© 2016 Keith Rischer/www.KeithRN.com
Sickle Cell Anemia
Anthony Perkins, 15 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of
... [Show More] emphasis)
1. Pain
2. Clotting
3. Fluid and Electrolyte Balance
4. Clinical Judgment
5. Patient Education
6. Communication© 2016 Keith Rischer/www.KeithRN.com
UNFOLDING Reasoning: ANSWER KEY
Sickle Cell Crisis
History of Present Problem:
Anthony Perkins is a 15-year-old African American male who was at a medically monitored summer camp and
participated in several sports activities when the temperature was greater than 90 degrees. He began having pain in his
knees and was evaluated by the camp nurse. After evaluation, he was transported to his primary care provider where he
was then transferred as a direct admit to the pediatric floor of the community hospital where you are the primary nurse
responsible for his care. He weighs 154 lbs or 70 kg.
Personal/Social History:
Anthony was diagnosed with sickle cell anemia at birth during a routine newborn screening. He was a term newborn with
normal childhood illnesses. He has been hospitalized with pneumonia four times – at age 8, 9, 11, and 14. Although up to
date on his usual childhood immunizations, he only recently became current with his pneumococcal and influenza
vaccines.
Anthony has had multiple hospitalizations for sickle cell crises and transfusions. He lives with his maternal
grandmother (age 65), his maternal uncle (age 31), his half-brother (age 18), and his half-sister (age 7). His mother is
absent and her whereabouts are unknown. His father has never been involved in his life.
The family lives in a three-bedroom, one-bath home with all utilities. The family has an automobile; however, it is not
reliable. The grandmother has never worked and is on Social Security. Anthony’s uncle works a full-time job as a
delivery driver and helps support the family. The children are on Medicaid and Supplemental Nutrition Assistance
Program (SNAP).
What data from the histories are important and RELEVANT and have clinical significance for the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Anthony was attending a medically
monitored summer camp.
Was active in sports at camp, on a very hot
day.
Anthony began having knee joint pain at
camp.
Camp nurses are responsible for medication administration at medically
monitored camps. This would indicate Anthony is compliant with his
medication regime at this time.
Anthony likely became dehydrated through his activities and thermal
heat. This is a clinical RED FLAG that must be recognized by the
nurse! Dehydration can help trigger a sickle cell crisis.
Joint pain is usually one of the first signs of a sickle cell crisis, therefore
this assessment finding is a clinical RED FLAG!
RELEVANT Data from Social History: Clinical Significance:
Diagnosed with sickle cell at birth.
Only recently became current on
pneumococcal and meningococcal vaccines.
Anthony lives with his grandmother, uncle,
and 2 half siblings.
Income for the family is grandmother’s
Social Security and uncle’s wages.
Family automobile is unreliable.
The children are on Medicaid and SNAP
Management of Anthony’s disease has been recognized and available
since he was an infant.
History of pneumonia x 4. Hopefully, with the immunization, this will
help prevent future pneumonia occurrences.
Anthony has family support, although mother and father are absent.
Family’s income is fixed and limited.
It may be difficult for the family to keep appointments and run errands
for medication, etc. Follow up with social services to see if this has been
a problem in the past.
With Medicaid, Anthony is able to access the health care system and
resources for medical care, transportation, prescriptions, and therapies.© 2016 Keith Rischer/www.KeithRN.com
With access to SNAP, Anthony and his siblings have access to healthy
food choices.
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm.
Classification:
Expected Outcome:
*Sickle cell anemia 1. Folic Acid 1 mg po
daily
2. Hydroxycarbamide
200 mg po daily
1. Water-soluble B
vitamin
2. Anti-neoplastic
1. Stimulates production of new red blood
cells.
