Sickle Cell Crisis question

  1. Without giving too much info, I just need to know if I could have/should have handled this situation better.

    Pt came in with sickle cell crisis. Morphine ordered 10mg IV Q3H PRN pain. Also had a few other meds but only the morphine would touch his pain. He was tearing up, sweating, moaning--obviously in severe distress, altho O2 sat spot check was ok (we don't have cont monitoring). When I took report on him and then went in to check him out, I had that feeling about him...so I propped his door for the evening and stayed nearby to do all my charting, etc. He was snoring loudly, and I could his his rate creeping up--it had been 24, went up to 36 (about 2 hours post-morphine)...HR was 144, grabbed the sat monitor---28% Threw a simple facemask on him and cranked up the O2 and he got up to 58% sat. It would go higher if I could get him to talk to me, but he was really sleepy. Finally got him up to 90's. We ended up transferring him to a higher acuity floor.

    Now...
    I had much more seasoned nurses (I am a new grad) tell me that I had oversedated. Well...I don't really agree with that because his rate was UP up up--his drive wasn't gone. He was able to wake up and request more meds (he was still in pain). I haven't had a sickle cell patient before, and if I handled things poorly, I'd like to know so I can provide better care next time.
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  2. 30 Comments

  3. by   Harleyhead
    ht wt age general health. 10 mg of ms is not a lg dose.
  4. by   Godswill
    I tell u what I am not a nurse, but my sis has sickle cell, and if i rember they would give her a lot of morphine for pain.If I am correct i could have swore at one time they gave her a pump and she would pump when she had pain granted she could only pump some at a certain time, I am so grateful everyday i just got the trait and not the full blown diease :uhoh21:
  5. by   Godswill
    By the way, my sis alway have to get oxygen,(even after she get blood transfusion and meds) when she goes through a crisis, i thought that was because she was not getting enough oxygen through her blood
  6. by   ageless
    consider this option before you are too hard on yourself:

    although its cause is not fully understood, acute chest syndrome is more likely to develop after:

    • an infection.
    • a painful event (particularly one in the chest area that causes shallow breathing).
    • use of general anesthesia for surgery.
    • a reduction of normal blood flow to part of the lungs (caused by a blood clot).
    • pain treatment with heavy doses of opiate medication.
    treatment of acute chest syndrome includes:

    • encouraging deep breathing, especially important when a person has chest pain or drowsiness and shallow breathing from opiate medication.
    • possible antibiotic therapy, oxygen, pain medications, and blood transfusions.1, 2
    • monitoring the amount of fluids being consumed, because fluids may build up in the lungs (pulmonary edema) during acute chest syndrome.1



    acute chest syndrome is the leading cause of death among patients with sickle cell disease, but its cause is largely unknown. to determine the cause of acute chest syndrome and its response to therapy, vichinsky and colleagues performed a study of 671 episodes of the acute chest syndrome in 538 patients with sickle cell disease. they found that among patients with sickle cell disease, acute chest syndrome is commonly precipitated by fat embolism and infection, especially community-acquired pneumonia. among older patients and those with neurologic symptoms, the syndrome often progresses to respiratory failure. treatment with transfusions and bronchodilators improves oxygenation, and with aggressive treatment, most patients who have respiratory failure recover. acute chest syndrome is commonly precipitated by fat embolism and infection and most patients with respiratory failure can recover with aggressive treatment
    vichinsky ep, neumayr ld, et al; causes and outcomes of the acute chest syndrome in sickle cell disease. nejm 2000 june 22; (342): 1855-1865.
    http://jama.ama-assn.org/issues/v283.../jci00033.html
  7. by   memphispanda
    I should have been more clear about the O2--he had been on 2L BNC, but when I went in the room he was mouth-breathing so I switched to 6L with a mask.

