HESI Case Study - Sickle Cell Anemia

To evaluate the discharge teaching completed at the hospital, the home health nurse discusses acute exacerbations of SCD with the client and her caregiver. Which behavior indicates to the nurse the caregiver understands about acute exacerbations of sickle cell disease? A. She is able to take the client's radial pulse within 4 beats of the nurse. B. She does not allow client to go outside unless she is with her. C. She measures client's fluid intake to remain under 1 liter a day. D. She demonstrates how to accurately read an oral thermometer.

D. An elevated temperature is the first sign of infection, which can, and many times does, lead to an acute exacerbation of SCD. Therefore, being able to take client's temperature correctly is vital.

Introduction

The child, who is school-aged is admitted to the Pediatric Unit with an exacerbation of sickle cell disease (SCD). The child is accompanied by her caregiver. The nurse meets with the client and the caregiver to discuss their health condition. The caregiver asks the nurse, "I have heard of sickle cell disease (SCD) and I know it can be very bad, but I don't know exactly what it is."

The nurse calculates the client's intake and output (I&O) for the shift. She has had 24 ounces of water, 8 ounces of apple juice, and three 4-ounce cartons of milk. She received 50 mL of IV fluids per hour for the last 12 hours and had a urinary output of 1200 mL, plus one episode of wetting the bed. What is the total intake for this shift? (Enter the numerical value only. If rounding is necessary, round to the whole number.)

1920 1 ounce is equal to 30 mL; 24 ounces (24 × 30) = 720 mL, 8 ounces (8×30) = 240 mL, 4 ounces (4×30) = 120 × 3 cartons = 360 mL for a total of 1320 mL of oral fluids; 50 mL × 12 = 600 mL; therefore the total intake for this shift is 1920 mL.

After fluids have started, the client relates that her pain is an 8 on the Wong-Baker FACES pain scale. Which medication should the nurse expect to be ordered for pain control? A. Morphine sulfate B. Ibuprofen. C. Acetaminophen. D. Meperidine.

A. Opioids provide systemic relief for the client with sickle cell.

Which statement by the client indicates she is meeting Erikson's stage of development for her age? A. "Look, I finished putting the puzzle together." B. "I don't want any of my friends to visit me here." C. "I need my stuffed dog so that I can go to sleep." D. "When I grow up, I want to be a nurse just like you."

A. School-aged children are in Erikson's stage of developing a sense of industry, meaning they like to do and accomplish things.

The charge nurse is transcribing prescriptions at the nurse's station. Other responsibilities of the charge nurse include answering the phone, assisting with visitor's questions, and answering the child's call lights. Which nursing task is best for the charge nurse to delegate to the UAP? A. Take the hourly vital signs for a child receiving a unit of blood. B. Teach the child's caregiver how to apply warm soaks to her joints. C. Educate the child about a healthy lifestyle. D. Change the morphine vial on the client-controlled analgesia pump.

A. The UAP can take the vital signs but the RN must evaluate the results

The caregiver listens attentively to the nurse discussing the client's condition and what must be done to competently care for her. After reviewing the needed care, the nurse asks the caregiver if there are any other questions. The caregiver asks, "How did my child get this awful disease?" How should the nurse respond? A. "This disease is an inherited autosomal recessive disease and your daughter inherited the gene responsible for causing the disease." B. "Your daughter has the disease because she inherited the gene from one of her parents, who is a carrier." C. "She must have had a bad reaction to a transfusion as a child." D. "She was exposed to a virus while her caregiver was pregnant." This is not the etiology for SCD.

B. For a child to acquire the disease, both parents must have the SCD trait. Each child of a couple with the SCD trait has a 1 in 4 chance of developing the disease.

Which action should the ED nurse implement first? A. Request arterial blood gasses stat. B. Administer oxygen via nasal cannula. C. Send the client for an x-ray of her knees and elbows. D. Prepare to administer analgesics as prescribed.

B. A pulse oximeter reading of less than 93% indicates hypoxia, which warrants oxygen administration. Oxygen will not help reverse the sickling crisis because oxygen cannot reach the enmeshed sickled erythrocytes in clogged vessels. However, it will help oxygenate the cells that are not sickled.

The ED nurse continually assesses the client for signs and symptoms of hypoxia. The client's caregiver presses the call bell to tell the nurse there is blood in the commode after the client went to the bathroom to urinate. Which action should the nurse implement? A. Notify the HCP immediately. B. Explain that blood in the urine is expected. C. Request a stat hemoglobin level. D. Request a stat sterile urine specimen.

B. Hematuria is an expected clinical manifestation during a vaso occlusive sickle cell crisis.

The client is transferred from the ED to the pediatric intensive care department (PICU). In developing the plan of care with the RN team leader, the nurses identify the nursing problem, "Acute pain related to tissue ischemia" as a priority. Which intervention should be included in the care plan? A. Assess pain by using a numerical pain scale. B. Explain how to use a patient controlled analgesic pump. C. Apply cold compresses periodically to painful joints. D. Administer acetaminophen as needed (PRN) as needed for pain.

