Pace University

Lienhard School of Nursing

Nursing Care Plan
Name: Giselle Campos Pt’s initial: VQ Age: 64 Gender: Female Diagnosis: Sickle cell anemia Date: 10/20/22
Assessment Pathophysiology Goals Nursing Diagnosis Nursing Rationale Evaluation
intervention
“I feel nauseous” What is sickle cell Short term goals: 1. Acute pain 1.If I want to 1.Opioids are 1.Short term goal
The patient was anemia? 1. Patient will be because of sickle decrease the given to control evaluation: Goal
fully oriented “In sickle cell able to have a cell crisis as patients pain levels, pain during a was met when
times 3 and well anemia, some red pain level of 0 evidence by use of I may medicate the sickle cell crisis. patient had a pain
organized. She blood cells are with reassessment PRN narcotic. patient with level of 0 upon
understood her shaped like sickles in 2 hours. prescribed opioids. 2.Assistance with reassessment post
diagnosis or crescent moons. 2. Increased risk ambulation will 2 hours.
completely, had a These sickle cells 2. Patient will be for fall related to 2.If I want to minimize or
full medical also become rigid able to ambulate use of opioids as decrease the eliminate the risk 2.Short term goal
history and and sticky, which from the room to evidence by patients pain levels, for falls. evaluation: Goal
information in her can slow or block the cab unstable gait and I may dissimulate was met upon
phone to help her blood flow.” independently patient reporting the environment. discharge; patient
keep track of her (Mayo Clinic, upon discharge drowsy. was able ambulate
disease. 2022) today. 3.If I want to to the cab
Chief complaint: Signs and reduce the risk for independently.
Severe symptoms: Long term goals: fall, I will assist the
pneumonia, acute “Anemia, episode 1. Patient will be patient when 3.Long term goal
chest syndrome, of pain, swelling able to walk free needing to evaluation: Goal
and sickle cell of hand and feet, of falls in 4 ambulate to meet was met, patient
crisis. frequent months. needs. was able to walk
HPI: Patient has infections, delayed free of falls within
suffered from growth or puberty, 2. Patient will be 4.If I want to the 4 months.
severe vision problems.” able to ambulate reduce the risk for
pneumonia, acute (Mayo Clinic, with no pain in 3 fall, I will keep the 4.Long term goal
chest syndrome 2022) months. bed in the lowest evaluation: Goal
and sickle cell Who it affected position. was met, patient
crisis from “Children born was able to
multiple years. from parents that ambulate with no
Client was carry a sickle cell pain in 3 months.
admitted to the gene. In the United
hospital 3 weeks States it is most
ago for her severe commonly to
pneumonia where affect people of
she was treated African,
with Mediterranean,
Azithromycin and Middle
administered Eastern descent.”
intravenously. (Mayo Clinic,
2022)

References:

Mayo Foundation for Medical Education and Research. (2022, March 9). Sickle cell anemia. Mayo Clinic.

https://www.mayoclinic.org/diseases-conditions/sickle-cell-anemia/symptoms-causes/syc-20355876