ANJAE KRISTELLE D.
GARIANDO
BSN 3-2
Case Study, Chapter 33, Management of Patients With Nonmalignant Hematologic
Disorders
1. Angela Clayton, a 7-year-old girl, was diagnosed with sickle cell disease at birth. She
was outside playing in the snow when she developed severe abdominal pain. Her
parents immediately took her to the emergency room suspecting a sickle cell crisis.
(Learning Objective 3)
a. Describe the nursing process for the patient with sickle cell crisis:
Assessment:
Pain assessment should always be done. Pain should be carefully
monitored and measured on a 0-10 scale, as well as the location and type
of the pain should be documented. The abdomen is assessed for pain and
tenderness because of the possibility of splenic infarction.
Careful assessment of all body systems is necessary notably circulatory
and respiratory systems.
Cardiopulmonary systems must be assessed carefully
Assessed for signs of dehydration by a history of fluid intake and careful
examination of mucous membranes, skin turgor, urine output, and serum
creatinine and blood urea nitrogen values.
Neurologic examination
MRI and Doppler studies
Assessed by the hemoglobin level, hematocrit, and reticulocyte counts;
these are compared with the patient’s baseline values.
Patient’s current and past history of medical management is also
obtained, particularly chronic transfusion therapy, hydroxyurea use, and
prior treatment for infection.
Diagnosis:
Acute pain and fatigue related to tissue hypoxia due to agglutination of
sickled cells within blood vessels
Risk for infection
Risk for powerlessness related to illness-induced helplessness
Deficient knowledge regarding sickle crisis prevention
Nursing Intervention: Managing Pain
Any joint that is acutely swollen should be supported and elevated until the
swelling diminishes.
Relaxation techniques, breathing exercises, and distraction.
After the acute painful episode has diminished, aggressive measures
should be implemented to preserve function (Physical therapy, whirlpool
baths, and transcutaneous electrical nerve stimulation (TENS)).
Nursing Intervention: Managing Fatigue
Assisting the patient to find an appropriate balance between exercise and
rest to develop strategies to cope with daily life demands in the setting of
chronic fatigue.
Maximizing nutrition, hydration, healthy sleep cycles, and diminishing
tissue hypoxia can all serve to minimize fatigue.
Nursing Intervention: Preventing and Managing Infection
Monitoring patients for signs and symptoms of
infection.
Prescribed antibiotics should be initiated promptly, and patients should be
assessed for signs of dehydration.
If patients are to take prescribed oral antibiotics at home, they must
understand the importance of completing the entire course of antibiotic
therapy.
Providing the patient with opportunities to make decisions about daily care may
increase the patient’s feelings of control.
Patients with SCD benefit from understanding what situations can precipitate a
sickle cell crisis and the steps they can take to prevent or diminish such crises.
Keeping warm and providing adequate hydration can be effective in diminishing
the occurrence and severity of attacks.
Monitor and manage potential complications.
Nursing Evaluation
Control of pain and fatigue
Absence of infection
Expresses improved sense of control
Enhanced sense of self-esteem and power.
Increases knowledge about disease process
Absence of complications.
2. Mary Saeger, a 56-year-old woman, is receiving outpatient chemotherapy for bladder
cancer. A round of chemotherapy consists of gemcitabine on day 1 and day 8.
Cisplantin is administered on day 2. A CBC with differential is ordered prior to the
chemotherapy on day 1, day 8, and 1 week after the chemotherapy. The absolute
neutrophil count (ANC) is 489/mm³ at 1 week after the chemotherapy. The patient’s
temperature is 97.6°F. (Learning Objective 5)
a. What is the significance of the absolute neutrophil count?
The actual number of neutrophils, known as the absolute neutrophil count
(ANC), is determined by a simple mathematical calculation using data
obtained from the CBC and differential. It is significant as neutrophils are
responsible for the body’s immune response against infection. The risk of
infection increases proportionately with the decrease in neutrophil count
such as when it is less than 500/mm3. The patient has low neutrophils
(489/mm³) than the normal range thus, indicates infection.
b. Based on the reason for the neutropenia, what medical management would you
anticipate?
Withholding or reducing the dose of chemotherapy may be required when
the neutropenia is caused by this treatment. On the other hand,
administration of growth factor is considered to be preferable so that the
maximum effect can be achieved by maintaining the chemotherapy
regimen as originally planned.
.
c. What patient teaching will the nurse provide to the patient?
The nurse will need to instruct the patient on how to limit their risk of
infection.
o To reduce the risk of infection, state modifications in lifestyle (e.g.,
food, activity) or home environment are required.
o Maintain proper hand, oral, and total body hygiene, as well as skin
integrity.
o Avoid cleaning birdcages and litter boxes; garden work (dirt) and fresh
flowers in stagnant water are also to be avoided.
o Maintain a high-calorie, high-protein diet with a 3000 mL daily fluid
intake (unless fluids are restricted).
o People with infections should be avoided, as should crowds.
o Show how to keep an eye out for indicators of infection.
o Describe who to report indicators of infection to, how to report them,
and when to do so.
