Care Plan - Essay Example

?NURS 401 NURSING CARE PLAN Part ____________________________________ submitted:_________ Patient Initials: S.B Age/Sex: 21 y.o./ Male Medical Diagnosis: Sickle cell anemia I. Etiology and Pathophysiology: Sickle cell anemia is an inherited autosomal recessive trait, more common in African American race, that results in morphologically and functionally abnormal red blood cells. When these cells are exposed to blood with a low oxygen tension such as in the venous system, the normally round and pliable disk- shape RBCs change to a rigid and sickle- shape deformity. Furthermore, the abnormally elongated shape has an increased tendency to pile up, form clumps, and block minute vascular systems especially capillary beds. Specifically, limitation of tissue oxygenation directly due to a sluggish blood flow is the major pathophysiologic feature of sickle cell anemia. End- organ damage may result when tissue hypoxia is prolonged, which then can lead to death (Smeltzer & Bare, 2006, p. 886). II. Clinical Manifestations (Signs & Symptoms): Severity of the clinical manifestations depends largely on the proportion of RBCs that have sickled. That is, when more cells are sickled, the chances of thrombosis also increase, thus causing decreased oxygen supply to tissues and organs. Pain is one of the most common manifestations as hypoxic tissues generate lactic acid that easily irritates nerve endings and other pain receptors. When the heart tissue is involved, acute chest pain manifests and more commonly associated with tachycardia, fever, falling hemoglobin levels, and sometimes bilateral infiltrates seen on the chest x-ray. Since these cells have relatively shortened life- span, simultaneous hemolysis raises blood bilirubin level up to toxic levels. This is manifested as jaundice. Complications result from chronic hemolysis or thrombosis (Smeltzer & Bare, 2006, p. 887). III. Treatment and Nursing Management: The primary standards of treatment with sickle- cell anemia include a bone marrow transplant (BMT), hydroxyurea, and long- term RBC transfusion. Although the BMT can potentially provide a cure for the condition, this therapy is often limited by the difficulty in finding a compatible donor. In addition, other organs might have been already damaged and their functions reduced due to chronic hypoxia before BMT is initiated. On the other hand, chemotherapy using hydroxyurea increases hemoglobin F levels in affected patients, therefore reducing the formation of sickle cells. Still, there has been no evidence yet if the drug reverses organ damage. Lastly, chronic RBC transfusion is particularly helpful in acute exacerbations of the condition causing severe anemia and infections. However, the patient may also develop complications due to iron overload and thrombosis (Smeltzer & Bare, 2006, p. 888). Nursing interventions are focused on providing continuous pain relief by prompt administration of pain medications prescribed by the physician and helping the client relax and reduce anxiety. Prevention of infection by maintaining a therapeutic environment and using aseptic technique in nursing procedures performed must be an integral part of the care plan. IV. Diagnostic Studies/Lab analysis: Blood tests reveal the presence of sickle RBCs. WBC Count- 9x103/mm3 (N: 3.54-9.06 x103/mm3). Hemoglobin level is 7 mg/ dl (N- 13- 16 mg/dl) which implies anemia and decreased tissue oxygenation, thus, necessitating blood transfusion. Discharge Planning and Client Teaching Continue medications as prescribed by physician. Determine learning needs and educate as necessary especially the common triggers of an exacerbation. Inform S.B. and his mother about his increased risk of acquiring infection and provide directions to prevent it. Caution about severe chest pain and other signs of exacerbations that warrant immediate hospitalization. NURS 401 NURSING CARE PLAN Growth and Development According to Erickson Stage: 6 Crisis: Intimacy vs. isolation (Videbect, 2007, p. 53) I. Describe your patient’s ability to achieve growth and development tasks. The major growth and developmental tasks for this period is to form a meaningful relationship with another person. Prior to this admission, S.B. has been able to establish closeness with other people aside from his family. Since he has just entered this period, he is still expected to fulfill this task. II. How is this ability affected by the underlying disease process and/or the current admission? Physical limitations may have interfered with S.B.’s attempt to approach other people and establish an intimate relationship. S.B. has an unsteady gait. When he was still an adolescent, his chronic condition might have affected his self- esteem, thereby interfering also his ability to relate with his age- group. III. List nursing actions to assist your client in meeting their growth and developmental needs. 1. Encourage S.B. to establish and maintain an open communication with his family. 2. Maintain an effective pain management because inadequate relief can increase his feelings of powerlessness. 3. Focus on S.B.’s strengths rather than weaknesses in the care plan to increase his sense of control of his condition. 4. Increase S.B.’s knowledge of his condition especially on how he can prevent frequent exacerbations. IV. List in priority order all relevant nursing diagnoses for your patient. 1. Acute pain related to tissue hypoxia due to agglutination of sickled cells within blood vessels 2. Risk for infection related to decreased protective function of the immune system 3. Deficient knowledge regarding sickle crisis prevention References Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 68, 72). Philadelphia: W.B. Saunders. Smeltzer, S.C. & Bare, B.G. (2006). Brunner and Suddarth's textbook of medical-surgical nursing, 12th ed. Philadelphia, PA: Lippincott Williams & Wilkins. Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 30-34). St. Louis: Mosby. Videbect, SL. (2007). Psychiatric mental health nursing (4th ed). New York: Lippincott Williams and Wilkins. Morgan State University NURS 401 – Nursing Process and Health Assessments Nursing Care Plan Part 2 Assessment Data Nursing Diagnosis (according to NANDA) Nursing Actions List in order of priority. Label aspect of care. Patient Non-Verbal State the rationale for each nursing action. Cite reference and page number. Evaluation Evaluate each nursing action. S.B., 21 yo, diagnosed as having Sickle cell anemia. He is currently scheduled for a blood transfusion. Subjective: “I have been having pains but this one is unbearable,” as verbalized. Objective: Pain score of 8 in a scale of 10 Guarding position noted Tensed abdominal muscles noted Vital signs BP 120/60 mmHg Resp 20 cpm Pulse 60 bpm O2 sat 98 Acute pain related to tissue hypoxia due to agglutination of sickled cells within blood vessels. Assess level of pain in a regular basis and as necessary. (Physiologic) Administer pain medications as ordered by physician. (Physiologic) Demonstrate and encourage performance of nonpharmacological techniques such as relaxation and breathing techniques to lessen pain experience. (Learning) Encourage to verbalize feelings about situation. (Psychosocial) Pain is managed easier when it is milder (Ignatavicius & Workman, 2006, pp 68, 72). For severe pain, analgesics are required on a regular basis to prevent aggravation and prolongation of suffering. This type of pain does not respond to relaxation techniques that well (Ignatavicius & Workman, 2006, pp 68, 72). Relaxation techniques are effective interventions to lessen the demand for pain and prevent overdose of analgesics (Ignatavicius & Workman, 2006, pp 68, 72). Verbalization of feeling help ease the psychosocial burden of illness (Stuart & Laraia, 2005, pp. 30-34). Pain was assessed every 2 hours and every patient contact as seen necessary. Pain medications were ordered by physician and administered as scheduled. Pain score reduced from 8 to 4 within the eight- hour time frame. S.B. performed relaxation and breathing exercises as demonstrated and is willing to perform on a regular basis. S.B. was emotional in dealing with current condition. Expected Outcome: After 8 hours, S.B. will have relief and adequate control of pain. Pain score will be 4 in a scale of 10. Evaluate each expected outcome: Goal met. After 8 hours, S.B. experienced relief from pain and verbalizes effective ways to lessen pain like relaxation and breathing techniques. Pain scale is 4. Read More