2. Decreases hgb sickle cells and increases
fetal hgb
(http://www.ncbi.nlm.nih.gov/books/NBK38503/)
Sickle cell anemia>>> Folic Acid 1 mg po daily/ Hydroxycarbamide 200 mg po daily
Patient Care Begins:
The nurse recognizes the need to validate concern about fluid volume deficit, performs a set of orthostatic VS
and obtains the following:
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
T: 99.4 F. (37.5 C.) (oral)
P: 92
BP: 102/74
Lying:
HR: 92
BP: 102/74
Standing:
HR: 132
BP: 92/42
Though normal, the temperature is always relevant because of the possible
complication of infection/sepsis.
Heart rate is elevated at rest. This could be as a result of pain, or dehydration.
Remember the importance of the patho formula: CO=SVxHR. The first
compensatory response by the body is to elevate HR in order to maintain
adequate cardiac output.
Though this BP is technically within normal range, the nurse must recognize that
it is in the LOW range of normal for an adolescent who is 70 kg. Is likely
confirming fluid volume deficit.
Review the definition of an abnormal orthostatic BP finding. An increase in the
heart rate of 20 beats or more from lying baseline to standing is by itself a
POSITIVE finding and is usually seen in mild to moderate dehydration from my
clinical experience.
If a decrease in 20 points or more of mm/Hg in SBP is seen from lying to standing
in addition to the increase in HR, this reflects moderate to severe fluid volume
deficit/dehydration.
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 99.4 F. (37.5 C.) (oral) Provoking/Palliative: Movement and weight bearing/Rest, elevation, warm compresses
P: 92 (regular) Quality: “My knees are really hurting…deep ache”
R: 20 (regular) Region/Radiation: Bilateral knees
BP: 102/74 Severity: 8/10
O2 sat: 96 Timing: Constant since around noon today
Position: HR: BP:
Lying 92 102/74
Standing 132 92/42© 2016 Keith Rischer/www.KeithRN.com
Because he has both a drop of BP and increase in HR as well as being
symptomatic, this confirms moderate to severe fluid volume
depletion/dehydration.
What assessment data is RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Assessment Data: Clinical Significance:
Uneasy in bed, changing position
frequently
Increased respiratory effort, nasal flaring
Pulses strong and palpable at radial/
pedal/ post-tibial landmarks
Urine clear/dark amber in color
No priapism present
Knees swollen bilaterally; erythemic,
warm to touch; decreased ROM of knees;
pain reported with movement
RED FLAG– patient is clearly uncomfortable and will need pain control.
RED FLAG – patient is demonstrating increased work of breathing. Patient
must be observed closely for worsening respiratory status.
Yellow alert – this patient is susceptible to complete occlusion; current
assessment is reassuring; however, pulses must be assessed completely and
frequently.
Dark amber color is a result of concentration of urine seen with
dehydration.
Priapism, defined as a sustained, painful, and unwanted erection, is a wellrecognized complication of SCD. Priapism tends to occur repeatedly. When
it is prolonged, it may lead to impotence.
According to one study, the mean age at which priapism occurs is 12 years,
and, by age 20 years, as many as 89% of males with sickle cell disease have
experienced one or more episodes of priapism. Priapism can be classified as
prolonged if it lasts for more than 3 hours or as stuttering if it lasts for more
than a few minutes but less than 3 hours and resolves spontaneously.
Stuttering episodes may recur or develop into more prolonged events
(Maakaron, J.E. & Taher, A.T. 2015).
RED FLAG – assessment reflects inflammatory response and vasoocclusion; this must be monitored very closely for complete occlusion;
patient must be treated for this very painful condition; complications could
include complete occlusion and bone necrosis.
Current Assessment:
GENERAL
APPEARANCE:
Uneasy in bed, changing position frequently, cooperative and responds to questions
appropriately.
RESP: Breath sounds clear with equal aeration bilaterally, increased respiratory effort; mild nasal
flaring noted; no tracheal tugging, no retractions.
CARDIAC: Pink, warm and dry, no edema, heart sounds regular with no abnormal beats, no murmur
noted, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, denies chest
pain.
