average life span of a person with SCD was 14 years until 1973. Recent developments for comprehensive care models has led to increased life expectancy of SCD patients to 42 years while women with haemoglobin C for up to 68 years or more (Claster & Vichinsky, 2003). In the United States, there are about 75,000 people with SCD and that 1 out of 12 African Americans have the sickle cell trait. While it has been suggested that chronic pain is more prevalent and severe during the earlier years of study about the disease, there still are reported daily experiences of pain by SCD patients in more recent cases (Adegbola, 2009). Pain in SCD Pain was extensively studied on crisis events in SCD as well as in adults with SCD. Many SCD adult patients are ambulatory and enter the acute inpatient system for catastrophic events as crises or acute pain and Adegbola (2009) suggested that chronic pain in persons with SCD has rarely been investigated. Advances in treatment for patients with SCD already resulted to lengthened lifespan but patients still experience pain, lower quality of life, depression and mortality at young ages still remain for some patients. However, it was also pointed out that pain and experiences may not be similar between patients even for those with the same genotypic subset (Houston-Yu, Rana, Beyer, & Castro, 2003). SCD patients commonly complain of crippling pain (Edwards, Scales, et al., 2005). Pain was described as “unrelenting, unpredictable, and chronic and is the leading cause of emergency department visits and hospitalizations among adults with SCD,” (Adegbola, 2009, 82). There is also little epidemiological research on the prevalence of chronic pain especially in SCD cases (Adegbola, 2009). For SCD patients, the pain experienced has become a major focus throughout their lives (Newcombe, 2002). SCD pain was also described as complex and past, present and anticipated pain experiences has impacted on the individual’s’ response to life and pain events (Max et al, 2006). Pain among SCD patients has been classified into three: acute, chronic and mixed (Okpala et al, 2002). Ballas (1998) suggested that the pain is caused by the tissue ischema and vaso-occlusion of the microcirculation by sickled cells. The acute pain serves as a warning of the body against possible harmful agents to tissue injury (Ballas, 1998; Ballas and Lusardi, 2005). Pain is said to disappear after the injury has healed although acute pain occurs within a few days to several weeks. The pain may also exacerbate and prolonged to chronic state and results to mixed pain (Todd, 2005). Acute pain in SCD usually leads to tissue infarction (Okpala et al, 2002). In a study conducted by Smith and colleagues (2008) validating the biopsychosocial model for management of adults with SCD pain and their health care use, found that pain among SCD patients were a daily phenomenon and many of the patients struggled with their pain at home than coming to the hospital or ER. Out of the 232 participants, 56% indicated experiencing of pain and only 15% said they rarely suffered pain. One of the more important result of the findings showed that only 4% of the days when they were under study that patients sought treatment (Smith et al, 2008). The study also concluded that patients with SCD may experience pain without necessarily be in crisis. They may be experiencing mixed or chronic pain (Smith et al, 2008). SCD in general has been characterized by severe pain episodes, long-term organ damage, frequent hospitalizations, acute chest syndrome events, stroke and a shortened lifespan Pain Management for SCD In the management of pain for SCD patients, it has been established that SCD patients lacked access to adequate pain management. They usually endure unnecessary waits in the emergency departments and long lengths of hospital stays due to poor pain control. In the end, they are also discharged with persistent moderate to severe pain. Getting opioid prescriptions filled at neighborhood pharmacies were also additional problem for patients and their families (Benjamin, 2008). It has also been suggested that problems on access to treatment include the attitudes of nurses, physicians, and other health care providers with regards to race and ethnicity, opiophobia or opiophilia on opioid use, and biases for persons who complain of recurring and pain (Benjamin, 2008). Okpala et al (2002) suggested that methods of pain relief in SCD may depend on the type of pain presented: acute, chronic or a mixture of the two types, and if the patient is opioid-naive or opioid tolerant. A stepwise approach was also useful similar to determining hypertension (Okpala et al, 2002). A new patient can be asked what types and doses of analgesics have in the past been effective. However, drug-seeking behavior may exaggerate the intensity of their pain or the effective doses of analgesics so as to obtain more medication due to risky behavior (Okpala et al, 2002). A protocol for treating acute or crisis pain for SCD is presented below: Source: Okpala et al, 2002 The practices employed in addressing SCD patients are based on the