Chavez, Amala Fay O.

NURSING CARE PLAN

ASSESSMENT S> O> Dyspnea >use of accessory muscles >diminished peripheral pulses and capillary refill >visual disturbances >Restlessness >Confusion > palpitations > Tingling in extremities >bone pain > pallor T> 36.5C RR>34bpm PR>123 bpm BP>120/90 bpm DIAGNOSIS Impaired gas exchange related to decreased oxygencarrying capacity of the blood, reduced RBC life span or premature destruction, abnormal RBC structure, sensitivity to low oxygen tension due to strenuous exercise, as evidenced by Dyspnea, use of accessory muscles, Restlessness, confusion PLANNING Within 4-8 hours of nursing intervention the patient will demonstrate improvement in ventilation and oxygenation. INTERVENTION Monitor respiratory rate and depth and use of accessory respiratory muscles Auscultate breath sounds, noting presence or absence, and adventitious sounds. Monitor vital signs; note changes in cardiac rhythm. RATIONALE indicator of adequacy respiratory function Development of atelectasis and stasis of secretions can impair gas exchange. Changes in vital signs and development of dysrhythmias reflect effects of hypoxia on cardiovascular system. Reflective of developing acute chest syndrome, which increases the workload of the heart and oxygen demand. Brain tissue is very sensitive to decreases in EVALUATION After 4-8 hours of nursing intervention the patient will demonstrate improvement in ventilation and oxygenation as evidenced by: >RR= 16 >absence of cyanosis >clear breath sounds >not using accessory muscles

Investigate reports of chest pain and increasing fatigue. Observe for signs of increased fever, cough, and adventitious breath sounds. Assess LOC and mentation regularly.

Chavez, Amala Fay O.

oxygen, and changes in mentation may be an early indicator of developing hypoxia. Evaluate activity tolerance; limit activities to those within clients tolerance or place client on bedrest. Assist with ADLs and mobility, as needed. Assist in turning, coughing, and deepbreathing exercises. For safety

Promotes optimal chest expansion, mobilization of secretions, and aeration of all lung fields; reduces risk of stasis of secretions and pneumonia. Protects from excessive fatigue and reduces oxygen demands and degree of hypoxia. Relaxation decreases muscle

Encourage client to alternate periods of rest and activity. Schedule rest periods, as indicated. Demonstrate and encourage use of

Chavez, Amala Fay O.

relaxation techniques, such as guided imagery and visualization. Promote adequate fluid intake, such as 2 to 3 L/day within cardiac tolerance.

tension and anxiety and, hence, the metabolic demand for oxygen. Sufficient hydration is necessary to provide for mobilization of secretions and to prevent hyperviscosity of blood with associated capillary occlusion.

Chavez, Amala Fay O.

ASSESSMENT S> O> Dyspnea >use of accessory muscles >diminished peripheral pulses and capillary refill >visual disturbances >Restlessness >Confusion > palpitations > Tingling in extremities >bone pain > pallor T> 36.5C RR>34bpm PR>123 bpm BP>120/90 bpm

DIAGNOSIS ineffective tissue Perfusion related to Vaso-occlusive nature of sickling, inflammatory response, Arteriovenous (AV) shunts in both pulmonary and peripheral circulation, Myocardial damage from small infarcts, iron deposits, and fibrosis.

PLANNING Within 4-8 hours of nursing intervention the patient will demonstrate improved tissue perfusion .

INTERVENTION

RATIONALE Sludging and sickling in peripheral vessels may lead to complete or partial obliteration of a vessel with diminished perfusion to surrounding tissues. Sudden massive splenic sequestration of cells can lead to shock. Changes reflect diminished circulation and hypoxia potentiating capillary occlusion Changes may reflect diminished perfusion to the CNS due to ischemia or infarction (stroke).

EVALUATION After 4-8 hours of nursing intervention the patient will demonstrate improved tissue perfusion as evidenced by: >stabilized vital signs >strong and palpable pulses >adequate urine output >absence of pain >usual mentation >normal capillary refill >skin warm and dry >nail beds and lips of natural pale or in pink color >absence of paresthesias

Monitor vital signs carefully. Assess pulses for rate, rhythm, and volume. Note hypotension; rapid, weak, thready pulse; and tachypnea with shallow respirations. Assess skin for coolness, pallor, cyanosis, diaphoresis, and delayed capillary refill.

Note changes in LOC; reports of headaches, dizziness; development of sensory or motor deficits, such as hemiparesis or paralysis; and seizure activity. Maintain adequate fluid intake. Monitor urine output.