NEURO: Alert and oriented to person, place, time, and situation (x4).
GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants.
GU: Voiding without difficulty, urine clear/dark amber in color, no priaprism present.
SKIN: Skin integrity intact.
MUSKULOSKELETAL: Knees swollen bilaterally, erythemic, warm to touch, decreased ROM of knees, pain
reported with movement.© 2016 Keith Rischer/www.KeithRN.com
Lab Results:
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
WBC 10.5
Neutrophil %: 55
Hgb 9.8
Hct 28.5
Retic 2.6
IRF 30.8
Not significantly elevated therefore presence of infection is
likely low. Continue to TREND closely
First responder to infection/inflammation. Though normal it
is confirming absence of systemic response to infection or
inflammation.
Decreased ability for RBCs to carry oxygen. Due to sickle
cell anemia this is EXPECTED
Decreased volume of RBCs in the blood available for
circulation. Due to sickle cell anemia this is EXPECTED
Bone marrow is attempting to produce more RBCs.
In an effort to produce more RBCs, bone marrow is sending
out immature cells.
No concerning trends of labs.
Acceptable ambiguity is
present.
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
Creatinine 1.5
BUN 38
GOLD standard to assess renal function. Creatinine
elevation could be due to volume depletion/dehydration or
could represent kidney damage as a complication of sickle
cell crisis. Will need further evaluation. Monitor closely and
TREND over the next 24-48 hours.
Though not as specific as creatinine to assess renal function,
it does elevate in acute renal failure as well as dehydration.
Monitor closely and TREND over the next 24-48 hours.
Worsening
Worsening
Complete Blood Count (CBC:) Current: High/Low/WNL? Previous:
WBC (4.5–11.0 mm 3) 10.5 WNL 9.5
Hgb (12–16 g/dL) 9.8 Low 10.2
Hct (36.0 – 46.0%) 28.5 Low 30.2
Platelets (150-450 x103/µl) 385 WNL 425
Neutrophil % (42–72) 55 WNL 65
Band forms (3–5%) -0- WNL 0
Retic (0.5 – 1.5%) 2.6 High 1.4
IRF (9.0 – 18.7%)
(Immature reticulocyte fraction)
30.8 High 22.8
Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Previous:
Sodium (135–145 mEq/L) 139 WNL 143
Potassium (3.5–5.0 mEq/L) 4.2 WNL 4.5
Glucose (70–110 mg/dL) 106 WNL 95
BUN (7–25 mg/dl) 38 High 6
Creatinine (0.6–1.2 mg/dL) 1.5 High 0.5© 2016 Keith Rischer/www.KeithRN.com
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
Specific Gravity 1.038
Protein Trace
Ketones Trace
Bilirubin 1+
Urine is concentrated,
Supportive of dehydration diagnosis
This is a yellow flag – warrants watching but not alarming.
Could be due to exercising at camp.
Ketones are a byproduct of fat breakdown. This is a yellow
flag - warrants watching. This could be due to inadequate
calorie intake during exercise.
Bilirubin would be expected in a sickle cell patient due to
the rapid breakdown of RBCs. This is a yellow flag and
warrants watching.
Urine specific gravity,
protein, and ketones have
normalized due to the
hydration. The bilirubin is
likely a chronic condition due
to the breakdown of RBCs
seen in sickle cell anemia.
Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required:
Creatinine
Value:
1.5
Normal Value:
0.5-1.2 mg/dl
Critical value:
>1.5
*End product of creatine
metabolism, which is performed in
skeletal muscle
*Gold standard for kidney function
because creatinine is produced in
consistent quantity and rate of
clearance reflects glomerular
filtration
*Assess I&O closely
*Daily weights
*Fluid restriction if ordered
*Assess for signs of fluid retention/edema
Van Leeuwen, A. & Poelhuis-Leth, D.J.
