Sickle Cell Crisis I. Data Collection Chief complaint/History of Present Illness: You are admitting Tia who is a 14-year-old young woman with Sickle…

Question Sickle Cell Crisis I. Data Collection Chief complaint/History of PresentIllness: You are admitting Tia who is a 14-year-old young woman with Sickle Cell disease who presented to the emergency room early this morning with a 2-week history of worsening headache and 2-day history of diffuse back pain. The headache started after she participated in a week of basketball camp. Tia reports that she has been “sensitive to light.” She denies having had any vision change, although Tia reports that yesterday while still at home she had some tingling in the right side of her face and in her right arm and leg. She has not had any respiratory symptoms and she has not had fever. She had a CBC, UA with culture, and type and crossmatch in the ER. She is to receive packed cells when the blood is ready. Personal/Social History: Lives with parents. Is in the eighth grade. PMH: Mother reports that Tia’s sickle cell clinical course has been mild. She has never had a painful crisis per Mom. She has never had acute chest syndrome. Tia has a history of recurrent urinary tract infections and nasal allergies. Current Medications: Tia and Mother report that Tia’s medications are Tylenol; an iron supplement; Allegra; and folic acid. Patient Care Begins: You are waiting for the lab to send the packed red blood cells for the transfusion. You also need to inform the patient that the MRI will be done later in the morning after the blood is infused. Your Initial VS: T: 99.4 *F P: 98 BPM R: 24 RR BP: 134/62 mmHg O2 sats: 98% Pain: 4/5 on Verbal Analog Scale Weight: 77.2 kg (170 lb 3.1 oz) Height: 179.1 cm (5′ 10.5″) Your Initial Nursing Assessment: GENERAL APPEARANCE: Large for age and appearing older than chronological age. Appears to be in moderate distress with head down and hand on forehead. Cooperative with assessment. RESPIRATORY: Denies SOB or chest pain. Breath sounds equal and with good aeration bilaterally. CARDIAC: Pulses 3+ throughout. No edema in extremities. Heart rate regular- S1 S2 Very soft systolic murmur. NEUROLOGIC: Alert and oriented x4. Complaining of diffuse lower back pain and severe headache and tingling right arm and leg. ABDOMEN/GI: Abdomen soft, non-tender with active bowel sounds. No guarding or tenderness present. GENITOURINARY: Urine clear and yellow. EXTREMITIES/SKIN: Skin is warm and dry-normal for color of skin. IV 20 gauge in right antecubital infusing D5 ½ NS with 10 mEq. KCL. Site without redness or edema. Mucus membranes moist and pale.What data above is relevant to this patient that must be recognized as clinically significant to the nurse?Which labs when trended are showing improvement and/or reveal concerning potential complications?Lab Results: CBC Current ER WBC (4.5-11.0) 13.8 16.8 RBC ( 3.04 2.33 HGB (12-16) 9.8 7.4 PLTS (140-440) 431 407 Neuts. % (42-72) 48 85 Lymphs % (20-44) 39 19 Reticulocytes (0.5-1.5) 32 27.9 Anisocytosis (neg) 1+ Polychromasia (neg) 1+ Hypochromia (neg) 1+ Microcytes (neg) 1+ Ovalocytes (neg) 1+ Target Cells (neg) 1- Sickle Cells (neg) 2+ Schistocytes (neg) 1+ Tear Drop Cells (neg) 1+ Basic Metabolic panel Current ER Sodium (135-145) 139 144 Potassium (3.5-5.1) 4.4 4.9 Glucose (65-100) 126 104 Creatinine (0.5-1.5) 0.5 UA Current Color (yellow) Yellow Clarity (clear) Clear Sp. Grav (1.002-1.030) 1.013 Protein (neg) Neg Glucose (neg) Neg Ketones (neg) Neg Blood (neg) Neg Nitrate (neg) Neg Leukocytes (neg) Trace RBC’s (0-2) 4 WBC’s (0-5) 19 Bacteria (0-few) Many Epithelial (0-few) FewIdentify the relevant lab results to this patient and their clinical significance:II. Evaluation: Evaluate the response of your patient to nursing & medical interventions during your shift. All physician orders have been implemented that are listed under medical management.Eight hours later…VS:                                                     8 Hour Shift I & OT:  98.2P:  72                                            Intake  IV                     888R:  18                                                        enteral             1850BP:  118/60                                   Output                         2385O2 sats: 98%Pain:  1/5  Verbal Analog ScaleWhat VS data is relevant to this patient that must be recognized as clinically significant to the nurse? Health Science Science Nursing NURADN 403 Share QuestionEmailCopy link Comments (0)