UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Keenan Fitts

Assignment Date: 18 Oct 2016
.
Agency: TGH
1 PATIENT INFORMATION
Patient Initials: JTS Age: 45 Admission Date: 09 Oct 2016
Gender: MALE Marital Status: Single Primary Medical Diagnosis
Primary Language: English Sickle Cell Crisis
Level of Education: 14 years, Associates Degree Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Project Manager for Financial Srvc Hypertension
Number/ages children/siblings: Insomnia
3 Brothers and 1 sister (ages not asked)
Served/Veteran: Army Code Status:
If yes: Ever deployed? No Full Code
Living Arrangements: Brandon, FL; lives alone in a 2 bdrm/ 1 bath Advanced Directives: No
townhouse. 2 levels with stairs. Does have family living nearby. If no, do they want to fill them out? No
Surgery Date: N/A Procedure:
Culture/ Ethnicity /Nationality: African American, Native American
Religion: African Methodist Episcopal Type of Insurance: Medicaid

1 CHIEF COMPLAINT: I started having bad pain in my left foot so I took a tab of dilaudid. It didnt help and
then I started having pain in my hip. Thats when I knew it was going to a bad one

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay) Pt states he was sitting on his sofa when the pain started suddenly in his left foot. Eventually the pain spread to his
right hip and to his right shoulder. The severe pain had been going on for about 3 hours. The pain was a sharp throbbing.
Any type of movement of his hips or his right shoulder increases pain. However, heat & sometimes repositioning helps
alleviate pain. Pt states he has been taking hydroxyurea and took some dilaudid but has no relief. Pt states his pain is 8/10.

Pt states that once he realized the dilaudid was not working, he called his brother who then brought him to the ER. Pt has
extensive history of complications associated with sickle cell disease. The pt States he typically has about 3-4 crisis events a
year and Pt states his pain like that of a sickle cell crisis. His labs upon admission HGB 10.0, WBC 13.19, and Retic 11.35,
indicating Low hemoglobin, increase in leukocytes, and increase in reticulocytes. Pt was admitted for suspected sickle cell
Crisis and to r/o osteomyelitis.

University of South Florida College of Nursing Revision September 2014 1

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
Mar 2015 Sickle cell crisis
27 Jun 2014 Sickle cell crisis
19 Apr 2014 Sickle cell crisis
04 Jun 2013 Sickle cell crisis
02 May 2013 Sickle cell crisis

(angina, MI, DVT etc.)

Stomach Ulcers
Environmental

Mental Health
Age (in years)

FAMILY

Heart Trouble
Bleeds Easily

Hypertension
Cause
Alcoholism

MEDICAL

Glaucoma

Problems

Problems
Allergies

of

Diabetes
Arthritis

Seizures
Anemia

Asthma

Kidney
HISTORY Cancer

Tumor
Stroke
Death

Gout
(if
applicable)
Father
Mother
Brother 49 Lung Cx
Sister
Brother
47
relationship

relationship

Comments: Include age of onset

*Ages were not asked*

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received

University of South Florida College of Nursing Revision September 2014 2

 1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Penicilin Facial swelling and edema of upper & lower extremeties

Medications

Other (food, tape,

latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment) A pain crisis happens whenever a collection of sickle-shaped red blood cells block blood flow through tiny vessels
in your abdomen, chest, and joints. Signs and symptoms include severe pain in joints and sometimes in bones. Most patients
can tell you whether or not their pain is similar to a crises but you confirm Sickle cell crises with labs. Typically hemoglobin is
low and reticulocytes are elevated. If hemoglobin is too low the patient may require a blood transfusion. You will also want to
r/o any potentially serious infection most commonly osteomyelitis. Patients with sickle cell disease are usually started on a
daily regimen of hydroxyurea and folic acid. The hydrea medication replaces the protein that creates the sickled shaped RBCs
and the folic acid promotes the creation of more RBCs. The sickle cell disease is an inherited genetic disorder in which both
parents must have the sickle cell trait before the disease can manifest in their children. The life expectancy is somewhat
reduced with this condition, however, with current treatments and medications people can live well beyond their late 40s with
intermittent crises events. Generally, complications will arise if patient is dehydrated, physical training, and high altitudes.
Some people frequent crisis and others may have only a few. Other serious complications may include: sudden pooling of
blood into the spleen, lung & heart injury, death of bone tissue, pneumonia, and ulcerations. These complications are
during pregnancy. Pregnant women with sickle cell disease have an increased likelihood of miscarriage, poor fetal
development, preterm labor, as well as still births.