(2009)
Clinical Reasoning Begins…
1. What is the primary problem that your patient is most likely presenting with?
Sickle cell crisis
2. What is the underlying cause/pathophysiology of this concern?
The abnormal cells (Hgb S) are sickle shaped, leading to vaso-occlusion and pain. This condition is often
precipitated by dehydration.
Repeated and prolonged sickling involves the membrane; the RBC assumes the characteristic sickled shape. After
recurrent episodes of sickling, membrane damage occurs and the cells are no longer capable of resuming the
biconcave shape upon reoxygenation. Thus, they become irreversibly sickled cells. From 5-50% of RBCs
permanently remain in the sickled shape. Sickle RBCs adhere to endothelium because of increased stickiness
(Maakaron & Taher, 2015).
Urine Analysis (UA:) Current: WNL/Abnormal? Previous:
Color (yellow) Yellow WNL Yellow
Clarity (clear) Clear WNL Clear
Specific Gravity (1.015-1.030) 1.038 Abnormal 1.010
Protein (neg) Trace Abnormal Neg
Glucose (neg) Neg WNL Neg
Ketones (neg) Trace Abnormal Neg
Bilirubin (neg) 1+ Abnormal 1+
Blood (neg) Neg WNL Neg
Nitrite (neg) Neg WNL Neg
LET (Leukocyte Esterase) (neg) Neg WNL Neg© 2016 Keith Rischer/www.KeithRN.com
Collaborative Care: Medical Management
Care Provider Orders: Rationale: Expected Outcome:
Morphine patient controlled
analgesia (PCA) 1 mg
continuous, PCA dose 1 mg
every 10 minutes
Initiate IV fluid therapy of
D5 ½ NS with 20 MEq KCL
@ 120 ml/hr
Complete blood count
(CBC)
Reticulocyte count
Basic metabolic panel
(BMP)
Urine analysis (UA)
Apply Oxygen, 2 liters per
minute (LPM) via nasal
cannula (NC)
Sickle cell patients require opioids for the severe pain
that is a result of crises. PCA administration allows the
patient to control pain quickly with no need to wait for
the nurse to administer.
Hydration will help prevent vaso-occlusion of the
sickled cells. Will also help transport normal hgb/
oxygen to the organs.
Establish current hematologic status
Establish current hematologic status
Establish baseline metabolic function. Evaluate renal
function
Establish baseline renal function
Increase available O2 for oxygenation
Decreased pain.
Decreased vaso-occlusion,
decreased pain, increased
oxygenation.
Likely reveal anemia. Rule out
metabolic imbalance. Establish
renal function.
Decreased work of breathing,
increased oxygen saturation.
No change from baseline
Decreased work of breathing,
increased oxygen saturation
PRIORITY Setting: Which Orders Do You Implement First and Why?
Care Provider Orders: Order of Priority: Rationale:
Morphine patient controlled
analgesia (PCA) 1 mg
continuous, PCA dose 1 mg
every 10 minutes
Initiate IV fluid therapy of
D5 ½ NS with 20 MEq KCL
@ 120 ml/hr
Apply O2, 2 LPM, via nasal
cannula (NC)
1. Initiate IV fluid therapy of
D5 ½ NS with 20 MEq
KCL @ 120 ml/hr
2. Morphine patient
controlled analgesia
(PCA) 1 mg continuous,
PCA dose 1 mg every 10
minutes
3. Apply O2, 2LPM, via NC
1. IV access must be initiated immediately to begin
rehydration. Is also a circulatory or “C” priority. IV
access is also essential to pain control.
2. Pain control is a very high priority for sickle cell
patients. Pain control will help decreased O2
demands, as well.
3. Although supplemental O2 is not considered beneficial,
it is often performed in clinical practice. If oxygen
saturation is >95% has ? benefit, therefore it is not a
true “B” or breathing priority.
Medication Dosage Calculation:
Medication/Dose: Mechanism of Action: Volume/time frame to
Safely Administer:
Nursing Assessment/Considerations:
Ketorolac 30 mg
IV push every 6
hours
Inhibits prostaglandin
synthesis, producing
analgesia. Also has
antipyretic and antiinflammatory effects.
