Concept Map: Concept Map Sickle Cell Disease

Concept Map: Sickle Cell Disease
October 8, 2010
Duke University School of Nursing

Introduction

My client, known as 20SE03, is a four year old preschooler that lives in a two-parent household along with his younger one year old sister. His family has recently moved to North Carolina where he was recently presented with new onset of seizures and status post cerebral vascular accident (CVA). He has a history of sickle cell disease, ulcerative colitis, acute chest syndrome, and asthma. Symptoms began about 18 months ago when his mother observed that he complained of intense pain in his lower extremities. As the pain worsened, he started having breathing problems; resulting in a series of subsequent hospitalization starting 13 months ago for pulmonary embolus. Upon
admission to UNC Hospital PICU, he was given a unit of blood and IV rehydration therapy in order to treat his anemia and dehydration. Multiple tests were performed to determine the etiology of his presenting symptoms. It was determined that he had mini seizures that led to a vasoocclusive attack of the brain, e.g., stroke, complicated by sickle cell disease. Continued assessment and examination of his case revealed that he might have been having seizures up to several hours before his initial admission to Wake Med. He spent four weeks in intensive care before being transferred to the step down unit where he was on seizure precautions and fall risk during my nursing care. The foci of care for 20SE03 included pain management, hypertension management, detection of risk for infection (temp >38.5 degrees celsius), oral rehydration therapy, and compliance to nursing interventions with the help of the parents.

N221 Pediatric Nursing --- Clinical Database
|De-identified Patient Information |Reason for Admission: Seizures r/t complications from sickle cell disease |
|Patient's Age: 4 LOS: 26 days | |
|Gender: Male |Past Medical History: Sickle cell disease, ulcerative colitis, CVA, acute chest syndrome, PNA, anemia,|
| |pancreatitis, asthma, liver dysfunction, hyperbilirubinemia, hypokalemia, hypocalcemia, hypomagnesemia,|
| |hypophosphatemia, malnutrition, mucositis, s/p exchange transfusion |
| | |
| |Surgical Procedure: Bronchoscopy |
|Unique Code | |
|Student Initials: JAA |Treatments: Oral Rehydration Therapy |
|Week: 3 | |
|Name of Agency: UNCH |Assistive Devices: N/A |
|Advance Directives: |Pertinent Diagnostic Tests---Radiology, Laboratory, EKG, etc. (for results: indicate low, normal, or |
|DNR Status: FULL CODE |high values) |
|Source of Information: Medical chart |See next page |
| | |
|Family Composition: Father, mother, |Pathology Report or Infection Precautions: Standard precautions |
|sister (1 y.o.) | |
| |Allergies- Medications and Food: Piperacillin (severe hypersensitive skin reaction). No food allergies. |
| | |
| |Medications (List known pre-admission and discharge meds, if available. List current drug, dose, route, time & frequency): |
| |See next page |
| |Level of Development Prior to Admission (developmental milestones achieved, gross & fine motor skills, language, socialization): |
| |Physically: 4 yr; Gross Motor: 3 or 4 yr old; Fine Motor: 3 or 4 yr old; Language: 3 yr; Socialization: 3 yr; Cognition: 3 yr old; Family |
| |relationships: 3 yr old |
| | |
| |Current Level of Development: Physically: 3 yr; Cognition 3 yr |
| | |
| | |
| |Mobility: Selectively immobile r/t pain in lower periphery d/t sickle cell disease |
| |Psychosocial Assessment (Erikson’s developmental tasks, child & family’s: ability to adapt to illness, living arrangements, support |
| |system, other stressors): Unable to assess Erikson’s developmental tasks due to extreme pain.
The father and mother play an instrumental|
| |role in child’s development. A paternal aunt babysits for the parents. Few friends and primarily plays indoors with sister; lives with |
| |both parents, sister, and paternal grandmother. Lots of family that live nearby and come to visit. |
| | |
| |Risk Assessment: Risk for infection r/t Sickle Cell Disease; Risk for fluid and electrolyte imbalance; Fall risk; Braden Score: 22 |