References

Shiel, W.C. Sickle Cell Disease. Medicinenet.com, Retrieved from http://www.medicinenet.com. (22 October 2016) .

Health encyclopedia- University of Rochester medical center. (2016). Retrieved from: https://www.urmc.edu/encylcopedia/
content.aspx. (22 October 2016).

American Society of Hematology. (10 May 2016). Retrieved from: http://www.hematology.org/Patients/ (22 October 2016).

5 MEDICATIONS: [Include both prescription and OTC; hospital, home (reconciliation), routine, and PRN medication (if
given in last 48). Give trade and generic name.]
Name Hydroxyurea/ Hydrea Concentration 1000 mg Dosage Amount 1G
Route Oral Frequency 2 caps bid
Pharmaceutical class Antineoplastic Both
Indication Sickle Cell Disease
Adverse/ Side effects Bone marrow suppression, immune system suppression, orthostatic hypotension.

Nursing considerations/ Patient Teaching: Assess for bleeding. Monitor for dyspnea and orthostatic hypotension. Discuss with patient the possibility of
hair loss. Explore methods of coping. Caution patient to avoid crowds and persons with known infections.

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Name Hydrochlorothiazide/ Prinizide Concentration mg Dosage Amount 12.5 mg
Route Oral Frequency 1 tab daily
Pharmaceutical class: Diuretic, Anti-hypertensive Both
Indication: Hypertension
Adverse/ Side effects: Dizziness, Decreased blood pressure, increased urine output, hyperkalemia, and orthostatic hypotension
Nursing considerations/ Patient Teaching: Caution patient to make position changes slowly. Advise patient to be cautious with alcohol use while using
this medication. HCTZ is potassium-sparing, consult HCP about dietary guidelines concerning potassium intake.

Name Folic Acid/ Folvite Concentration mg Dosage Amount 1 mg

Route Oral Frequency 1 tab daily
Pharmaceutical class Erythropoiesis Both
Indication: Stimulates the production of red blood cells, white blood cells, and platelets. To counter act the hydroxyurea.
Adverse/ Side effects: Rash. CNS: irritability, difficulty sleeping, malaise, confusion
Nursing considerations/ Patient Teaching: Assess patient for signs of megaloblastic anemia (fatigue, weakness, dyspnea) before and periodically
throughout therapy. Monitor plasma folic acid levels, hemoglobin, hematocrit, and reticulocyte count.

Name Hydromorphone/ Dilaudid Concentration mg Dosage Amount 4mg

Route Oral Frequency 1 tab q.i.d. pr n
Pharmaceutical class Opioid, Analgesic Both
Indication Severe pain associated with occlusive crisis
Adverse/ Side effects Respiratory depression, orthostatic hypotension, Constipation, Nausea & Vomiting, and suppressed cough
Nursing considerations/ Patient Teaching: Onset 30-45 mins, Do not take with alcohol. Do not take if experiencing dyspnea. Withdrawal symptoms can
include nausea, vomiting, cramps, fever, faintness, anorexia.

Name Zolpidem/ Ambien Concentration mg Dosage Amount 10mg

Route Oral Frequency 1 tab daily
Pharmaceutical class Sedative Both
Indication Insomnia, sleep issues
Adverse/ Side effects : Daytime drowsiness, dizziness, abnormal thinking, agitation, amnesia, behavior changes. Also physical dependence,
psychological dependence, tolerance.
Nursing considerations/ Patient Teaching: Because of rapid onset, advise patient to go to bed immediately after taking zolpidem. Caution patient to
avoid concurrent use of alcohol or other CNS depressant.

Name Meloxicam/ Mobic Concentration mg Dosage Amount 15mg

Route Oral Frequency 1 tab daily
Pharmaceutical class Anti-inflammatory Home
Indication Joint pain associated with sickle cell disease
Adverse/ Side effects : Cardiovascular edema, GI bleeding, diarrhea, dyspepsia. Elevated liver enzymes. Steve-Johnson syndrome, puritis.
Nursing considerations/ Patient Teaching: Advise patient to consult health care professional if rash, itching, visual disturbances, weight gain, edema,
black stools, or signs of hepatotoxicity (nausea, fatigue, lethargy, jaundice, upper right quadrant tenderness, flu-like symptoms) occur. Caution patient
to avoid the concurrent use of alcohol, aspirin, acetaminophen, or other OTC medications.