30 mg/1 mL vial
Volume/time frame:
0.5 mL every 15
seconds
Use for short-term management of pain
<5 days
Onsets in 10 minutes, peak effect in 1-2
hours, lasts 6 hours. Use this
knowledge to reassess pain in 60-90
minutes after administration
Minimal side effects, can cause
bleeding.
Contraindicated with renal disease. Is
an injectable NSAID© 2016 Keith Rischer/www.KeithRN.com
3. What nursing priority(s) will guide your plan of care? (if more than one-list in order of PRIORITY)
C (circulatory priority): Ineffective tissue perfusion
C (circulatory priority): Fluid volume deficit
Acute pain/control of pain
In the care plan below, encourage your students to see the relationship between these three priorities and how by
addressing the “C” priorities of fluid volume deficit, it will also influence tissue perfusion and even help decrease pain as
hydration is improved.
4. What interventions will you initiate based on this priority?
Nursing Interventions: Rationale: Expected Outcome:
Establish peripheral IV and administer IV
fluids and pain medications
Apply warm compresses to knees.
Dehydration can precipitate pain, since
acidosis results in a shift of the oxygen
dissociation curve, causing hemoglobin to
desaturate more readily. Hemoconcentration
also is a common mechanism.
Warm compresses help with pain and vasodilate vessels to prevent occlusion.
Improved oxygenation
to cells
Decreased pain
Decreased pain and
vaso-occlusion through
vasodilation
Additional Nursing Interventions:
Assist patient to adjust bed position to
position of comfort.
Position of comfort is very individualized. Comfortable position
will lead to decreased
pain and decreased
oxygen demands.
5. What body system(s) will you most thoroughly assess based on the primary/priority concern?
Circulatory system, respiratory system
6. What is the worst possible/most likely complication to anticipate?
Acute chest syndrome (pulmonary embolus) is leading cause of death in adults.
Complete vaso-occlusion of vessels- peripheral circulation may be impacted as well as organ perfusion–including
peripheral and cerebral arteries that can cause a CVA.
Infection/sepsis
o Life-threatening bacterial infections are a major cause of morbidity and mortality. Recurrent vasoocclusion induces splenic infarctions and consequent autosplenectomy, predisposing to severe infections
with encapsulated organisms (eg, Haemophilus influenzae, Streptococcus pneumoniae) (Maakaron &
Taher, 2015).
7. What nursing assessment(s) will you need to initiate to identify this complication if it develops?
Oxygenation status must also be closely monitored (RR, O2 sat)
Pedal, post-tibial pulses must be assessed frequently to assure complete vaso-occlusion does not occur.
Baseline neuro assessment to assess for any neuro changes
8. What nursing interventions will you initiate if this complication develops?
Any of the most likely complications require EARLY recognition and prompt notification of the primary care provider so
the nurse must know who to contact. For any impaired oxygenation concerns be prepared to administer oxygen to
maintain O2 sat >92% and raise the HOB.
9. What psychosocial needs will this patient and/or family likely have that will need to be addressed?
Emotional support
Knowledge and education about what is taking place and what the care priorities will be in the days ahead© 2016 Keith Rischer/www.KeithRN.com
10. How can the nurse address these psychosocial needs?
Emotional support
o BE PRESENT and AVAILABLE. See the section on caring at the end of this case study for more
information.
Knowledge and education about what is taking place and what the care priorities will be in the days ahead
o The nurse can integrate patient/family education naturally while providing care by simply explaining at
their level everything that the nurse/physician has ordered and WHY it needs to be done. This is why it is
essential for the nurse to know and DEEPLY understand the rationale for both the physician and nursing
plan of care; so it can be readily taught and explained to the patient/family at a level they can
understand.
Evaluation:
Evaluate the response of your patient to nursing and medical interventions during your shift. All physician orders have
been implemented that are listed under medical management.
