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Outline
Overview
Pathophysiology
A hereditary disease that destroys red blood cells by causing them to become rigid and “sickle” shaped. Occurs mainly in persons of African descent. When red blood cells release oxygen to the tissues and O2 concentration is reduced, the red cells and become rigid, assuming a sickle shape. The sickle-shaped cells become clogged in the small blood vessels causing obstruction of the circulation. This results in damage to the various tissues.
Etiology
A single genetic mutation of the hemoglobin molecule. Inheritance of the mutated gene from both parents results in sickle cell disease. A person who inherits the mutated gene from only one parent is a carrier of the trait. There is no cure for this condition.
Desired Outcome
Manage pain of SC crisis, promote optimal perfusion and prevention of complications
Sickle Cell Anemia Nursing Care Plan
Subjective Data:
- Fatigue
- Pain crisis
- Severe pain
- All over body
- Shortness of breath
- Chest pain
- Irritability
Objective Data:
- Swelling of hands / feet
- Fever
- Jaundice
- Cyanosis
- Presence of sickled cells on histologic exam
Nursing Interventions and Rationales
- Assess respiratory status
- Rate
- Use of accessory muscles
- Cyanosis
- Monitor cardiac status
- Perform 12-lead ECG
- Assess for and manage pain
- Administer medications
- Apply warm compresses
- Clogged vessels result in damage to the tissues and organs which causes intense throbbing pain that may change location from one body part to another.
- Avoid using cold compresses as cold causes further vasoconstriction and exacerbates pain and crisis. Warm compresses dilate vessels to promote circulation and reduce pain and muscle tension.
- Administer medications / blood products as necessary
- IV fluids (prevent or treat dehydration)
- Analgesics for pain – opioids may be used
- Antibiotics for infections
- Hydroxyurea – prevents sickling of red blood cells to reduce the number of crisis episodes
Medication is given to manage the symptoms of a crisis event and treat any underlying infections that may cause a crisis. In some cases, blood transfusions may be necessary to manage crisis events and increase perfusion to vital organs.
- Monitor vital signs carefully
- Monitor respiratory status and breath sounds
- Assess for signs of infection
- Fever
- Assess for and manage dehydration
- Provide wound care as necessary
- Encourage routine eye exams
- Monitor vital signs closely
- Minimize stress
- Teach guided imagery techniques
- Encourage deep breathing exercises
- Provide resources for stress management
- Assess for changes in consciousness and mentation
References
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