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Acute Pain

By rggsux Jul 30, 2013 427 Words
Nursing Diagnosis: Acute pain related to vasoocclusive crisis hypoxia, which causes cells to become rigid and elongated, thus forming the crescent shape as evidenced by tenderness on palpation and complaint of localized pain.

Goal: Be relaxed and comfortable with controlled pain (<2/10) throughout stay until discharge.
Interventions| Rationale|
Assess knowledge of disease and prescribed management| Patients need to understand that sickle cell anemia is a chronic lifelong disease in which they play a vital role in effective management| Assess for pain characteristics: severity, location, type, duration| Pain can be severe requiring large doses of medication. Pain may be reported as tenderness or inability to move.| Monitor laboratory values and electrophoresis for amount of sickling| A severe decrease in functioning RBC’s may indicate the need for replacement transfusion of packed RBC’s| Administer prescribed IV and oral fluids (6-8 L/day)| Fluids promote hemodilution, which reverses agglutination of sickle cells.| Use distraction devices such as television, movies, cell phone | This can facilitate pain control.|

Nursing Diagnosis: Potential for repeated sickle cell crises related to ineffective disease management as evidenced by repeated admissions (4 in 12 months)
Goal: Verbalize understanding of sickle cell disease and how to prevent crises within 7a-3p shift.
Interventions| Rationale|
Teach patient to avoid situations that increase cellular metabolism ie. Strenuous physical activity, contact sports, emotional stress and high altitudes| The patient may not understand her ability to follow the prevention and treatment plan.| Assess pattern of physical activity| Regular, non strenuous exercise is recommended.| Assess current eating habits| Knowledge of patient’s food preferences, eating habits, attitudes about food developing an individualized nutritional plan| Set aside time to talk to the patient when the patient’s pain is controlled| During crisis, the patient is distracted by the pain therefore less receptive to teaching.| Teach about the importance of fluid intake | Adequate fluid intake will help prevent blood stasis and sickling|

Nursing Diagnosis: Risk for infection related to decreased number of normal red blood cells Goal: Will remain free from infection until next appointment Interventions| Rationale|
Ensure thorough handwashing by patient and any caregiver and visitor| Reduce spread of infection by effective handwashing| Teach importance of meticulous hygiene, oral and perianal/perineal care| Reduce risk for infection reducing risk for skin breakdown| Encourage frequent position changes, coughing and deep breathing exercises| Promotes ventilation of all lung segments to help prevent pneumonia| Administer prescribed IV and oral fluids (6-8 L/day)| Fluids promote hemodilution, which reverses agglutination of sickle cells.| Monitor vital signs | Reflective of inflammatory process which is first sign of infection|

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