Two hours later…
1. What clinical data is RELEVANT and must be recognized as clinically significant?
RELEVANT VS Data: Clinical Significance:
HR now 72
RR now 14
HR has decreased – likely due to hydration and pain control.
RR has decreased – likely due to pain control and less oxygen demand from
the body (patient is resting now)
RELEVANT Assessment Data: Clinical Significance:
Patient is more restful in the bed now.
No nasal flaring.
Hydration and pain control are effective.
Oxygen demands have decreased, resulting in decreased work of breathing.
This, coupled with hydration and pain control have improved patient’s
respiratory status.
Current VS: Most Recent: Current PQRST:
T: 99.0 (37.2 C) (oral) 99.4 (37.5 C) (oral) Provoking/Palliative: Movement and weight bearing/Rest,
elevation, warm compresses
P: 72 (regular) 92 (regular) Quality: “My knee pain is a little better, still ache”
R: 14 (regular) 20 (regular) Region/Radiation: Bilateral knees
BP: 112/68 112/74 Severity: 4/10
O2 sat: 97% RA 96% RA Timing: Constant since around noon today
Current Assessment:
GENERAL
APPEARANCE:
Resting quietly in bed. Cooperative and responds to questions appropriately.
RESP: Breath sounds clear with equal aeration bilaterally; nasal flaring has ceased; no tracheal
tugging, no retractions.
CARDIAC: Pink, warm and dry, no edema, heart sounds regular with no abnormal beats, no murmur
noted, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks; denies chest
pain.
NEURO: Alert and oriented to person, place, time, and situation (x4)
GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants.
GU: Voiding without difficulty, urine clear/yellow; no priaprism.
SKIN: Skin integrity intact
MUSKULOSKELETAL: Knees swollen bilaterally; erythemic, warm to touch; decreased ROM of knees; pain
reported with movement.© 2016 Keith Rischer/www.KeithRN.com
2. Has the status improved or not as expected to this point?
Status has improved. Work of breathing has decreased. Patient is more comfortable. Vital signs are reassuring and
trending in the right direction.
3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?
No. Nurse must continue to closely monitor current situation and care. Fluids, pain control and monitoring of renal
function must be vigilant.
4. Based on your current evaluation, what are your nursing priorities and plan of care?
Priorities remain hydration and correcting fluid volume deficit, pain control, and monitoring of I/O (monitor renal
function).
It is now the end of your shift. Effective and concise handoffs are essential to excellent care and
if not done well, can adversely affect this patient’s care. You have done an excellent job to this
point, now finish strong and give the following SBAR report to the nurse who will care for this
patient:
Situation:
Name/age:
Anthony Perkins is a 15-year-old male
BRIEF summary of primary problem:
He was at a medically monitored summer camp and participated in several sports activities when the temperature was
greater than 90 degrees. He began having pain in his knees and was evaluated by the camp nurse.
Background:
Primary problem/diagnosis:
Increased pain/sickle cell crisis
RELEVANT past medical history:
Anthony was diagnosed with sickle cell anemia as a newborn (Newborn screening and Sickledex); he has had multiple
hospitalizations for transfusions and treatments of crises
Assessment:
Most recent vital signs:
T: 99.0 (37.2 C) (oral)
P: 72 (regular)
R: 14 (regular)
BP: 112/68
O2 sat: 97% RA
RELEVANT body system nursing assessment data:
GENERAL APPEARANCE: Resting quietly in bed. Cooperative and responds to questions appropriately.
MUSKULOSKELETAL: Knees swollen bilaterally; erythemic, warm to touch; decreased ROM of knees; pain reported
with movement.
Current PQRST:
Provoking/Palliative: Movement and weight bearing/Rest, elevation, warm compresses
Quality: “My knee pain is a little better, still ache”
Region/Radiation: Bilateral knees
Severity: 4/10
Timing: Constant since around noon today© 2016 Keith Rischer/www.KeithRN.com
Education Priorities/Discharge Planning
1. What will be the most important discharge/education priorities you will reinforce with his medical condition to
prevent future readmission with the same problem?