Name Nebivolol/ Bystolic Concentration mg Dosage Amount 10mg

Route Oral Frequency 1 tab daily
Pharmaceutical class Anti-hypertensive, Beta-blocker Both
Indication: Hypertension
Adverse/ Side effects: Dizziness, fatigue, headache. Decrease in BP.
Nursing considerations/ Patient Teaching: Abrupt withdrawal may precipitate life-threatening arrhythmias, hypertension, or myocardial ischemia.
Patients on antihypertensive therapy should also avoid excessive amounts of coffee, tea, and cola.

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Name Hydromorphone/ Dilaudid Concentration 20 mg/ 0.2ml Dosage Amount 20 mg
Route Intravenous (I.V.) via PCA Frequency 15 minute intervals
Pharmaceutical class Opioid, Analgesic Hospital
Indication Severe pain associated with sickle cell disease
Adverse/ Side effects : Respiratory depression, orthostatic hypotension, Constipation, Nausea & Vomiting, and suppressed cough
Nursing considerations/ Patient Teaching : Onset 15-30 mins, Do not take with alcohol. Do not give if patients respirations fall <12. Withdrawal
symptoms can include nausea, vomiting, cramps, fever, faintness, anorexia.

Name Docusate Sodium/ Colace Concentration mg Dosage Amount 100mg

Route Oral Frequency 1 cap daily
Pharmaceutical class Laxatives, Stool softner Both
Indication Prophylactic for constipation
Adverse/ Side effects: Throat irritation, mild cramps, diarrhea
Nursing considerations/ Patient Teaching: Advise patient not to take docusate within 2 hr of other laxatives. Instruct patients with cardiac disease to
avoid straining during bowel movements. Encourage patients to use other forms of bowel regulation, such as increasing bulk in the diet, increasing
fluid intake.

Name Enoxaparin/ Lovenox Concentration 40mg/ 0.4ml Dosage Amount 40 mg

Route SQ Frequency 1 injection daily
Pharmaceutical class: Antithrombotic Hospital
Indication prophylactic to prevent venous thromboembolism and/or pulmonary embolism
Adverse/ Side effects: Bleeding, anemia, hyperkalemia, edema
Nursing considerations/ Patient Teaching: Monitor for hematoma and other blood thinning drug-drug interaction. Trend/monitor platelets

Name Doxycycline/ Vibramycin Concentration mg Dosage Amount 100mg

Route Oral Frequency 1 cap b.i.d
Pharmaceutical class: Anti-infective Home
Indication: prophylactic to prevent pneumonia or other respiratory infections
Adverse/ Side effects: Hepatotoxicity, pseudomembranous-colitis, diarrhea, nausea, vomiting, esophagitis, pancreatitis, photosensitivity, Steven-
Johnson syndrome. Blood dyscrasias, superinfections.
Nursing considerations/ Patient Teaching: Instruct patient to notify health care professional immediately if rash, diarrhea, abdominal cramping, fever,
or bloody stools occur and not to treat with antidiarrheals without consulting health care professionals. Caution patient to use sunscreen and protective
clothing to prevent photosensitivity reactions. Advise patient to report the signs of superinfection (black, furry overgrowth on the tongue; vaginal
itching or discharge; loose or foul-smelling stools). Skin rash, pruritus, and urticaria should also be reported. Advise patient to avoid taking milk or
other dairy products concurrently with oral tetracyclines. Also avoid taking antacids, zinc, calcium, magnesium- or aluminum-containing medications,
sodium bicarbonate, and iron supplements within 13 hr of oral tetracyclines.

University of South Florida College of Nursing Revision September 2014 5

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Regular Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: 3 eggs(scrambled), grits, pancakes, cereal, Patient is obese and suffers from hypertension as well.
Oatmeal, breakfast sandwhich. Consider he is a black male in his late 40s.
Lunch: pasta, burger, fries. Other fast food. Note the patient has a relatively high intake, of sodium,
sugar, and saturated fats. The high sodium intake can
Dinner: Ox-tails, rice, chicken breast, mixed vegetables be associated with his hypertension.

Snacks: chips

Liquids (include alcohol): wine, Cola, ginger ale

Use this link for the nutritional analysis by comparing the patients
24 HR average home diet to the recommended portions, and use.

The top graph shows his home diet:

-The patients diet was high in sugar, fat, and sodium.

