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Medical Diagnosis: sickle cell anemia with vaso-occlusive crisis
Nursing Diagnosis List
1.Impaired Comfort related to sickle cell anemia as evidenced by acute vaso-occlusive crisis. The patient’s pain should take precedence as the nursing diagnosis, because it is in all-encompassing factor that affects the client’s ability to function within the other areas of Maslow’s hierarchy of physiological needs, such as breathing and sleeping. The pain from the vaso-occlusion makes it difficult for the client to become comfortable enough to rest in addition to other factors that affect sleep patterns. The pain caused by the client’s chest pain also makes it difficult to for her to take deep, adequate breathes and to assess her lung sounds. 2.Ineffective Breathing Pattern related to acute chest syndrome secondary to sickle cell anemia as evidenced by alterations in depth of breathing. Breathing should be prioritized as the secondary nursing diagnosis, because the patient’s sickle cell anemia is presenting her with diminished lung sounds in the lower right lung. Since the primary nursing diagnosis is associated with vaso-occlusion, the client is not getting proper oxygenation to parts of their body, and interventions may include administering analgesics to treat the discomfort, of which an adverse effect may include an altered breathing pattern, it is especially important to pay attention to and assess respiratory functioning in order to treat the effects of smoking and administration of analgesics on respiratory function and assure adequate oxygenation. 3.Disturbed Sleep Pattern related to excessive noise as evidenced by reports of being awakened all night. Disturbed sleep pattern should be prioritized third, because lack of adequate rest can cause fatigue, further discomfort, and decreased ability to function and perform ADL’s which is important to a client’s self-esteem and independence.
Nursing Diagnosis: Acute Pain related to vaso-occlusive crisis secondary to sickle cell anemia as manifested by grimacing and verbalization of pain Outcome/Short Term Patient Centered GoalsPlanning/Interventions ImplementationRationale for interventions/Evaluation
The client will “perform appropriate interventions, with or without significant others, to improve and/or maintain acceptable comfort level,” a 5 or less on a 0-10 pain scale, by the end of the day (Ackley & Ladwig, 2013).
The client will “identify strategies, with or without significant others, to improve and/or maintain comfort level” by the time of discharge (Ackley & Ladwig, 2013).1. “Assess pain intensity level in a client” every hour utilizing a 0-10 pain scale (Ackley & Ladwig, 2013). 2. “Describe the adverse effects of unrelieved pain” every hour along with each pain assessment until patient verbalizes understanding (Ackley & Ladwig, 2013). 3. Teach the client about prescribed medications (oxycodone, for pain), such as how to use it, how often to take it, how much at once, and the desired and adverse effects of it. 4. “Ask the client to report side effects, such as nausea and pruritus, and to describe appetite, bowel elimination, and ability to rest and sleep” by performing an interview every hour while assessing pain level (Ackley & Ladwig, 2013).
1.”The first step in pain assessment is to determine if the client can provide self-report” (Ackley & Ladwig, 2013). 2. “Ineffective management of acute pain has the potential for…neuronal remodelin, an impact on immune function, and long-lasting physiological, psychological, and emotional distress…” (Ackley & Ladwig, 2013). 3. “Instruct the client and family on prescribed medications and therapies that improve comfort” (Ackley & Ladwig, 2013). 4. “Constipation is one of the most common side effects of opioid therapy and can become a significant problem in pain management” (Ackley & Ladwig, 2013).Short-Term Desired Outcomes
The client is able to properly utilize the prescribed oxycodone in their therapy to achieve a comfort level of 5 by the end of the day. Verbalizing an understanding of adverse effects of unrelieved pain helped patient understand the importance of reporting an accurate pain score whenever experiencing discomfort. Goal Met. Nursing interventions for this goal were effective to help the patient achieve a more comfortable state. Long-Term Desired
The client is able to identify and report the side effects of the oxycodone, so that they can report any nausea, constipation, or abnormal sleep patterns to a nurse or physician. Goal met.