principles of care and follow sequence of stages. The first stage is assessment where self-appraisal of attitude and readiness in determining the type of the SCD, nature of the pain and the assessment of its importance for the patient. The second stage is treatment and includes planning and execution of an assessment-based management of the illness and pain. The third stage is the reassessment and evaluation of the effectiveness of the treatment employed. This system encompass feedback loops or regimen-adjusting strategies from titration, maintenance, to rescue and taper dosing in order for the health care provider to change original or subsequent treatment based on assessment of the SCD and pain (Benjamin, 2008). There are various methods and medicines used to treat or reduce pain among SCD patients. Use of the medicine Hydroxyurea has been forwarded (HemOnc Today, 2010). This medication has been approved by the FDA in 1998 and widely used for pain control and treatment among adults but its use among children has not been widely documented (HemOnc Today, 2010). Its use, however, was seen as limited. Barrier of use were cited to include lack of knowledge about its effectiveness as a therapeutic option, fears of short and long-term risks, and physicians’ doubts about the ability of the patient or parent to comply with the therapy and the monitoring required (HemOnc Today, 2010). Hydroxyurea has been prescribed to adults with severe sickle cell disease since the mid-1960s. It has not been approved yet for use in children and adolescents with sickle cell disease. The past 25 years showed hydroxyurea’s efficacy and safety in several clinical trials, but its use for SCD was low. This has been attributed to lack of access as well as resources because many of SCD patients in the US are from poor families and from ethnic minorities (Hem Onc Today, 2010). Support for its wider use has been called on federal agencies like the NIH, CDC and HRSA in the form of programs to improve the lives of people with SCD. In addition, SCD patients were also seen as underserved, lacked health insurance, and with limited access to hydroxyurea. It costs about $30 to $40 per month. The drug was seen as effective in adults and adolescents for increasing hemoglobin level, fetal hemoglobin (HbF), mean corpuscular volume and leukocyte count (HemOnc Today, 2010). Hydroxyurea was seen as an effective treatment to decreases pain crises and hospitalizations, the need for blood transfusion therapy, and episodes of acute chest syndrome in adults and adolescents. (HemOnc Today, 2010). Day Hospital, Recidivism Project and Home care models are said to be interdisciplinary team approaches for the optimal result in pain management of SCD patient. It was suggested that the management of pain in SCD “has never been viewed with a straightforward approach by many practicing hematologists, pain experts, or generalists, especially for the adult patient. Pain is the hallmark feature of SCD and the lifetime bete noire for many of the patients. Greater understanding of a disease whose pathogenesis is associated with increased mortality and complex quality-of-life issues and of the lethality of pain itself has made the care of patients with sickle-related pain more urgent and more challenging,” (Benjamin, 2008, P 4). Following is a diagram that illustrates the pain management, age-related complications and continuum in SCD patients: Pain management and age-related complications, and pain on a continuum Source: Benjamin, 2008. The Day Hospital Care Model was adopted at the Bronx Comprehensive Sickle Cell Center (BCSCC) was the Day Hospital (DH). This has been established about 20 years ago in the SCC as an alternative to the Emergency Department (ED) for improved access and quality treatment of acute painful episodes in individuals (Benjamin, 2008). Source: Benjamin, 2008. In the DH, individualization of care uses the basic practices of “rapid assessment, early treatment, frequent reassessment and aggressive titration to relief,” (Benjamin, 2008, P 7). Pain assessment is an integral part of the pain management process although it may turn very complex and difficult if inconsistent or inattentive in appropriating dimensions of pain. Simple self-reporting scales ranging from 0 to 10 with 0 representing “no pain” and 10 representing “the worst possible pain imaginable” is invaluable. However, the health provider should consider that the meaning of the level of pain ranking can fluctuate from one pain episode to another even for the same patient (Benjamin, 2008). It was suggested that the rating scale may be used to base analgesic treatment can lead to suboptimal treatment. Various degrees of facial pain expression in children equivalent to this rating scale has been used in pediatric clinics. Care providers must recognize the multidimensional nature of pain and evaluate dramatic changes in intensity scores with caution, especially in single pain episode (Benjamin, 2008). Assessment of acute or chronic pain that is integrally interwoven into a chronic illness such as SCD should be performed in periodically in multiple