Introduction:
Patient at KAMCJD, ward 5, Room 1 bed 3, Patient’s MRN: 147215, and her name is Fatemah Alshumrani. She is twenty-four years old. Her chief complaint for this present admission are severe generalized pain especially in her back and her both legs that worsen in coldness and relives by resting. She admitted to the hospital with medical diagnosis of sickle cell anemia,
Definition of the medical diagnosis:
Sickle cell anemia is an inherited condition in which there aren\'t enough healthy red blood cells to carry enough oxygen throughout the body. Normally, RBC are flexible and round, moving easily through the blood vessels. In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. These irregularly shaped cells can adhere to each other in small blood vessels, which can slow or block blood flow and oxygen to parts of the body.
Cause of the disease:
Patient has sickle cell anemia from her family (inherited). It is a sever hemolytic anemia that’s result from inheritance of sickle hemoglobin gene causes hemoglobin to be defective. The sickle cell gene is passed from generation in a pattern of inheritance called autosomal recessive inheritance. This means that’s both the mother and father must pass on the defective from of the gene for a child to be affected.
Clinical manifestation and classification according to the subjective and objective data:
Subjective data:
Objective data:
Fatigue / weakness
* Dizziness
* Shortness of breath
* Chest pain
* Headache
Pale or yellowish skin
* Bleeding / hemorrhage
* Syncope
* Hypotension
* Tachycardia
* Abnormal labs (CBC = decreased RBC and HGB)
Health assessment process done on Ms. Fatemah:
Five open questions:
1-DO you face difficulty in breathing at times?
Yes, I face difficulty in breathing when I do any sternuous activity .
2-do u feel suffocation at any time of the day due to any reason?
Yes , after any kind of extra work I feel suffocation and shortness of breath
3- how much water do you intake in a day?
Not much maybe 1 liter or less.
4-Could you describe the color of your urine?
It is dark brown in color and sometimes has a brownish shade.
5- any bone pain? where did the pain start? and how would you describe it?
Yes, I have pain in the back and both of my legs and feels like throbbing pain.
Five closed questions:
1- Are you able to breathe easily?
No
2-Do you experience any kind of pain in your joints?
Yes
3- Is your urine color brown sometimes?
Yes
4- Do you experience uneasiness due to increased heart beats
Yes
5- Do you feel like you have a heavy chest sometimes?
Yes
The physical assessment technique used for Ms. Fatemah are described below:
Technique Assessment Finding
Inspection
Inspect the general appearance including: the color of skin, face, lips, the breathing pattern, the color of sclera, and the color of the urine. 1- Jaundice obvious in the sclera of both eyes.
2- Pale skin color.
3- Shortness of breath 12 and use of accessory muscle.
4- Dark brown urine due to dehydration.
Palpation
Palpation of skin temperature and check capillary refill.
Palpation of the spleen.
Palpation of the back and legs.
Palpate for skin turgor. 1- Poor capillary refill and vascular insufficiency.
2- Cold skin.
3- No spleen enlargement.
4- Bone pain evidence by scale pain 8 of 10.
5- Poor skin turgor due to dehydration.
Percussion Percussion of the spleen. The percussion note is tympanic which is normal and no enlargement.
Auscultation Auscultate the lung by using the ladder manner.
Auscultate the heart. 1- Tachycardia as evidence by Herat rate 114.
2- Vesicular sound over the lung.
Nursing Diagnosis
Actual:
• Acute pain related to Intravascular sickling with localized stasis evidence by generalized pain score 8/10 described as throbbing, severe, and incapacitated
• Ineffective tissue perfusion related to Vaso-occlusive nature of sickling evidence by poor capillary refill less than 2 second.
• Impaired gas exchange related to Decreased oxygen-carrying capacity of the blood evidence by Tachycardia and Use of accessory muscles.
Potential:
•Risk for fall related to unsteady gait
•Risk for bleeding related to use Anti-thrombin medication, low Hemoglobin
•Risk for infection related to low hemoglobin levels
Conclusion
Finally, based on the theory and physical assessment we learned how to obtain health history and physical exams but that\'s was not enough for asking questions. We also learned how to focuses on the problems by critically analyze and synthesize the data we obtained. although, reassessment based upon the problem and the diagnosis is important. Result from that, health assessment guide us to identify and diagnose the problems to ensure the appropriate plan care for the patient.