Event 2: Nursing Care Plan

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, Diagnoses, Interventions, and Evaluation
NANDA Domains and Classes	Diagnoses¹	Interventions	Evaluation
Health Promotion Health awareness Health management	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
Nutrition Ingestion Digestion Absorption Metabolism, incl. blood glucose Hydration	Possible dehydration -- determine if patient was exposed to excessive heat/exercise on 4th of July. (For additional lists of factors precipitating SCD crises, see: (Children’s Hospital and Regional Medical Center, Seattle WA, 2006) At risk for decreased food intake, if crisis is prolonged.	Check BUN 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 Urinary function Gastrointestingal function Skin function Respiratory function	Respiratory function At risk for hypoxemia	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)
Activity/rest Sleep/rest Activity/exercise Energy balance Cardiovascular/pulmonary Self-care	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)
Perception/cognition Attention Orientation Sensation/perception Cognition Communication
Self-perception Self-concept Self-esteem Body image
Role relationships Caregiving roles Family relationships Role performance
Sexuality Sexual identify Sexual function Reproduction
Coping/Stress tolerance Post-trauma responses Coping responses Neurobehavioral stress
Life principles Values Beliefs Value/belief/action congruence
Safety/protection Infection Physical injury Violence Environmental hazards Defensive processes Thermoregulation	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
Comfort Physical comfort Environmental comfort Social comfort	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: Denial Difficulty transitioning from pediatric to adult care Need to keep up with peers Lack of primary care provider No convenient SCD clinic in the area 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: Presence and intensity of pain, based on verbal reports by Devon, need to be believed/accepted. A verbal report of pain is considered primary data that cannot be disputed, and is a value to be documented and used to direct pain treatment and monitor results. 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 Children’s Hospital and Regional Medical Center, Seattle WA, 2006. If the patient is to be hospitalized and PCA used, instruct patient on PCA use The tendency for SCD patients to under medicate themselves. The importance of medicating one’s self to effect pain relief (Jacob & Mueller, 2006). If patient is to be hospitalized, include notation in hand-off to RN to monitor PCA use because SCD patients are known to under medicate themselves (Jacob & Mueller, 2006). 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. Evaluate Devon’s attitude toward hydroxyurea (perceived benefit, knowledge regarding, side effects experienced, and adherence.and adjust plan of care to address his issues (Haywood, Beach, Bediako, et al., 2010). 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. 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)	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. Have home health nurse monitor pain medication record/diary for adequacy or pain medication treatment at home/school. Verbal reports of pain are primary data to be used in the evaluation/monitoring of increases/decreases in pain intensity. 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 (Osunkwo, Ziegler, Alvarez, et al., 2012; Osunkwo, 2011) pain with daily pain diary, hard copy or smart phone app Number of ED admissions/12 months Number of hospitalizations/12 months Number of hospitalization days/12 months Number of all-cause readmissions within 30 days (metric added with this plan) 25 hydroxy Vit D (mmol/l) Calcium (mmol/l) Alkaline Phospatase (mmol/l) Health related QOL Physical activity School functioning Monitor outcomes with pain and analgesic medication diary. Evaluate patient/family satisfaction with care/approach to analgesis. 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.
Growth/development Growth Development	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) Use developmentally appropriate pain assessment measures (Children’s Hospital and Regional Medical Center, Seattle WA, 2006)² 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).