domains including physical and emotional functioning, and social and symptom domains. Rating the pain at each site and finding a sum of sites and relief score leads to a more discernable therapy (Benjamin, 2008). Recidivism Model Project The Recidivism Model Project is for frequently recurring ‘acute’ pain. In a single-center study of acute pain recidivism in SCD at Montefiore Medical center, patients presented with great frequency to the DH or the ED as direct visits or often as rapid bouncebacks after discharge from inpatient care (Banjamin, 2008). After biopsychosocial assessments, long-acting opioids were used as an alternative to short-acting opioids to prevent the occurrence of persistent and escalating pain linked to neuroadaptive phenomena of tolerance and physical dependence that can occur with chronic opioid use (Benjamin, 2008). In this model, tapering was also used to prevent withdrawal. Long-acting opioids were also use to replace short-acting opioids in order to stabilize the pain and to normalize the stress response. This is employed because the hypothalamic pituitary adrenal axis can become hyperresponsive during opioid withdrawal (Banjamin, 2008). The goal was to reduce or alter the predominantly inpatient and outpatient hospital-based utilization to home-based life focused on activities of daily living (Benjamin, 2008). Self-hypnosis was proposed by Zeltzer, Dash and Holand (1979) for adolescents with SCD and suggested that the patients gained control over the frequency and intensity of SCD crises. This was seen as effective in recurrent painful vaso-occlusive crises. Okpala et al (2002) also suggested that cognitive behavior therapy helps patients to develop strategies for coping with pain and other psychological disturbances caused by SCD. Combination dosages such as analgesia for acute pain, morphine injections and rapid release preparations at 4-6 hours, and opioids at 2-hourly. These combination methods are used to prevent tolerance developing in patients due to a limited choice of injectable opioids that can be used in acute painful episodes. Combination of analgesics with paracetamol or diclofenac keeps doses of opioids at a minimum (Okpala et al, 2002). Okpala a et al (2002) also recommended multidisciplinary management of SCD pain using analgesic drugs, nerve block, physiotherapy, orthopaedic intervention or surgery, and cognitive behaviour therapy. For mild chronic pain, dihydrocodeine or co-proxamol, a combination of dextropropoxyphene and paracetamol may be used. Pain that cannot be controlled by two tablets every 4-hours is moderate to severe, and morphine is recommended. Oral morphine taken 12-hourly is for long-term analgesia, and smaller amounts of rapid-release oral morphine may be used for breakthrough pain. “A switch from morphine to hydromorphone, or viceversa, is made when tolerance develops to one or other drug; tolerance (the need for increasing doses to maintain the same effects) is a feature of long-term opioid therapy,” (Okpala et al, 2002, p 9). Non-steroidal anti-inflammatory drugs (NSAIDs) relieve the inflammatory component of infarctive (vaso-occlusive) bone pains (Okpala, 2002). Oral diclofenac at 50 mg three times daily or 75 mg twice daily is in combination with analgesic regimen for SCD patient without contraindications such as peptic ulcer, asthma or renal impairment. Suppository diclofenac at 100 mg daily is also an option. A complication of SCD - nephropathy characterized by proteinurea, ranging from microalbuminuria to massive excretion with nephrotic syndrome - can be worsened by NSAIDs (Okpala et al, 2002). Treatment with these agents must be stopped within the next 7 days and patient-controlled analgesia or PCA may be used since these are seen as safe and effective as intermittent opioid injections (Okpala et al, 2002). PCA may be of diamorphine subcutaneous infusions instead of intermittent injections (Okpala et al, 2002). Opioid is an alternative for uncontrolled pain and the amount may be increased in small increments such as diamorphine at 2-3 mg to prevent the risk of central nervous system depression (Okpala et al, 2002). The dose is tailed off gradually rather than stopped abruptly once the pain subsides in order to prevent withdrawal symptoms that can mimic those of sickle-cell crisis (Okpala et al, 2002). This process is applicable to intermittent injections or oral administration of opioids but not to PCA. For patients started on diamorphine of less than 10 mg/injection, opioid is stopped once crisis is resolved (Okpala et al, 2002). In the use of opioids in SCD, side-effects must be prevented or treated. One of the side effects include constipation and should be treated with sodium docusate 100 mg three times daily, lactulose 10-15 mL twice daily or senna 2-4 tablets daily (Okpala et al, 2002). Another side effect is nausea or vomiting and can be relieved with metoclopramide 10 mg or oral or injected cyclizine 50 mg 8-hourly. Pruritus can be treated with oral hydroxyzine 25 mg twice daily but it does not mean allergy to morphine or switching to pethidine. Respiratory depression, a