B. Opioids are the mainstay for analgesic treatment for acute pain, and when they are administered via PCA pump the client has better control of the pain. Both the client and the caregiver should receive information about use of the PCA pump.

The client's caregiver asks many questions about sickle cell anemia. She is very concerned about the child and what will happen to her in the future. The nurse is aware there are many serious complications she could experience. Which potentially fatal complication(s) can occur? (Select all that apply. One, some, or all options may be correct.) A. Vaso-occlusive crisis. B. Cerebral vascular accident. C. Priapism. D. Hypertensive crisis. E. Heart failure.

B., E. Due to the sickling of the blood and to tissue hypoxia, a cardiovascular accident (CVA) or stroke may occur and is potentially fatal. The patient with SCD can develop heart failure related to cardiomegaly.

Discharge Instructions Client is scheduled for discharge the next day. The nurse is completing discharge teaching with her caregiver who says they are planning a visit to Colorado to see the caregiver's sister and her family for the Christmas holidays. The client is very excited and can't wait to meet her cousins. What is the best response by the nurse? A. "I know that she will enjoy meeting her family." B. "I think you should talk to her HCP before you go." C. "Your planned trip may put her at risk for a crisis." D. "Could your family come here for the Christmas holidays instead?"

C. High altitudes have decreased oxygen, which could lead to a sickle cell crisis. In addition, cold will cause constriction of blood vessels, further decreasing the oxygen supply.

ManagementThe day shift is coming on duty to the pediatric department. The staff available includes two experienced RNs, one new graduate who has just finished the 3-month pediatric internship, and two unlicensed assistive personnel (UAP). Which child should the charge nurse assign to the new graduate nurse? A. A school-aged child newly diagnosed with Cystic Fibrosis. B. The adolescent, who is scheduled as a probable discharge for tomorrow. C. A school-aged child who had an appendectomy 2 days ago. D. A school-aged child being evaluated for possible physical abuse.

C. This child had a routine surgery. There is no data indicating that the child is unstable; therefore, a new graduate should be able to provide safe care for this child.

Once the client is cleaned up and repositioned in bed, she states she is hungry, and would like to have a snack. Which food should the nurse offer to the client who is in a sickle cell crisis? A. Peaches B. Cottage cheese C. Popsicles D. Lima beans

C. This will improve the child's hydration status. Other select items are gelatin, juices and puddings.

The school nurse reviews immunization records from the client's previous school. The nurse notes the client had four scheduled doses of DTaP, three scheduled doses of Hib, and one dose of MMR and received her Hep B series as an infant. Which recommendation about immunization should the school nurse make to the client's caregiver? A. The client needs her second scheduled dose of MMR #2. B. The client is current with her immunizations. C. The client needs her Hepatitis A immunizations. D. The client needs her influenza vaccine.

A. According to current immunization schedules, she should have had two scheduled doses of MMR, with the second due at 4 to 6 years of age.

The client's HCP has advised her caregiver to get pneumococcal and meningococcal vaccines for her at the follow-up office visit. The caregiver asks the nurse, "Why does she need to have those other vaccines? I hate for her to get more shots. She cries, and I know it hurts." What is the best response by the nurse? A. "I will get the HCP to explain why the vaccines are needed." B. "She is susceptible to infections. These vaccinations may help prevent a crisis." C. "These vaccines are required for all children younger than 10 years of age." D. "I know you don't like to see her hurt, but she must have these vaccines."

B. An individual with SCD has a functional reduction in splenic activity, which progresses to the point at which the spleen is no longer able to function. This increases susceptibility to infection.

The client's caregiver goes downstairs to get something to eat from the hospital cafeteria. The unlicensed assistive personnel (UAP) informs the nurse the client urinated in the bed, is crying, and wants her caregiver. Which intervention should the nurse implement first? A. Change the bed linens. B. Help change her clothes. C. Find the client's caregiver in the cafeteria. D. Document the incident in the chart.

B. The nurse should address physical needs first, then find her caregiver, have the bed linens changed, and document the incident. Enuresis is expected due to increased fluid intake.

The client is discharged home with a home health referral. The home health nurse visits the day after she is discharged from the hospital. The client's caregiver asks the home-health nurse, "I received some information from the Sickle Cell Foundation, but I have never heard of it. What kind of group is it?" How should the nurse respond? A. "It is a foundation that deals primarily with research to find the cure for sickle cell anemia." B. "It provides information on the disease and on support groups in this area." C. "They didn't discuss this organization with you in the hospital?" D. "The foundation arranges for families with children who have sickle cell to meet each other."

B. This correctly describes the mission of the foundation. Knowing about resources helps decrease the primary caregiver's feelings of frustration and helplessness.

