Devon's Nursing Care Plan
(Version 1.0, June 25, 2020)
Saint Louis University School of Nursing
Mary Ann Lavin, DSc, RN, APRN, FNI, FAAN, Associate Professor and Nurse Lead
Sickle Cell Disease Team
- Gilbert Jones, MD, MSc (Med Ed), Adjunct Assistant Professor
- Deborah Loman, PhD, APRN, CPNP, Associate Professor
- Karen S. Moore, DNP, APRN, ANP, BC, Assistant Professor
- Nina K. Westhus, PhD, RN, CPN, Associate Professor
|NANDA Domains and Classes||Diagnoses1||Interventions||Evaluation|
||Ineffective self-health management or impaired self-health management edducation||Provide copy of: NLM & CDC (2011). Sickle Cell Disease:Symptoms, Diagnosis, Treatment and Recent Developments of Sickle Cell Anemia. Atlanta: CDC.||Evaluate patient/family satisfaction|
Possible dehydration -- determine if patient was exposed to excessive heat/exercise on 4th of July. (For additional lists of factors precipitating SCD crises, see:
At risk for decreased food intake, if crisis is prolonged.
If patient is to be hospitalized, inform RN during hand-off to monitor food intake as SCD patients decrease food intake during painful episodes (Jacab, Miaskowski, Savadra et al., 2006)
|Elimination and exchange
||Monitor pulse oximetry (Children’s Hospital and Regional Medical Center, Seattle WA, 2006)||Maintain at ≥92% of baseline value (Children’s Hospital and Regional Medical Center, Seattle WA, 2006)|
||At risk for decreased activity and sleep||If patient is to be hospitalized, inform RN during hand-off to monitor activity and sleep as each is disrupted during SCD crises (Jacab, Miaskowski, Savadra et al., 2006)|
At risk for HIV
At risk of infection, r/t hydroxyurea medication
Rapid HIV assay screen as per CDC 2006 recommendations (Branson, Handsfield, Lampe, et al).
Monitor temperature, report elevation
Chronic/persistent pain with frequent, severe episodes (crises), with hip and lower extremity pain predominant today (Devon is among the 20% of SCD patients in this high pain frequency category per (Children’s Hospital and Regional Medical Center, Seattle WA, 2006)
At risk for racial stereotyping by providers, e.g., having requests for pain being labeled as drug seeking behavior.
At risk for delaying medical care for fear of being stereotyped as drug seeking.
At risk for being under medicated by self for fear of being labeled a drug seeker or by others, because patient is stereotyped as a drug seeker.
Chronic SCD pain, with frequent crises.
Determine cause of frequent pain episode’s in Devon’s case and develop with Devon a cause-specific plan. Common causes among adolescents are:
If needed, advocate for appropriate pain medication e.g., morphine + ketorolac), dosing and scheduling during crises.(Pasero & McCaffery, 2011)
Teach other professionals as needed that:
Discuss with patient and family advantages of prompt and appropriate treatment even while expressing that his desire to delay care is understandable -- just that it leads to greater pain.
Make sure that pain diary includes pain medication (dose and frequency) record as well.
If pain diary is unavailable, ask patient for a best possible recall of pain medication use during last 24 hours and during last week.
Administer morphine sulfate with the following dosing schedule: 0.05 – 0.1 mg/kg/dose IV every 2 hours or 0.01 – 0.1 mg/kg/hour per continuous infusion or via PCA ((Children’s Hospital and Regional Medical Center, Seattle WA, 2006)
If the morphine dose actually ordered is suboptimal, advocate for higher dose as per the guidelines of the
If the patient is to be hospitalized and PCA used, instruct patient on
Once pain is controlled, instruct patient to record pain intensity at least twice daily each day at home and identify its location (Children’s Hospital and Regional Medical Center, Seattle WA, 2006). Perform more frequent evaluations, as needed before and after each pain intervention.
Consider adding/ recommending high dose Vit D i.e., cholecalciferol (Osunkwo, Ziegler, Alvarez, et al., 2012)
Consider adding/advocating for addition of SSRI/anticonvulsant adjuvant pain therapy (Jerrell, Tripathi, Stallworth. 2010).
Discuss analgesic needs/changes with patient and family (Children’s Hospital and Regional Medical Center, Seattle WA, 2006)
Determine if patient uses cannabis for pain reduction and relaxation purposes (Howard, Anle, Holdcroft, Korn, Davies, 2005; Knight-Madden, Lewis, Hambleton, 2006).
Instruct patient that there are genetic variations in people. Some of these genetic variations are at increased risk of expressing themselves in the presence of cannabis use during adolescence. For example, in people with one genetic feature, the incidence of schizophrenia is higher among those who used cannabis in their teens (Caspi et al., 2005; Borgelt, Franson, Nussbaum, Wang, 2013).
Discuss with patient the above pros and cons in addition to the legal issue involved in cannabis use.
Determine is the above indicated genetic variant test is available for bedside clinical use.
Contact social worker/home health nurse to follow-up on possible causes of frequent ED use and presence/absence of primary/specialty care for patient.
Evaluate medication, dosing and schedule ordered to determine its effectiveness in relieving pain intensity (Jacob, Miaskowski, Savedra, 2005). If intensity is not decreasing, then advocate for more effective analgesia.
If analgesia is not attained, call/recommend interprofessional team conference.
Insure that pain at discharge is less than moderate and that patient/family are confident about its control within home.
Ask social work/er/home health nurse to follow-up on this teaching.
Obtain patient’s report of pain before first dose and then monitor at two hour intervals or more frequently, if needed.
Have home health nurse follow up on hydroxyurea use.
Monitor outcomes with pain and analgesic medication diary.
Reevaluate cannabis use at next encounter with social work/home health nurse. If using, monitor mental health status.
Have patient monitor their effectiveness, using pain diary.
||Adolescent, age 15||
Determine what other complementary measures patient uses to relieve pain, e.g., rest, distraction, heating pad (Children’s Hospital and Regional Medical Center, Seattle WA, 2006)
Suggest to patient that there are technologies available to communicate with providers, wirelessly, should he like to pursue this possibility (Jacob, Paylish, Duran et al., 2012).
Begin patient-centric methods of transitioning to adult care (Jordan, Sverdiow, Coates, 2013).
1The notion that only NANDA approved diagnoses are the only acceptable diagnoses or clinical judgments that professional nurses make is erroneous. The NANDA diagnoses represent that that have been submitted and approved by NANDA but that does not preclude recognizing that patients with sickle cell disease are at risk of being stereotyped as drug seeking or, for that matter, any number of other clinical judgments that direct the patient centered care nurses provide.
2Developmentally appropriate pain tools include The Numeric Rating scale (NRS) of the Oucher Pain Scale (Beyer & Aradine, 1986, 1888, 1998; Jacob, Miaskowski, Savedra, et al., 2007) and Adolescent Pediatric Pain Tool (Savadra, Tesler, Holzemer, et al., 1989,1993; Crandall M, Savedra M, 2005; Jacob, Miaskowski, Savedra, et al., 2007).