He was wholly over his daily recommend calorie intake
for a person that is primarily sedentary. Also, his heavy sodium
intake was not helping to manage his hypertension. The patient
states he incorporates a few vegetables in his diet per week.

The bottom graph shows the recommended diet:

-I would recommend better choices with foods that are low in

sodium and fat. Since he is sedentary primarily his recommended
daily calorie intake should be no more than 1800 calories. So I
recommend exchanging some foods that are high in carbs and
sugar and replace them with fruit & add more vegetables.

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1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
My oldest brother is the one who usually takes me to the hospital.
How do you generally cope with stress? or What do you do when you are upset?

I usually listen to music or watch football.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)

My pain gives me anxiety and it has affected past relationships.

+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.

Have you ever felt unsafe in a close relationship? __Yes _____________________________________________

Have you ever been talked down to?_____Yes______ Have you ever been hit punched or slapped? __Attempted_

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
__________ Yes, threats of violence ____________ If yes, have you sought help for this? _________Yes__________

Are you currently in a safe relationship? No

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs.
Inferiority Identity vs. Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair
Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group: 40-60 yrs

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
I would describe my patient as being in the Generativity stage. He is still employed and productive in society.
He is also readily anxious to gain back his autonomy and start working again.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
His hospitalization is probably making him feel more stagnate. His condition probably makes for a constant
struggle between generativity and stagnation.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
I understand my disease is hereditary and related to genetic evolution.

What does your illness mean to you?

I hated my illness in the beginning of my life. I have since came to peace with my disease.
University of South Florida College of Nursing Revision September 2014 7
+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record

Have you ever been sexually active?_____________Yes___________________________________________________

Do you prefer women, men or both genders? _____Women________________________________________________
Are you aware of ever having a sexually transmitted infection? ___No_______________________________________
Have you or a partner ever had an abnormal pap smear?_______No__________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? _________No______________________________

Are you currently sexually active? _____________No___________ If yes, are you in a monogamous relationship?
____________________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? _________Condoms_______________

How long have you been with your current partner?___Single_____________________________________________

Have any medical or surgical conditions changed your ability to have sexual activity? __No_________________

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

University of South Florida College of Nursing Revision September 2014 8

1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
________Its pretty important. ___ _ _________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
___________No not really, but it helps me deal with my condition._________________________________________________
_______________________________________________________ _______________________________________________

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes
If so, what? How much?(specify daily amount) For how many years? 3 years
Cigars 2 Cigars a day (age 40 thru 43 )

If applicable, when did the

Pack Years:
patient quit? 2 yrs ago

Does anyone in the patients household smoke tobacco? If Has the patient ever tried to quit? Yes
so, what, and how much? No If yes, what did they use to try to quit? Just stopped

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes
What? How much? For how many years?
Liquor, wine Volume: (age 22 thru 44 )
Frequency:
If applicable, when did the patient quit?
Last year

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? No
If so, what? N/A
How much? N/A For how many years? N/A
(age thru )

Is the patient currently using these drugs?

If not, when did he/she quit?
Yes No N/A

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No, not that I can remember.

5. For Veterans: Have you had any kind of service related exposure?
I spent 4 years in the Army and no, I dont recall.

University of South Florida College of Nursing Revision September 2014 9

 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)

How do you view your overall health?

Integumentary: Patient denies any history of eczema, psoriasis, or parasitic infections of the dermis.
HEENT: Patient negative for ear pain, tinnitus, neck pain
Pulmonary: Patient denies shortness of breath or wheezing, Negative for cough
Cardiovascular: Patient denies chest pain, palpitations
GI: Patient denies nausea, vomiting, diarrhea, abdominal pain, heartburn, or melena.
GU: Patient denies dysuria or polyuria, frequency, nocturia. Patient denies unusual discharge.
Women/Men Only:
Musculoskeletal: Patient negative for myalgias or parethesia in extremities. Patient denies any weakness or decreased strength.
Immunologic: Pt denies having frequent chills, shakes, or night sweats, fever. Pt denies having HIV, lupus, rheumatoid arthritis,
sarcoidosis, tumor, enlarged lymph nodes, or anaphylaxis.
Hematologic/Oncologic: Patient has life long history of sickle cell anemia with 3-4 crises a year. Patient denies having a blood
transfusion. Pt doesnt know his blood type.
Metabolic/Endocrine: Patient denies having diabetes, hypothyroidism/hyperthyroidism, intolerance of hot or cold, and
osteoporosis. Negative for polydipsia and polyuria.
Central Nervous System: Patient denies dizziness, seizures, or chronic headaches.
Mental Illness: Patient denies depression or change in mood, denies any suicidal ideation, patient denies homicidal ideation
Childhood Diseases: Patient has been dealing with sickle cell disease all of his life. Pt states he had chicken pox but couldnt
remember what age.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
No

