1. Document the patient history you obtained for Brittany Long, including previous pain crises, hospitalizations, precipitating events, medical treatment, and home management.
Brittany Long is a 5-year old African Ameri
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1. Document the patient history you obtained for Brittany Long, including previous pain crises, hospitalizations, precipitating events, medical treatment, and home management.
Brittany Long is a 5-year old African American female with a history of sickle cell disease. She has been hospitalized twice, once at 4 years old for a vaso-occlusive crisis episode and once at 3 years for a fever. She does not have any allergies. There were no known precipitating events. Home management includes ibuprofen and and acetaminophen which have been successful in previous pain crisis. Today, 4/6/2020 she presented with right leg pain, a 3-5 pain using the FACES scale, and a loss of appetite. Medical treatment included Normal Saline 250 mL (IV) to treat hypovolemia and morphine 2 mg (IV) for pain.
2. Document your initial focused assessment of Brittany Long.
My initial assessment included vitals signs (Pulse ox, BP, HR, Temp, RR, and pulses), a pain
assessment using the FACES scale, relative history, and then auscultating the lungs and heart as well as examining the right leg.
3. Identify and document key nursing diagnoses for Brittany Long.
-Ineffective peripheral tissue perfusion R/T vaso occlusion due to viscous RBCS AEB skin pallor and coolness
-Acute pain R/T inefficient tissue perfusion and hypoxia AEB tachycardia and self report of pain using the FACES scale.
-Activity Intolerance R/T fatigue, affects of chronic anemia AEB generalized weakness and fatigue
4. Referring to your feedback log, document the nursing care you provided and Brittany Long's response.
1. Washed my hands and identified the patient and relative
2. Checked vitals -Heart rate: 125 (tachycardiac). Pulse: Present. Blood pressure: 107/73 mmHg. Respiration: 25 . Conscious state: Appropriate. SpO2: 98%. Temp: 37.3 C
3. Asked about pain- 3 out of 5 using FACES scale
4. Auscultated the heart and lungs
5. Assessed the right leg- It was warm to the touch
6. Assessed skin- cool and pale
7. Offered juice and a stuffed dog.
8. Assessed the IV site and administered ordered medications and fluids- reassessed breathing The patient stated she felt better! Heart rate: 113. Pulse: Present. Blood
pressure: 101/68 mmHg. Respiration: 19. Conscious state: Appropriate. SpO2: 99%. Temp: 37.3 C
9. Reviewed respirations again
10. Hand off communication
5. Document the patient teaching that you would provide for Brittany Long and her family before discharge, including disease process, nutrition, signs and symptoms of crises, prevention of infection and dehydration, and pain management.
I would include education on the pathophysiology of Sickle cell and what tends to
cause/precipitate a crisis: such as a sudden change in temperature, infection, dehydration, high altitudes, and excessive exercise-due to poor perfusion. Sickle cell is an autosomal recessive,
inherited genetic mutation. It causes red bloods cells to be “sickle shaped” which are less pliable and more viscous. Red blood cells are destroyed which causes anemia. This is a chronic
condition that can cause life-long immunocompromise (spleen dysfunction) but can be managed with the appropriate care. Symptoms of a crisis can include extreme fatigue, shortness of breath or difficulty breathing (dyspnea), headache, dizziness, and acute pain. Diet should include lots of fruits, vegetables, lean meats and whole grains and be low in saturated fats, sodium and sugar. A healthy diet is helpful with staying free from illness/infection. I would also include information on daily low-dose prophylactic antibiotics and folic acid supplements. Sickle cell patients should drink plenty of water (at least 8 glasses) to prevent dehydration. Home management of sickle cell can include pain medications such as acetaminophen, aspirin, and ibuprofen, and then rest and hydration! If pain is not relieved the patient should be taken to the hospital where they will most likely receive stronger medications like morphine, oxycodone, codeine, or hydromorphone and then intravenous normal saline.
How did the simulated experience of Brittany Long's case make you feel?
I felt very empathetic towards Brittany Long. This patient may have been a simulation but real people struggle with this condition. Children have to be cautious their whole lives and feel real pain during a crisis. As a nursing student I felt empowered to be able to help ease her pain. I did well when providing care and that made me happy.
Describe the actions you felt went well in this scenario.
I felt her assessment was very organized and thorough. I tried to gather as much information as possible, without disregarding her pain, to make sure my treatment would be appropriate and
effective. I remembered to Identify the parent, ask about allergies, and do nonpharmacologic interventions like supplying a toy and her favorite juice (to encourage oral intake).
Scenario Analysis Questions*
EBP What is the relationship between fluid and oxygen therapy in the treatment of sickle cell anemia?
