SICKLE CELL DISEASE
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Acute pain r/t After 6 hours of N.I a.) Maintain adequate fluid a.) Dehydration After 6hours
sharp, achy, or intravascular the patient will be intake increases of N.I the
throbbing pain sickling due to able to: b.) Apply heat packs to the sickling/vaso- patient was
as verbalized agglutination of painful areas occlusion and able to:
by the patient sickled cells A.) verbalize c.) Encourage the patient corresponding a.) Verbalize
within the blood relief or to do a non- pain. a relief or
Objective: as evidenced by control of pharmacologic regimen b.) Warmth causes control of
Pain scale: a pain scale of pain with a (Relaxation techniques, vasodilation and pain
6/10 6/10, facial pain scale of deep breathing increases b.) Decrease
Facial grimace grimace, 4/10 from techniques) circulation to pain from
(+) irritation, and 6/10 d.) Advice the patient not hypoxic areas. 4/10 to 6/10
Irritated (+) change in vital to go in the high c.) Cognitive- c. Return
signs altitude areas behavioral pain vital signs
BP-130/90 e.) Promote bed rest management back to its
HR-105 f.) Monitor vital signs may reduce normal range
T-37.9 g.) Administer medications reliance on
as ordered pharmacological BP: 120/90
h.) BT as ordered means of pain HR:80
control. T: 37.2
d.) High-altitude
areas has less
oxygen which
can precipitate
to clumping of
RBCs
e.) It reduces the
metabolic
demand of the
body, thus
improving
healing and
recovery.
f.) To establish
baseline data
g.) For better
control of pain
h.) The frequency
of painful sickle-
cell crises may
be reduced by
routine partial
exchange
transfusions to
maintain the
population of
normal RBCs.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Impaired gas After 6 hours of N. I the A.) Elevate the head a.) To provide After 6hours of N.I
Nahihirapang exchange related patient will be able to: of the bed/ clients with the patient was able
huminga ang to altered position the client stability and to:
aking anak” oxygen-carrying a.) Demonstrate appropriately comfort,
as verbalized capacity of blood improved gas B.) Encourage the which will a.) Demonstrate
by the secondary to exchange as patient to rest and leave them improved
patients sickle cell evidenced by have enough calmer and ventilation
mother disease as oxygen saturation sleep more relaxed. and
evidenced by greater than 95%. C.) Monitor vital signs b.) To reduce the adequate
Objective: dyspnea, b.) Participate in the D.) Assist the client in metabolic oxygenation
Irritability (+) irritability, and treatment turning, coughing, demand of of tissues by
Dyspnea (+) changes in vital regimen (e.g., and deep- the body, HBGs within
signs breathing breathing thus clients
HR: 110 exercises, exercises. improving normal
RR: 28 effective E.) Advise the patient healing and limits
O2- 89% coughing, use of to limit activities recovery b.) Clients vital
oxygen) within within the c.) To establish signs were
the level of patient’s baseline data slightly back
ability/situation. tolerance. d.) Promote to its normal
F.) Administer expansion of range
supplemental the chest
humidified oxygen optimally,
as indicated. mobilization
G.) Administer packed of secretions,
RBCs or exchange and aeration
transfusion as of all lung
ordered. fields.
e.) Reducing the
metabolic
requirements
of the body
would reduce
the oxygen
requirements.
f.) Supplemental
oxygen
maximizes
the transport
of oxygen to
the tissues.
g.) Increasing the
number of
oxygen-
carrying cells
dilutes the
percentage of
HbS to
prevent
sickling,
improves
circulation,
and
decreases the
number of
sickled cells.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: N/A Ineffective tissue After 6hours of N.I the A.) Maintain a.) Maintains After 6hours if N.I
perfusion related patient will be able to: adequate circulating the goal was
Objective: to the vaso- fluid intake volume to partially met as
occlusive nature of a.) Demonstrate B.) Monitor I maximize evidenced by slight
Edema (+) sickle cells leads to increased and O tissue increased perfusion
Pallor (+) clumping of RBC perfusion as C.) Monitor perfusion as manifested by
Cool skin (+) evidenced by Vital signs b.) Dehydration increased in
the presence of D.) Maintain causes an peripheral
Low strong bed rest increase in pulses ,hemoglobin
hemoglobi peripheral E.) Provide sickling and (120g/L),
n pulses, absence safety by occlusion of hematocrit (40%)
(99g/L )an of edema, and raising side capillaries but still with the
d warm skin rails up other than presence of
hematocri temperature F.) Render hypovolemia edema, pallor and
t level health or a decrease cool skin
(30%) b.) Demonstrate teachings in blood
Capillary behaviors and such as volume.
refill time lifestyle changes eating c.) To establish
(3 to improve foods rich baseline data
seconds) circulation in iron d.) Restricted
Weak G.) Provide activity
peripheral oxygen as reduces
pulse required. oxygen
H.) Transfuse demands of
PRBCs as the body
prescribed. e.) Weakness,
fatigue and
restlessness
are signs of
hypoxia which
may cause
injury to the
patient
f.) Iron is an
essential
element for
blood
production.
g.) Administratio
n of oxygen
will help
increase
oxygen and
tissue
perfusion.
h.) Transfusions
of red blood
cells enhance
the quantity
and quality of
healthier,
more flexible
red blood
cells to
reduce
complications.
