Question

1. Create a table and identify ranges of acceptable vital sign values (temperature, pulse rate, respiration rate, blood pressure and oxygen saturation) for an infant, a child, and an adult.

1.a--J.P. is a 15-year-old African American adolescent who was diagnosed with sickle cell disease 3 years ago. J.P. presents to the emergency department with pain related to sickle cell crisis.

Subjective Data

Pain level is an 8/10 location = bilateral legs, described as deep muscle pain

Student in 10th grade, honor roll student

On the track team

Lives with mother and father

Objective Data

Vital signs: T 37 P 80 R 18 BP 140/68

Weight: 140

HT: 5 feet, 6 inches

Questions

a. What other assessments should be included for this patient? Explain your answers.

b. Discuss the various types of pain that a patient can experience. Explain your answers.

c. What type of pain does this patient describe? Explain your answers.

d.,What standards of assessing pain will be applied to this patient’s plan of care? Explain your answers.

e. Discuss three (3) patient education/teachings that should the nurse consider from the problems list. Explain your answer.

f. Provide four (4) interventions that should be included in the plan of care for this patient. Explain your answers.

Answer 1

	INFANT	CHILD	ADULT
TEMPERATURE	98.6F	98.6F	97.6F - 99.1F
PULSE RATE	100-160bpm	70-120bpm	60-100bpm
RESPIRATION RATE	30-60bpm	20-30bpm	12-18bpm
BLOOD PRESSURE	90/45 mm Hg	110/55 mm Hg	120/80 mm Hg
OXYGEN SATURATION	94.3	95-100%	97-100%

a) ASSESSMENT DETAILS:

• Monitor vital signs: assess pulse rate, rhythm and volume.
• Take a note : hypotension,rapid weak, thready pulses and increased or shallow respiration.
• assess skin for pallor, cyanosis, coolness, diaphoresis and delayed capillary refill
• monitor and note : changes in level of consciousness, reports of headache, dizziness, development of sensory and motor deficits and seizure activity.
• maintain : adequate fluid intake and monitor urine output.
• assess the lower extremities for skin: texture, ulceration and edema
• note reports: change in character of pain, development of bone pain, angina, tingling of extremities, eye pain and disturbances in vision.
• assess client for edema
• monitor lab values : ABGs, CBC ,LDH, AST/ALT , CPK , BUN
• monitor: electrolysis
• note urine characteristics and specific gravity
• assess: mucous membrane pain, dryness of skin

b) VARIOUS TYPES OF PAIN ASSOCIATED WITH SICKLE CELL ANEMIA

1. ACUTE PAIN: result of a vaso-occlusive crisis and should be treated in emergency.

• sickle shaped red blood cells block small blood vessels, obstruct blood flow. this leads to tissue damage and causes pain

2. CHRONIC PAIN: Pain lasts for three to six months or more.

• cause of pain is due to extension of recurrent painful episodes.
• it is associated with neuropathic pain which cause nerve damage

c) TYPE OF PAIN THAT DISCRIBED BY THE PATIENT

• CHRONIC PAIN: Patient having deep muscle pain which is a part of chronic pain
• chronic pain is associated with neuropathic pain, it will cause tingling, burning, numbing or sharp pain.

d) STANDARDS OF ASSESS  PAIN

• Self report scales 0-100 VAS
• Numerical pain scale
• assess behavioral or physiological signs of pain and anxiety
• rating of pain intensity.

e) PATIENT EDUCATION:

• Avoid emotional stress
• avoid smoking
• avoid chances for infection
• avoid too much exposure to sunlight
• avoid chances for dehydration

f) INTERVENSIONS IN CARE PLAN

• monitor : respiratory rate , depth , use of accessory muscles and areas of cyanosis
• schedule rest periods and encourage patient to alternate rests and activity
• assess chances of edema and ulcer formation
• maintain adequate fluid intake and monitor urine output