Pacing activities and maintaining hydration are paramount education priorities with Anthony.
Anthony is very familiar with his condition. However, it is likely he became engrossed in an activity, did not drink
enough fluids, and became dehydrated.
Nursing staff should stress to Anthony that he must be aware of his condition at all times. He should be supported
in being a self-advocate, as well. He is coming into adulthood and he needs to be empowered to advocate for his
care. In this instance, he could have advocated for a break or more fluids.
2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?
Anthony should be able to verbalize understanding of the teaching. The nurse can also perform role playing
exercises in order to give Anthony experience at advocating for his care and needs. This will empower Anthony to
be the advocate he will need to become as an adult.
Caring and the “Art” of Nursing
1. What is the patient likely experiencing/feeling right now in this situation?
Anthony is likely very disappointed that he is missing out on his camp experience. Peers and peer relationships are
very important to adolescents. It is likely Anthony is worried about what his friends think/feel about his health
condition and need to leave camp for treatment. He may be embarrassed that he had to leave camp.
2. What can you do to engage yourself with this patient’s experience, and show that he matters to you as a person?
Anthony must be given time to rest and recover from the initial pain of the crisis before intervention begins.
If he is in a great deal of pain, he will not be receptive to sharing and opening up to the nurse.
It is sometimes difficult for teens to imagine adults as teens. If the nurse had experienced a similar instance
of embarrassment or disappointment as a teen, it may be helpful to share this with Anthony. The nurse should
be a non-judgmental ear and be willing to listen to Anthony when he feels able to share his feelings.
RELEVANT lab values:
Hgb: 9.8
IRF: 30.8
Creatinine: 1.5
UA: sp. gr: 1.038
Protein: trace
Ketones: trace
How have you advanced the plan of care?
IV established
IV fluids initiated to rehydrate
Ketorolac given for pain
Patient response:
Pain has decreased with ketorolac
INTERPRETATION of current clinical status (stable/unstable/worsening):
Stable, gradually improving
Recommendation:
Suggestions to advance plan of care:
Continue hydration and pain control with morphine PCA. Warm compresses have been helpful for knee pain, as well.
Follow creatinine and BUN closely.© 2016 Keith Rischer/www.KeithRN.com
Nursing staff should also encourage Anthony to keep in touch with peers and family members through visits
as tolerated. If this is not possible (transportation issues, etc.), then perhaps Facebook, Twitter, or FaceTime
would be options to help Anthony.
Use Reflection to THINK Like a Nurse
Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention
in the moment as the events are unfolding to make a correct clinical judgment.
1. What did I learn from this scenario?
Have students share and reflect
2. How can I use what has been learned from this scenario to improve patient care in the future?
Have students share and reflect
Author
Kimberly Hill, DNP, RN, Assistant Professor, University of Arkansas at Little Rock
Reviewers
Linden Fraser, RN, MSN, Nursing Faculty, Nicolet College, Rhinelander, Wisconsin
References
Maakaron, J.E. & Taher, A.T. (2015). Sickle Cell Anemia. Retrieved from
http://emedicine.medscape.com/article/205926-overview#a4
Swanson, K.M. (1991). Empirical development of a middle range theory of caring. Nursing Research, 40(3), 161–166.
Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing
Education, 45(6), 204–211.
Vallerand, A.H., Sanoski, C.A., & Deglin, J.H. (2014) Davis’s drug guide for nurses. (14th ed.). Philadelphia, PA: F.A.
Davis Company.
Van Leeuwen, A. & Bladh, M.L. (2015). Davis’s comprehensive handbook of laboratory and diagnostic tests with
nursing implications. (6th ed.). Philadelphia, PA: F.A. Davis Company. [Show Less]