- Acute Pain related to Sickling of red blood cells occluding blood vessels and lack of perfusion and oxygenation to extremities as evidenced by intense complaint of pain anywhere in the body and the pain is described as stabbing, sharp, or throbbing
- Decreased Cardiac Output related to Inadequate filling of blood in the heart and decreased oxygenated blood to the heart due to Low red blood cells as evidenced by
Decreased cardiac output and Diminished pulses - Fatigue related to decreased haemoglobin as evidenced by Inability to maintain physical activity and increased need for rest
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: -Expressions of pain, such as crying -Unpleasant feeling Objective Data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns -Guarding or protective behaviours | Acute Pain related to Sickling of red blood cells occluding blood vessels and lack of perfusion and oxygenation to extremities as evidenced by intense complaint of pain anywhere in the body and the pain is described as stabbing, sharp, or throbbing | Patient will report a decrease in pain to a level of 2/10 by discharge. Patient will verbalize an understanding of behaviours that trigger a pain crisis. Patient will adhere to the prescribed pain medication regimen. | 1. Provide fluids. IV hydration is a priority for treating a sickle cell crisis. IV fluids will stop or slow the sickling process and reduce pain. Patients should also be encouraged to drink plenty of fluids. 2. Administer analgesics. Sickle cell patients often have a very high pain tolerance and will receive high doses of narcotics. Some patients may be on a PCA pump until their pain is better controlled. The nurse should closely monitor the patient and provide adequate pain control without over-sedating the patient. 3. Administer blood transfusions. Depending on the patient’s haemoglobin level, blood transfusions may be necessary to prevent worsening complications and correct anaemia. Some patients may receive long-term transfusions monthly on an outpatient basis. 4. Educate on preventing a sickle cell crisis. Patients should be educated on triggers of a sickle cell crisis to prevent them. Maintaining hydration, preventing infections, avoiding exposure to cold weather, reducing stress, and adhering to medications are necessary to manage sickle cell anemia. | Patient reported a decrease in pain to a level of 2/10 by discharge. Patient verbalized an understanding of behaviours that trigger a pain crisis. Patient adhered to the prescribed pain medication regimen. |
| Subjective Data: Verbalizes feeling tired Objective Data: -Decreased cardiac output -Tachycardia -Hypertension -Cardiac arrhythmias -Chest pain -Diminished pulses | Decreased Cardiac Output related to Inadequate filling of blood in the heart and Decreased oxygenated blood to the heart due to Low red blood cells as evidenced by Decreased cardiac output and Diminished pulses | Patient will demonstrate blood pressure and pulses within normal limits. Patient will manifest normal sinus rhythm in ECG. Patient will have no complaints of chest pain. | 1. Reduce cardiac stress. Anemia can affect heart performance by increasing the heart rate and stroke volume. It will also reduce blood flow to the kidneys and fluid retention, putting additional strain on the heart. 2. Treat the anemia according to its type. Manage anemia based on its type and cause. It will resume all the organ functions once the circulating volume is within normal limits. The heart will be able to pump acceptable cardiac output. 3. Prepare for a possible blood transfusion. Severe anemia would necessitate a blood transfusion to supplement cardiac output and aid in circulating oxygenated blood throughout the body. 4. Stop the cause of anemia. Anemia can be a result of treatment such as chemotherapy. Discontinue as ordered if the anemia is causing a life-threatening complication for the patient. Allow the heart to rest and be free from treatments or medications to maximize its function to pump quality RBCs. | Patient demonstrated blood pressure and pulses within normal limits. Patient manifested normal sinus rhythm in ECG. Patient chest pain relieved. |
| Subjective Data: Verbalizes feeling Dizziness and fatigue Objective Data: -Inability to maintain physical activity -Increased need for rest -Reported lack of energy -Lethargy | Fatigue related to decreased haemoglobin As evidenced by Inability to maintain physical activity and increased need for rest | Patient will verbalize reduction in fatigue. Patient will be able to engage in daily activities independently. Patient will be able to display adequate energy levels in order to complete activities. Patient’s vital signs and lab values will remain stable as they relate to any potential underlying chronic conditions. | 1. Instruct on energy conservation. Plan rest periods, delegate tasks to others, cluster activities together, prioritize activities when energy levels are highest. 2. Apply oxygen. Patients being treated for anemia in the hospital may require supplemental oxygen for very low hemoglobin levels. 3. Administer blood transfusions. If a patient is severely anemic or has suffered a blood loss causing anemia, blood transfusions may help with fatigue. 4. Administer erythropoietin injections. Epogen and Procrit are two common injections given that stimulate the bone marrow to produce red blood cells. Patients with cancer, HIV, or kidney disease often have severe anemia and require these injections. | Patient verbalized reduction in fatigue. Patient engaged in daily activities independently. Patient displayed adequate energy levels in order to complete activities. Patient’s vital signs and lab values remained stable as they not related to any potential underlying chronic conditions |