The ED HCP completes the assessment and diagnoses the client with a vaso-occlusive sickle cell crisis, probably secondary to pneumonia. Which orders should the nurse anticipate? A. Provide the client with cold packs to place on her joints. B. Admit the client to a private room and keep her in reverse isolation. C. Infuse 5% Dextrose in 0.33% sodium chloride (NS) at 75 mL/hr via pump. D. Insert a 22 French indwelling urinary catheter with an urometer.

C. Increased intravenous fluid reduces the viscosity of blood, thereby preventing further sickling due to dehydration. This rate is higher than usual for a 8-year-old, but it is indicated during a sickle cell crisis.

The client is in the ICU for 3 days and is transferred to the pediatric floor. Her caregiver has been at the hospital every day and is very concerned about her condition. The caregiver asks the nurse, "What can I do to make sure this never happens again?" Which is the best initial response by the nurse? A. "When your daughter gets a fever give her 1 baby aspirin." B. "Keep her away from anyone who has an infection." C. "There is no way you can make sure this never happens again." D. "Make sure she does not participate in any strenuous activity."

C. A child with sickle cell anemia will experience crises. The caregiver needs to understand that she cannot prevent a crisis from ever happening again. The nurse should provide instructions about measures to reduce the frequency of crises, as well as how to recognize crises when they do occur.

Client is starting to feel better and is requiring less pain medication. Client is sleeping as the nurse makes evening rounds. Her caregiver shares with the nurse, "I have no idea what my daughter should be allowed to do so she can have some fun?" Which statement is the best response by the nurse? A. "You sound like you are worried about taking your daughter home." B. "I recommend enrolling her in a sport with running, such as soccer." C. " School-aged children like being in groups like Girl Scouts or Girls' Clubs." D. "Your daughter should not be around a lot of children, so her activities will be limited."

C. Formal organizations foster self-esteem and competence as children earn ranks and merit badges. Interaction with peers, acquisition of new skills, and a sense of belonging to a group outside the family can help increase self-esteem.

Which is the best initial response by the nurse to explain SCD to the client's caregiver? A. I have some written material that will explain all about the disease. B. It is a disease of the blood that requires taking medication every day. C. Mary will probably have episodes of severe joint pain and will need to be hospitalized. D. Red blood cells become 'C' shaped, stiff, and sticky, which blocks the blood vessels.

D. Sickle cell anemia is a disorder of the red blood cells characterized by abnormally shaped red cells that block and damage blood vessels leading to oxygen deprivation, pain, anemia, serious infections, and damage to vital organs.

After attending school for 2 weeks without any problems, the client reports to the school nurse that she doesn't feel well. The nurse determines she has a temperature of 102° F (38.8o C). The school nurse calls her caregiver and advises the nurse to take the client directly to the emergency department (ED). She reported pain in her knees, in her elbows, and throughout her body. In the ED, the nurse confirms vital signs with temperature 102u00b0 F (38.8° C), pulse 104 beats per minute, respirations 24 breaths per minute, blood pressure 90/68 mmhg, and pulse oximeter reading 91%. The nurse notifies the ED physician of the child's vital signs, which are: vital signs as Temperature 102° F (38.8° C), Pulse 104 beats per minute, Respirations 24 breaths per minute, Blood Pressure 90/68 mmhg, and pulse oximeter reading 91%. The nurse anticipates an order for which diagnostic test by the ED HCP? A. Peripheral blood smear B. Hemoglobin electrophoresis C. Sickle-turbidity test (Sickledex) D. Blood cultures

D. An elevated temperature is the first sign of bacteremia, which leads to a sickle cell crisis. The bacteria must be identified so the appropriate antibiotic can be prescribed to treat the infection.

The following Monday, the client goes with her caregiver to the local elementary school, where she is enrolled in the third grade. The caregiver meets with the school nurse to discuss the client's needs while she attends school. The school nurse has cared for several children with SCD and is very knowledgeable about the needs of children with the disease. The school nurse discusses the client's condition with the classroom teacher. Which intervention should the nurse implement? A. Explain that the other children should be extra nice to the client. B. Instruct the teacher to have the client sit at the front of the classroom. C. Encourage the client to participate in all playground activities. D. Request the client be allowed to go to the bathroom whenever she asks.

D. The client needs increased hydration to prevent a sickling crisis. This increased fluid intake will lead to increased urination, so it is important that she be allowed to go to the bathroom as needed.

The night nurse assesses the client and notes that her vital signs are now temperature 98.3° F (36.8o C), pulse 108 beats per minute, respirations 22 breaths per minute, blood pressure 96/60 mmhg. Which action should the nurse implement? A. Notify the HCP immediately. B. Retake and assess the vital signs in 1 hour. C. Encourage the client to turn, cough, and deep breathe. D. Document the findings on the graphic sheet.

D. These are normal vital signs for a 8-year-old child; pulse is 70 to 110 beats per minute, respirations 18 to 22 breaths per minute, Blood Pressure systolic: 83 to 121 and diastolic 45 to 79. The HCP will use a detailed breakdown of height by age norms to determine normal vs. hypertensive.