Any other questions or comments that your patient would like you to know?
No further comments

University of South Florida College of Nursing Revision September 2014 10

10 PHYSICAL EXAMINATION:
General survey __Patient appears alert and oriented to person, place, and time._____________________________________
Height ___6ft_____Weight___245____ BMI _33.23kg/m2__ Pain (include rating and location)__8/10_R hip & toe___
Pulse__61__ Blood Pressure (include location)_143/60_R arm_______Temperature (route taken)__98.3_F_oral_
Respirations_____16____ SpO2 ___100%_________ O2___________________________
Overall Appearance:___ Patient appears well developed and well nourished. ___________________________
Overall Behavior:___ Patient is awake, calm and relaxed. _______________________________________________
Speech:___Speech is low pitched but clear_______________________________________________________________
Mood and Affect:_ Patient is pleasant, cooperative and talkative.______________________________________
Integumentary:_No pallor, no cyanosis. Cap refill <3 sec. Skin warm dry and intact, skin turgor is elastic.__________
IV Access:___Left hand metacarpal vein, peripheral IV with PCA device______________________________________
HEENT:_Normal cephalic, atraumatic, PERRLA, EOMI, nasal septum midline,_No redness, no exudate, no adenopathy
Pulmonary/Thorax:_lungs clear to auscultation bilaterally. No wheezes, rales, or rhonchi.__________________________
Cardiovascular:__Regular rate and rhythym, no murmur, no rubs or gallops.______________________________
GI:__Soft, non-tender, no distention, no rebound or guarding. Bowel sounds are present____________________
GU:___No indwelling catheter. Otherwise not examined.________________________________________________
Musculoskeletal:_hip flexion is limited due to pain, R arm is limited in motion due to pain. No edema, no bony tenderness
at left toe or R hip.____________________________________________________________________________________
Neurological: CN 2-12 intact to motor and sensation

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well
as abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.

Lab Dates Trend Analysis

HGB: Upon admission the patients Low HGB typically indicates a
10.0* L (10/09/2016) HGB was already low. Over low amount of RBCs. Sickle-
the course of the week it shaped cells usually are more
continued a downward trend. fragile and die a lot sooner
9.1*L (10/12/2016) This is often due to lack of than normal RBCs. This result
mature RBCs. usually correlates with a low
8.6*L (10/14/2016 RBC count.

8.2*L (10/15/2016)

Normal Range( 13.8- 17.2)

RBC: A few days into his admission The patients low HGB is
2.6* L (10/12/2016) his RBC count was low and reflection of his body not being
since then have been trending able to keep up with the
downward. Usually associated demand for more RBCs. This
2.4*L (10/14/2016) with anemia or low iron. is an indication of anemia.

2.3*L (10/15/2016)
University of South Florida College of Nursing Revision September 2014 11
 Normal Range (4.7- 6.1)
Retic: There are a high number of
11.35* H (10/09/2016) reticulocytes in the
bloodstream upon admission.
Which measures the rate at
which the bone marrow is
releasing RBCs.
Nomal Range (0.4-1.9)
WBC: Increased WBCs are usually a
13.19*H (10/09/2016) sign of a past or present
infection.
This lab test is perform to
measure how fast the body is
releasing reticulocytes from
the bone marrow. A high retic
count means there are a lot of
immature RBCs.
His elevated WBC count is
probably associated with a past
infection.

Normal range (3.6- 11.0)

Chest X-Ray: (There was documentation of a chest x-ray being ordered, but could not locate results.) You would order
chest x-ray to assess for pneumonia or any other respiratory infection. Sickle cell patients are at higher risks for infections
because of immunosuppressive therapy.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)

MRI- scheduled to rule out osteomyelitis. Sickle Cell patients are at an increased risk for developing bone infections as well as
bone infarctions. This can sometimes cause pain in the patients bone.

Blood transfusion- a blood transfusion may be necessary for patients who experience severe anemia.

