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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”( Mosby’s, 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”( Mosby’s, 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”(Mosby’s, 2011 pg. 853). 1
715). anorexia. flatulence. LOC. rash. Assess I&O ratio check for decreasing year-end output may indicate urinary retention. acute in MI after calcium Considerations: channel blockers in obstructive CAD is severe. weight gain. 2011 pg. Nursing “Assess cardiac status B/P. cramps. Side Effects: “Headache. miosis. and China intensity. Nursing “Assess pain location.*upset. palpitations. pruritus. allergic reactions. dysuria. anxiety. anaphylaxis”(Mosby’s. pupil reactions. 2011 pg. Evaluate therapeutic response decreased anginal pain. increase fluids. blurred vision. diplopia. give stimulant laxatives if needed. hypo tension. tachycardia. chest pain. nausea. dizziness. 2011 pg. the patient. pruritus. increases myocardial O2 delivery in patients with vasospastic angina”(Mosby’s. somnolence. polyuria. 134). dizziness. commenting. dyspepsia. type. decreased B/P. flushing. constipation.715). headache. rate. Assess for dizziness. tinnitus. rhythm notify physcian if respirations are less than 12”(Mosby’s. 134). paralytic ileus. Name: Action: Demerol ”Depresses pain and calls and mission at the spinal cord level by interacting with opioid receptors”(Mosby’s. character. nausea.Name: Action: Norvasc “Inhibits calcium ion influx across cell membrane during cardiac depolarization. nocturia. give before pain becomes extreme. vomiting. increased exercise tolerance”( Mosby’s. epistaxis”( Mosby’s. depressed corneal reflex. paresthesia. respiratory depression. bradycardia. peripheral edema. 2011 pg. I&O ratio. seizures. 2011 pg. or ration of pain. syncope. reassessed Considerations: after 5 to 10min IV. palpitations. bruising. anorexia. produces relaxation of ordinary vascular smooth muscle and peripheral vascular smooth muscle. or yet. constipation. diaphoresis. gingival hyperplasia. fleshing. dilates coronary vascular arteries. dysphagia. hair loss. serotonin syndrome. confusion. pulse. urticaria. 2 . 134). rash. ECG. diarrhea. depression character. muscle cramps. drowsiness. 2011 pg. sexual difficulties. tinnitus. euphoria. cough. insomnia. change in BP. ready cardiac. 715). Renal function prior to initiating therapy poor renal function can lead to accumulation of toxic metabolite and seizures. urinary retention. depression. weight daily. respirations. biliary spasms. hypotension. asthenia. Side Effects “Drowsiness. hallucinations. rested or if this function. constipation. increased intracranial pressure. location. rash. urticaria.
O2 sat 99% with oxygen running at 3 liters . Tolerates oral liquids well. good muscle strength. absence of seizures. Patient’s lower extremities very dry. vomiting. Gastrointestinal: Bowel sounds active X4. active range of motion of all extremities. capillary Refill <3 sec. pedal pulses non-palpable.skin turgor normal . respirations regular and non-labored w/o use of accessory muscles. foot presses and pulls strong and equal. Patient reports last BM yesterday without complications. cramping and diarrhea. abdomen soft. 35% of lunch stated “did not enjoy lunch as well”. absence of nausea.mucous membranes moist. Genitourinary: Patient continent of bladder. intact without breakdown. redness or blanching. hand grasp strong/equal. urine was slightly hazey. no visual disturbances.P 58. Patient tolerated meals without complications. symmetrical and trachea midline no cough present. denies burning and discomfort while urinating. skin warm to dry. edema absent.R 20. pupils pinpoint. regular diet. Integumentary: T 98. Patient voided 4x normal amount. patient independent of all ADLs. non-tender. Patient completed sponge bath without complications with minimal assistance. no rash. no JVD noted. tolerates fluid. bladder non-distended. BP 141/78. 3 .denies chest pain. gait steady without the use of assistive devices. memory intact. non-distended. Chest excursion. patient consumed 100% of breakfast. gross motor coordination intact. Mucous membranes pink. speech clear. No bruising or skin tears noted. gait steady without use of assistive devices.Assess the following systems Neurological: Patient alert and orientated X 3. Patient is continent of bowel. IV site intact without irritation or redness. Musculoskeletal: Pain R hip 8. no unusual odor. Cardiovascular: S1&S2 present. Respiratory: Breath sounds clear and equal in all lobes. no skin breakdown noted.
584). joints. circulation to the chest. bones. either because infection precipitated the crisis or as part of the inflammatory response to tissue hypoxia”(Linton.2007 pg. Commonly during a sickle cell crisis. brain. Patients in a sickle cell crisis often have a fever. obstructing blood flow and causing severe pain. or penis may be compromised. Symptoms vary depending upon where circulation is blocked by the sickle red blood cells. causing severe pain. Instructor: Mrs. abdomen. tissue hypoxia occurs.Nursing Care Plan Student: Margaret olivero Date: 3/2/11 Client’s initials: LW Age: 58 Diagnosis: Sickle cell anemia crisis. With circulation obstructed. Roberts Facility: Town & Country 4 . bone marrow. Diagnosis Definition:” A sickle cell crisis occurs when the sickled cells become stuck in larger blood vessels of the body.
Instruct patient to report signs or symptoms of infection promptly. 2007). 3. Monitor patient’s vital signs and comfort level.Administer o2 as ordered by physician 3liters. HGG 14. has had sickle cell disease since he was nine years old and has experienced a crisis before” OBJECTIVE DATA: HCT 43.Teach patient to prevent sickle cell crisis to maintain good hydration and avoid smoking. 6. lymphs 28.prot total 8. BUN 6. (Liefer. 4. Safety: 1. Gives you a baseline of the patient’s knowledge of disease to begin teaching. Decreases tissue hypoxia which will decrease pain levels(Liefer.Bilirubin 1.57. Instruct patient to call for assistance if dizziness occurs with ambulation. SEGs 65.Orient patient to room and surroundings. 3.Teach patient signs and symptoms of dehydration.0.Assess patient’s knowledge to chronic disease process. 2007). Sufficient oral intake decreases pain level. ( Liefer. AST 48. 5 . “I would like to have some prune juice” “Pain level is at a AS EVIDENCED 6-7” after BY: medication Patient states ”he administration. 2007).Assess patient’s pain level prior to pain medication administration and 30 min. 5.2. PLT336. GOAL: The patient will have a pain level of 5 or below by the end of the shift. after pain medication administration. NOT MET. Allows for appropriate interventions. 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. alcohol beverages. WBC 15. 3.( Liefer. glucose 119. urinalysis slightly hazey 1+ A trace A Cultural/Psychosocial Concerns: Patient has a history of alcohol use.Teach patient to make position changes slowly.8.4.64. 2. 2007) 2. 1. and high altitudes. 2007).ASSESSMENT NURSING DIAGN OSIS PROBLEM GOAL IMPLEMENTATION & EVALUATION Interventions & Rationales GOAL 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. Infection can lead to sickle cell crisis. RDW 20. Monitor patient’s oral intake.Orient patient to call bell and leave within reach. Allows evaluation of effectiveness of pain management efforts ( Liefer. 2. Education: 1.
L. Missouri: Elsevier Mosby. (2011). 6 .Louis. St. Louis Missouri: Elsevier Mosby. (2007) . Skidmore-Roth.Reference page Linton. Mosby’s nursing drug reference. St . Introduction to medical-surgical nursing.
Margaret Olivero Med-Surg care plan Town & Country Acute pain 3/2/11 Related to sickle cell crisis Mrs. Roberts 7 .
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