serious side effect requires opioid antagonist such as naloxone (Okpala et al, 2002). Supplementary approaches may be applicable for patients with chronic and severe pain requiring opioid therapy. For pain of avascular necrosis of the hip, shoulder or intervertebral joints, nerve block may be used. In addition, physiotherapy can lessen joint pain, prevent muscle contracture and lessen joint stiffness and physical disability (Okpala et al, 2002). Orthopaedic devices for back support, or for raising the foot to make up for differences in length between the legs, help reduce chronic pain in the hips or back. In some cases of avascular necrosis, orthopaedic surgery is the only treatment that effectively relieves pain but it was emphasized that it be performed as early as possible. Other orthopaedic procedures such as total hip replacement, deferring operation until the pain becomes intolerable is practiced (Okpala et al, 2002). Diamorphine also started to be used instead of pethidine as the analgesic of first choice for acute pain in SCD (Okpala, 2002). Out of 800 adults with the haemoglobinopathy who received treatment, only 3 reacted seriously to diamorphine and receive pethidine. Diamorphine is preferred due to pethidine metabolite causes excitation to the nervous system as well as seizures. According to Okpala et al (2002), “Diamorphine has a longer duration of action, and mass for mass is a more potent analgesic. Whereas diamorphine is soluble enough to be given subcutaneously, pethidine has to be injected into muscle,” (P 8). Repeated intramuscular injections of pethidine also cause muscle fibrosis and contractures and absorption from the injection site becomes less needing increased dosage and resulting to muscle fibrosis and drug dependence or addiction (Okpala, 2002). All the various methods applied to control, reduce or treat all types of pain in SCD will be considered and applied in this study. Methodology This study proposes to find out the various nursing intervention approaches to decrease or address pain among sickle cell disease patients at Kendall Regional Hospital in-patient section for the period January 2010 to January 2011. It will conduct an investigative research at the Kendall Regional Hospital records and nurses’ logs to learn the various methods used to decrease or reduce pain experiences by in-patient and out-patient hospital of the said period. It will also conduct a mini-survey using random sampling among attendant nurses at the hospital who handled SCD cases to determine the most immediate effect of using the pain reduction methods. The various methods shall be identified through the various literatures that listed pain-relieving, treatment, and reduction manners used by medical practitioners and HMOs. Design The research design shall use quantitative research method employing Fixed Effects Model, a quantitative approach towards controlling the un-observed records of sickle cell patients in the hospital, their medication and their nurses’ logs where pain management or related treatment occurred. The data are constant over time and correlated with the independent variables (Christensen, 2002). The fixed effect model assist in controlling for unobserved heterogeneity which are the applied pain control or reduction method used for the period January 2009 to January 2010 in the hospital of which this heterogeneity is constant over time and correlated with independent variables which are the frequency or limitation of use (Christensen, 2002).. The fixed effect model is yit = ?0 + Xit? + Zi? + ?i + uit, where yit is the dependent variable – the various methods applied in nursing intervention to control pain among SCD patients observed for individual i at time t, Xit is the time-variant regressor, Zi is the time-invariant regressor, ?i is the unobserved individual effect, and uit is the error term. ?i could represent institutional factors (Christensen, 2002). In order to arrive at an accurate estimate of the relationship between variables, a descriptive study usually requires a sample of hundreds or even thousands of subjects. For an experiment, it may need only a few subjects (Christensen, 2002). It was suggested that estimate of the relationship is less likely to be biased with a high participation rate in a sample selected randomly from a population. The sample population is the total of SCD patients listed and made available to the researcher in the required period from the hospital. Subject characteristics affect the relationship under investigation due to the requirement per each SCD patient and their pain experiences as well as assessment. To limit the effect, the sample was made less heterogeneous through limitation to one-year period of the observed or needed data about them. The use of various pain relieving or controlling methods will be included and analyzed (Christensen, 2002). First, it will seek consent from the hospital administrators to access the records of sickle cell disease patients for the purpose of this study through formal request. For ethical reasons, the names of the patients shall not be included in this study