Supplemental O2- shortness of breath can also be a sign of anemia. Monitor the patients spO2 and assess the need to apply a nasal
cannula or face mask.
Labs- check labs to monitor trend of HGB, RBCs, WBCs, Reticulocytes.
Consults- consult to hematology for more definitive care outside of the hospital setting.

8 NURSING DIAGNOSES (actual and potential - listed in order of priority)

1. Acute pain (actual )- Intermittent severe pain is associated with sickle cell crisis. AEB- self-report of intensity using standardize
pain scale. Related factors are biological injury agent or vascular occlusion.

2. Risk for infection (actual)- Patient was prescribed daily regimen of Hydroxyurea. Pt is vulnerable to invasion of multiple
Pathogens. Related factors are inadequate secondary defenses associated with use of Hydroxyurea.

University of South Florida College of Nursing Revision September 2014 12

3. Ineffective Health Management (actual)- Patient has hypertension. AEB: Ineffective choices in daily living for meeting health
Goals. Relating to insufficient knowledge of therapeutic regimen.

4. Insomnia (actual)- Patient reporting difficulty sleeping and is taking Ambien. AEB: Alteration of sleep pattern, difficulty
Initiating sleep. Related to anxiety and possible side effect of pharmaceutical agent.

5. Risk-prone health behavior (potential)- AEB- failure to take action that prevents health problems. Related to inadequate
Comprehension, other stressors.

University of South Florida College of Nursing Revision September 2014 13

 15 CARE PLAN
Patient Goals/Outcomes
Decrease pain
Report if pain management
regimen achieves comfort-function
goal without side effects.
Perform activities of recovery or
activities of daily living.
Prevent constipation.
University of South Florida College of Nursing Revision September 2014
Nursing Diagnosis: Acute Pain
Nursing Interventions to Achieve Rationale for Interventions
Goal Provide References
-Assess pain using standardized pain scale
to determine intensity. Determine onset,
location, duration characterization, and
quality. Include any aggravating or
alleviating factors.
-Choose an analgesic based on orders that
reflect the clients report of pain level.
-Obtain and review an accurate and
complete list of medications the client is
taking or has taken.
-Manage acute pain using a multimodal
approach.
- Use diverse analgesic delivery method
devices such as PCA.
-Select a route for administration of
analgesics based upon clients condition
and severity of pain.
-Teach and implement non-
pharmacological interventions when pain
is relatively well controlled.
-Support the clients use of non-
pharmacological methods to help control
pain.
-Encourage client to plan activities around
periods of greatest comfort.
-Provide client with stool softener to
prevent opioid related constipation.
-Use non-opioid analgesics for moderate
pain.
Evaluation of Goal on Day Care
is Provided
-You are better able to determine the -The patient verbalizes that pain
underlying cause of the pain and effective was decreased from 8 to a 4/10.
ness of treatment.
-The under treatment of pain can result in
various physiological and psychological
damage that decreases quality of life.
-Accurate medication list can help guide
analgesic therapy and prevent medication
errors.
-A multimodal approach enhances pain -The patient verbalizes his pain is
relief and allows the lowest effective dose steady at about 4/10 with PCA
of each drug to be administered.
-Compared to oral or IM injections, the
pump.
PCA pump provides patients with better -Patient is currently being tapered
control of their pain medication. off of potent analgesic.
-An IV route is preferred vs oral due to the
faster onset and duration.
-constant pain is damaging to organs, the
immune system, and effects cognitive -Patient is able to get to the
thinking.
-These methods can often be cheap and
bathroom unassisted, but with pain.
still effective.
-Its a good strategy for patients to learn to
balance activity and rest.
-Many clients are likely to experience - The patients states he has had
constipation with the use of opioids. If regular bowel movements, no hard
possible try to avoid this.
-Patients may experience delayed healing
stools.
time if pain isnt controlled properly.
14
Include a minimum of one
Long term goal per care plan
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult*
Dietary Consult*
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments*
Med Instruction/Prescription*
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

University of South Florida College of Nursing Revision September 2014 15

 References

Wells, N., Pasero, C., & McCaffery, M. (2008). Improving quality of care through pain assessment

management. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK2658/ (23 October 2016).

Ackley, B. J., Ladwig, G.B., Makic, M. B. F.(2016). Nursing diagnosis handbook: An evidence-based guide to

planning care. United States: Mosby, pp.640-652

(2015). Healthwise.org, Retrieved from: http://www.uofmhealth.org/health-library/zx1143 (23 October 2016).

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