Sickle cell anemia causes the destruction of red blood cells which results in a decreased oxygen carrying capacity of the blood. This makes breathing difficult. Oxygen therapy is helpful in
aiding with tissue perfusion and comfort. The sickled red blood cells are less pliable and more viscous- making vaso-occlusion common. Fluid therapy is vital to keep the arterial flow
sufficient and blood volume up (less sickle-cell promoting). More sufficient blood flow is helpful in maintaining perfusion.
EBP What complications might Brittany Long face if her symptoms are not recognized and treated in a timely manner?
Brittany Long could have been at serious risk of sepsis(if an infection) and a cerebrovascular
accident if her symptoms were not recognized and treated in a timely manner. Sickle-shaped red blood cells will occlude blood vessels leading to the brain, causing hypoxemia and result in a
stroke (CVA). Sickle cell also increases the risk of blood clots exponentially. The worst case scenario would be the patient dying due to not recognizing her symptoms.
EBP What methods of pain management did you use and what other methods should be considered for Brittany Long, based on the latest evidence-based practice?
Pain management methods I used to treat the patient’s acute leg pain were the normal saline to hydrate her and slow the sickling process, as well as morphine to directly ease the pain. I also used nonpharmacological methods like giving her a stuffed animal. I could have also used a
warm compress on her leg, massage, and blood transfusions if severe. Other pain medications that can be used are hydromorphone, codeine, oxycodone and oxymorphone.
Ikechukwu, & Okwerekwu. (2018, August 17). Sickle Cell Disease Pain Management. Retrieved from https://www.uspharmacist.com/article/sickle-cell-disease-pain-management
PCC/I What discharge teaching should be provided to assist Brittany Long's mother with her
home care?
Discharge teaching would include precipitating factors of a sickle cell pain crisis like sudden changes in temperature, infection, dehydration, changes in altitude (high), and excessive
exercise. She would also receive information of signs and symptoms of a sickle cell pain crisis like her child saying she is in pain or behaving like she isThis may help Brittany Long’s mother in helping her prevent future crises. Home treatment would be hydration, having a healthy/balanced diet, and using medications like ibuprofen and acetaminophen for pain. The patient’s mother would also be taught on when to bring her child in to the hospital; symptoms
continue or worsen.
S/QI Reflect on ways to improve safety and quality of care based on your experience with Brittany Long's case.
To improve safety and quality of care for Brittany Long I would have administered pain medication earlier and placed a warm compress on her right leg. I could have also distracted her from her pain more with music.
T&C/I Identify additional individuals who should be included on Brittany Long's care team.
A nutritionist could be included to Brittany Longs care team to improve nutritional intake. Long term this would help with preventing future infections and illnesses. I would also refer the patient to a respiratory therapist and a cardiac therapist to help manage acute chest syndrome and other
secondary complications.
T&C/I What key elements would you include in the handoff report for this patient? Consider the situation-background-assessment-recommendation (SBAR) format.
Brittany Long is a 5-year old African American female who came in with sickle cell pain crisis last night 4/5/2020 with her mother. Home medications, acetaminophen and ibuprofen are used at home but did not work. She had a 3 out of 5 pain with the FACES scale located in her leg
with a heart rate of 128, Blood pressure: 110/74 mmHg. Respiration: 25, Conscious state:
Appropriate. SpO2: 98%. Temp: 37.3 C. Her right leg was warm to the touch and pale and cool everywhere else. 250 mL Normal Saline IV and 2mg morphine IV were administered. She has no allergies. Keep checking her vitals and administering scheduled medications. Check her respiratory status after her morphine is administered. Update on the status of her right leg to see if symptoms subside. Repeat CBC. Call the provider if her symptoms worsen or stay the same.
QI Discuss quality-of-care indicators for the management of children with sickle cell disease. If a child with sickle cell disease is able to remain free of crises and stays compliant to care regimen , these are indicators of quality management of the condition. If the child is able to live every-day life with minimal pain and other symptoms this is a success.
***Handoff communication is vital for providing quality care.
Concluding Questions
Reflecting on Brittany Long's case, were there any actions you would do differently? If so, what were these actions, and why would you do them differently?
I would have applied a warm compress to the patient’s right leg to help dilate the blood vessels and I would have administered pain medication quicker. Sickle cell pain crisis can cause severe pain and that is the priority.
Describe how you would apply the knowledge and skills that you obtained in Brittany Long's case to an actual patient care situation.
For an actual patient I would be more educated on their disease process and the affect it has on the body. I would know to do a focused assessment on the location of pain and auscultate the lungs and heart to check for acute chest syndrome. I would know a variety of techniques to manage help manage pain like hydration, warm compresses, massages, and medications
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