Laboratory
Values

Phenytoin 4.6 [10-20]
Hbt 8.6 [11.5-13.5]
Hct 25.1 [34-40]
Plt 177 [150-450]
WBC 20.0 [5.0-14.5]
CK 0.28 [0.2-0.6]
BUN 8 [5-17]
PaCO2 24 [22-30]
Na+ 133 [135-145]
Cl- 106 [98-107]
K+ 4.6 [3.4-4.7]
Mg++ 1.5 [1.6-2.2]
Ca++ 8.7 [8.8-10.8]
Albumin 2.2 [3.5-4.8]
PT 13.7 [9.3-12.6] aPPT 24.3 [24.7-35.3]
AST 88 [20-60]
ALT 36 [10-25]

Total 24Hr urine collected: 200mL

Medication Lists

|Current drug (generic name) |Dose |Route |Time |Freq |
| |
|Scheduled |
|Phenytoin |50 mg |IV | |Q12Hr |
|Azithromycin |70 mg |IV | |Q24Hr |
|Hydroxyurea |0.2 mg |PO | |Daily |
|Sulfasalazine |100 mg |PO (liq) | |BID |
|Prednisolone |6 mg |PO (liq) | |Daily |
|Cefepime |750 mg |IV | |Q12Hr |
|Ceftriaxone |700 mg |IV | |Daily |
|famotidine |7 mg |IV | |Q12Hr |
| |
|PRN |
|Acetaminophen |210mg |PO (drops) |------ |QHS |
|Albuterol |2 puffs |PO (inhaler) |------ |PRN |
|Hydralazine |1.4 mg |IV |------ |PRN |

Pre-admission
|Drug (generic name) |Dose |
|Hydroxyurea |220 mg |
|Sulfasalazine |150 mg |
|Amoxicillin |5 mL (liq) |
|Folic acid |1 mg |
|Oxycodone |1.5 mg |
|Prednisolone |15 mg |
|Prevacid |15mg |
|Albuterol |90 mcg |

Discharge
|Drug (generic name) |Dose |Route |
|Folic acid |1 mg |PO |
|Calcium carbonate |500 mg |PO |
|Hydroxyurea |0.2 mg |PO |
|Sulfasalazine |150 mg |PO (liq) |
|Prednisolone |6 mg |PO |
|Levetiracetam |100 mg |PO (liq) |
|Oxycodone |2.5 mg |PO |
|Penicillin VK |250 mg |PO |
|Acetaminophen-codeine |5 mL |PO |
|Centrum – Kids |0.4-18 mg |PO |
|Albuterol |90 mcg |PO (inhaler) |
|Lansoprazole |15 mg |PO |

N221 Pediatric Nursing --- Physical Assessment

|Chief Complaints (subjective data): Seizures |Respiratory System |
| |Regular rate and rhythm; non-productive cough. SpO2 100% (room air). |
|Current Level of Independence: Self oral care, partial bath, no |Tachypneic (RR=30); symmetrical expansion; LUL, RML, RUL were all |
|ambulation d/t pain in lower extremities |clear. LLL & RLL clear but slightly diminished with occasional |
| |grunting. No cyanosis. Diaphragmatic breathing. No reported |
|Activity Order: Ambulate as tolerated. OOB for playtime. Sit upright|shortness of breath (SOB). No dyspnea noted. No incentive |
|for meals. |spirometry. No stridor. No labored breathing. |
|Cardiovascular System |Neurological System |
|Palp pulses (radial) x2 upper extremities. Unable to assess lower |A+ O x 3; Calm but slightly agitated; Fine & gross motor movements |
|extremities due to reported pain. HR (apical)=97bpm. Crisp, clear |generally intact. Unable to assess Doris extension/flexion or tactile|
|S1S2 noted and cap refill