vSim Pediatrics | Brittany Long (Sickle Cell Anemia)

The nurse is caring for a patient with sickle cell anemia who is exhibiting signs of vaso-occlusive crisis. Which of the following should be included in the plan of care for this patient? (Select all that apply)

a) Assess pain frequently and administer meds routinely d) Administer O2 if saturations are <92% to promote adequate oxygenation e) Administer hypotonic fluid IV to promote hemodilution

The nurse is performing a physical assessment on a 5 y/o pt. Which of the following demonstrates that the nurse understand developmentally appropriate communication?

a) I want to listen to you breathe. I need you to help me hold my stethoscope in place.

A pt with sickle cell disease experiencing vaso-occlusive crisis comes tot he ER for evaluation. Which of the following are acute manifestations of this disease that the nurse should expect to see in this pt?

a) acute leg pain and dactylitis Rationale: Acute manifestations of sickle cell anemia in a vaso-occlusive crisis include pain crisis and swelling of the fingers and toes (dactylitis). Hypertension and tachycardia are often associated with acute pain. Anemia, jaundice, enuresis, and proteinuria are chronic manifestations of sickle cell anemia.

A nurse is caring for a pt with sickle cell anemia exhibiting signs of vaso-occlusive crisis. Which of the following would be the highest priority and most appropriate nursing diagnosis in this case?

d) Acute pain r/t tissue ischemia Rationale: Tx of sickle cell crisis focuses on pain management. Thus, the diagnoses pertains to fatigue, impaired mobility, and anxiety would be lower priority that that of acute pain

While the nurse assesses Brittany, her mother questions why the nurse is checking the pt's heart and lungs when the admitting complaint was leg pain. The nurse is assessing for which of the following complications of vast-occlusive crisis?

d) Chest syndrome Rationale: Acute chest syndrome is caused b the clumping of sickled cells in the lungs, which results in decreased gas exchange, producing hypoxia, and further sickling. Pneumothorax, or collection of air in the pleural space, is not associated w/ vaso-occlusive crisis that occurs when blood is sequestered in the spleen; however, this would warrant assessment of the abdomen, not the heart and lungs. Dactylitis, another complication, is swelling of the fingers and toes.

Brittany has been receiving IV morphine for pain associated with a vaso-occlusive crisis for 1 week. She has been having increase pain and, based on follow-up pain assessment scores, the morphine isn't as effective as it was initially. The provider has increased the morphine dose, but her mother voices concerns that Brittany is addicted to the medication. Which of the following responses by the nurse is correct?

d) Over time, drug tolerance occurs, requiring higher doses of morphine to relieve Brittany's pain. Tolerance is not addiction. Rationale: Brittany is demonstrating drug tolerance,which is different from physical dependence, or addiction. Drug tolerance occurs when increasing doses of medication are required to manage pain. Physical dependence, which can occur after as few as 5 days of continuous medication use, is a perceives need by the pt to continue taking the drug to prevent sx of withdrawal, which can occur if suddenly stopped. Addiction to narcotics when used to treat children's pain is very rare but does occur. Meperidine is not recommended for pain relief in children, as severe side effects such as seizures are associated w/ use.