or the medical and care providers involved. Other data shall also be left behind including medical or health history of patients which will not necessarily aid or contribute to the purpose of this study. It will undertake to sort out the various methods used to reduce pain which data shall be dependent on the methods used such as: use of oral or injectable opiates, mixed methods, Recidivism Model Project, Day Hospital, use of NSAIDs, Hydroxyurea, diomorphine, and self-hypnosis. The mini-survey’s population shall involve several nurses that attended to SCD patients. At this time, target sample is about 20 nurses. A limited number is targeted due to the limited time and resources. The nurses will be asked to answer a questionnaire indicating the effects of using each pain relieving or pain reducing method for SCD patients. Each effect will be marked by the nurses depending on their observation of positive or negative occurrences. Sample The sample of the study shall be dependent on the list of patients with sickle cell disease recorded at the Kendall Regional Hospital in-patient section to be made available to the researcher and limited for the period January 2009 to January 2010. Records of patients prior to or beyond that period shall be excluded. It will be focused on sickle cell disease patients who underwent pain treatment. It is highly probable that individuals may not have secured or sought medical treatment for their SCD or pain experiences and attacks in the area. This will be limited to available records of SCD patients. The mini-survey shall involve a sample of 20 nurses that attended to patients with SCD at the Kendall Regional Hospital in-patient section during the period taken. The sample may vary depending on availability and willingness to participate by the nurses. Setting The setting is in the Kendall Regional Hospital in-patient section. The area has a substantial population afflicted with sickle cell disease to warrant observation of patient records. However, only the records shall be examined and will not engage the actual participation of the subjects and the practitioners although they are an important factor in the accomplishment and completion of the data to be gathered as well as the result of this study. Instruments The instrument to be used is a tabulation sheet that will determine the total frequency of each used method in controlling, reducing or treatment of pain among sickle cell disease patients. Each method shall be tabulated of its frequency used within the period to determine which is the most frequently used and least used. The following may be the simple tabulation form: Method / Treatment Frequency of Use Oral or injectable opiates Mixed methods Recidivism Model Project Day Hospital NSAIDs Hydroxyurea Diomorphine Self-hypnosis After tabulation and computation, the fixed effects model shall be used to determine the data being collected. The nurses at Kendall Regional Hospital in-patient section who attended SCD patients during the inclusive period will also be provided the questionnaire which is an additional instrument in this study. Data analysis An analysis of the data to be determined shall indicate the used methods in pain control, reduction or treatment in order of most frequent to the least. An accompanying explanation may be warranted that will link reasons why a certain method was most preferred, which methods are also influenced not only by assessment, the patient and his or her pain experience, allergy or anti-indication for a drug, as well as preference of assessor and patient, and most importantly, access. Reference: Adegbola, M.A. (2009). Can Heterogeneity of Chronic Sickle-Cell Disease Pain Be Explained by Genomics? A Literature Review. Biological Research for Nursing 11:81. Ballas, S. K. (1998). Sickle cell disease: Clinical management. Baillieres Clinical Haematology, 11, 185-214. Ballas, S. 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Stegenga. (2005). Neurocognitive Sequelae of Sickle Cell Disease: Current Issues and Future Directions. Journal of Pediatric Oncology Nursing 2005 22: 160 Sarcone, S. and K. Stegenga. 2005. Neurocognitive Sequelae of Sickle Cell Disease: Current Issues and Future Directions. Journal of Pediatric Oncology Nursing 22: 160 Schubert, S. (2005). Sickle cell patients find pain relief: New home treatment model reduces hospital emergency visits, inpatient days. Infusion, 11, 23. Smith, W. R., Penberthy, L. T., Bovbjerg, V. E., McClish, D. K., Roberts, J. D., Dahman, B., et al. (2008). Daily assessment of pain in adults with sickle cell disease. Annals of Internal Medicine, 148, 94-101. Steinberg, M.H. and Brugnara, C. 2003. Pathophysiological based approaches to treatment of sickle cell disease. Annual Review of Medicine, 54, 89-112. Todd, K. H. (2005). Chronic pain and aberrant drug-related behavior in the emergency department. Journal of Law, Medicine & Ethics, 33, 761-769. Zeltzer, L., J. Dash, J.P. Holland. 1979. Hypnotically Induced Pain Control in Sickle Cell Anemia, Pediatrics. 1979. From http://pediatrics.aappublications.org/content/64/4/533.abstract Read More