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NURS 125 Sickle Cell Clinical Care Plan
- Course
- NURS 125
- Institution
- Raritan Valley Community College
This is a comprehensive and detailed clinical care plan on sickle cell plan for Nurs 125. *An Essential Study Resource!!
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CONCEPT MAP WORKSHEETDESCRIBE DISEASE PROCESS AFFECTING PATIENT
Sickle Cell vaso-occlusive crisis occurs when a patient with sickle cells has a small blood vessel that
becomes occluded due to the sickle shaped red blood cells clumping together. The organ or tissue
downstream of the occlusion become oxygen starved which results in ischemia and pain as well as
tissue damage if the occlusion is not cleared.
(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
CBC to detect anemia, Sickle-turbidity 5yo female admitted with severe Family Hx of sickle cell anemia or
to detect the presence of HbS, Hgb pain 3 ut of 5 on faces scale. Pt sickle cell trait. Reports of severe pain,
electrophoresis to separate and complains of right leg pain and swollen joints, hands and feet.
definitively prove the presence of sickle on examination found warmth to Abdominal pain, hematuria. Shortness
cells, Hgb to determine presence of the touch of her lower right leg. of breath, fatigue, pallor, pale mucus
anemia, WBC to determine presence of On assessment, Pts mother membranes, obstructive jaundice,
infection, Bilirubin and reticulocyte to stated the patient had episodes cool hands and/or feet, dizziness,
evaluate destruction of RBCs, peripheral at 3 years of agew and 5 years of headache and visual disturbances.
blood smears to reveal sickle cells. age and the family had a Hx of Chronic may include respiratory
sickle cell disease. infections, blindness, systolic
murmurs, renal failure, liver cirrhosis
and hepatomegaly, seizures and
skeletal deformities.
DIAGNOSTIC TESTS
(REASON FOR TEST AND RESULTS) PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS
, ANTICIPATED NURSING INTERVENTIONS
- Promote rest to reduce oxygen demands
- administer oxygen if hypoxia is present
- provide hydration therapy while maintaining electrolyte balance
- Monitor I&O
- Give oral fluids
- Admionister IV fluids with electrolyte replacement
- Administer blood products “Packed RBCs”
- Treat and prevent infection
- Administer antibiotics
- Give prophylactic antibiotics
- Maintain vaccine status up to date
- Monitor and report lab values
- Manage patients pain with medication, redirection, heating packs and massage therapy.
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