Medical Definition of Sickle Cell Anemia

Introduction

Patient at KAMCJD, 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)

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.

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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 described as throbbing, severe, and incapacitated (pain score?)
• 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, reduced RBC life span/premature destruction evidence by Tachycardia and Use of accessory muscles(what is the hemoglobin?).

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.

References

1. Kanter J, Kruse-Jarres R. Management of sickle cell disease from childhood through adulthood. Blood Rev. 2013;27(6):279-287.
2. https://goo.gl/images/9Puek5
3. https://goo.gl/images/9Nzot9
4.  Jarvis, C. (2004)6th edition. Physical examination & health assessment. St. Louis, Mo: Saunders.
5. Smeltzer, S., & Bare, B. (2010). Textbook of Medical-Surgical Nursing. (12th ed.). New York: Lippincott Williams & Wilkins. Chapter 33: Page 920-923.