Dehydration not only causes hypovolemia but increases sickling and occlusion of capillaries. Decreased renal perfusion and failure may occur because of vascular occlusion.

Chavez, Amala Fay O.

Assess lower extremities for skin texture, edema, and ulcerations, especially of internal and external ankles. Investigate reports of change in character of pain, or development of bone pain, angina, tingling of extremities, and eye pain or vision disturbances. Maintain environmental temperature and body warmth without overheating. Avoid hypothermia.

Reduced peripheral circulation often leads to skin and underlying tissue changes and delayed healing. Changes may reflect increased sickling of cells and impaired circulation with further involvement of organs, such as myocardial infarction (MI), pulmonary infarction, or occlusion of vasculature of the eye. Prevents vasoconstriction, aids in maintaining circulation and perfusion. Excessive body heat may cause diaphoresis, adding to insensible fluid losses and risk of dehydration. Hypothermia may exacerbate cardiovascular compromise with severe anemia. Vaso-occlusion or circulatory stasis may lead to edema of extremities and priapism in men,

Evaluate for developing edemaincluding genitals in men.

Chavez, Amala Fay O.

potentiating risk of tissue ischemia and necrosis. Monitor laboratory studies, such as the following: Blood gases, liver and kidney function tests Decreased tissue perfusion may lead to gradual infarction of organ tissues, such as the brain, liver, spleen, kidney, skeletal muscle, and so forth, with consequent release of intracellular enzymes. Hydroxyurea, a cytotoxic agent, dramatically decreases the number of sickle cell episodes, and is given to prevent crises. Antisickling agents currently under investigational use are aimed at prolonging erythrocyte survival and preventing sickling by affecting cell membrane changes.

Administer hydroxyurea (Droxia) or experimental antisickling agents, such as sodium cyanate, carefully and observe for possible lethal side effects.

Chavez, Amala Fay O.

ASSESSMENT S>ano po bang nangyayari sakin as verbalized by he patient. O> Dyspnea >use of accessory muscles >diminished peripheral pulses and capillary refill >visual disturbances >Restlessness >Confusion > palpitations > Tingling in extremities >bone pain > pallor T> 36.5C RR>34bpm PR>123 bpm BP>120/90 bpm

DIAGNOSIS deficient knowledge regarding disease process, genetic factors, self-care and treatment medications related to unfamiliarity with the resources of the disease condition as manifested by questioning and statement of concern.

PLANNING Within 4-8 hours of nursing intervention the patient will verbalizes understanding of the disease & its long-term effects on target organs.

INTERVENTION Observe client's ability and readiness to learn (e.g., mental acuity, ability to see or hear, no existing pain, emotional readiness, absence of language or cultural barriers).

RATIONALE For assessment and to know the extent of intervention. Education in selfcare must take into account physical, sensory, mobility, sexual, and psychosocial changes related to age The client brings to the learning situation a unique personality, established social interaction patterns, cultural norms and values, and environmental influences. New information is assimilated into previous assumptions and facts and may involve negotiating, transforming, or stalling.

EVALUATION After 4-8 hours of nursing intervention the patient will verbalizes understanding of the disease & its long-term effects on target organs as evidenced by:

Assess barriers to learning (e.g., perceived change in lifestyle, financial concerns, cultural patterns, lack of acceptance by peers or coworkers).

describes self-help activities to be followed. Patientdescribes system for taking medications. intention to follow prescribed regimen.

Determine client's previous knowledge of or skills related to his or her diagnosis and the influence on willingness to learn.

Chavez, Amala Fay O.

Involve clients in writing specific outcomes for the teaching session, such as identifying what is most important to learn from their viewpoint and lifestyle. Objectives put the content into focus, provide a forum for evaluation outcomes, and ensure continuity. When teaching, build on client's literacy skills. In patients with low literacy skills, materials should be short and have culturally sensitive illustrations. Present material that is most significant to client first, such as how to give injections or change dressings; present additional material once client's most pressing educational needs have been met. Help client identify

Client involvement improves compliance with health regimen and makes teaching and learning a partnership.

For better comprehension.

Information building begins with explaining simple concepts and moves on to explanations of complex application situations.

To have an

Chavez, Amala Fay O.

community resources for continuing information and support. Learning occurs through imitation, so persons who are currently involved in lifestyle changes can help the client anticipate adjustment issues. Community resources can offer financial and educational support. For example, role modeling and skill training have been used to monitor symptoms and solve asthma problems Evaluate client's learning through return demonstrations, verbalizations, or the application of skills to new situations.

additional resources that he may know in managing the condition

Presenting information along with with examples of how to apply the information has been found more successful than providing information alone in a home care setting.