    Thanks for the info on acute chest syndrome--I had never heard of that. I knew the precipitating factor for this guy (can't post, would be TMI) and it possibly could have contributed to that if he indeed had this. I'm not sure that's what it was--his lungs sounded ok, but because of his snoring it was quite hard to tell--and the snoring wasn't much better when he was awake because he was making a lot of noise (moaning, grunting, etc.).
  8. by   renerian
    Many people underestimate the amount of pain meds a sickle cell client can have unless they really understand the unrelenting pain they are sometimes in. I have seen some turn bad on the drop of a dime. O2 problems are common and our standing orders use to slap it on them right away. Could have been a PE, sedation (I highly doubt that one), infection all the things previously posted.

    I have to shake my head when people do not take them serious. Many people think they are just drug seekers. Sorry but I always thought a necrotic shoulder joint from sickeled cells would be very painful.

    Let us know how your client is doing and if they are okay. Very complex people to care for..

    renerian
  9. by   Godswill
    Quote from renerian
    Many people underestimate the amount of pain meds a sickle cell client can have unless they really understand the unrelenting pain they are sometimes in. I have seen some turn bad on the drop of a dime. O2 problems are common and our standing orders use to slap it on them right away. Could have been a PE, sedation (I highly doubt that one), infection all the things previously posted.

    I have to shake my head when people do not take them serious. Many people think they are just drug seekers. Sorry but I always thought a necrotic shoulder joint from sickeled cells would be very painful.

    Let us know how your client is doing and if they are okay. Very complex people to care for..

    renerian
    I am glad u said this , when my sis first got sick, doc could not figure out was wrong with her, many docs are not truly educated on this disease everyone thought she was just over reacting, i mean she could not move a muscle with out crying, i rember my dad literally carrying her to doc,because she could not walk. I have seen her cry because she was in sheer pain , now thats she older it no different, it just now as soon as she see the crisis coming she take action, she still suffers but not as bad.
  10. by   traumaRUs
    Sickle cell disease kills - it shortens lifespans and must be taken very seriously. I work in an ER and we try to provide very consistent care for ALL patients, but especially those with chronic pain issues so we contract with the pt and primary care provider and also bring in the pain management folks. Its not unusual in our ER to give MS04 40mg IVP in a one hour span. Provided the resp status is stable, these pt must have pain control. Godswill - your sister is lucky to have you!
  11. by   rollingstone
    I would've popped him on a non-rebreather mask at 15L if his O2 sat was 28%. That way his sats would've recovered a little quicker and then the O2 could've been titrated down after reaching a satisfactory level. Good luck.
  12. by   Dragonnurse1
    you were the one taking care of the pt. not anyone else. you were very astute in your observation of the potential for your pt to crash. traumarus is right. here our er handles a very high number of ss patients. we do not have the pain management people to call so it fell on us, the er nurses, to be advocates for our pts. i was a night nurse and i cannot tell you how many times we got our ss pts in on nights and it would have been their second trip on the same day. i guess we were more compassionate on nights not to mention a little more liberal with both pain meds and admissions. if their private md would not come in and treat they got instant admit with several meds to work with and the orders always read the same : mso4 2 - 6mg, ivp q 5 min until pain relieved or resp decreased!!

    many of our ssers did not have ports and getting iv's started was an olympic event. i have started iv's on these pts in fingers, thumbs, shoulders and the occ. foot/ankle. many calls i(we) got to go to the floor and start new lines.
    fluids/o2 and pain meds and sometimes the occ blood transfusion - always the same for every sser.

    you did great!!!

    oh yeah - my all time record for morphine was 34 mg in 1 hourand the pt was still talking and thrashing in pain.
  13. by   purplemania
    you have already received good advice, but I would like to add that new grads have real confidence issues, mostly because you want to know everything at once and you want to do a good job. Do some research on Sickle Cell and pain meds. When I worked in Memphis there was a great group of pediatric hematologists next to LeBonheur Childrens. They had a Sickle Cell clinic. They used to lecture and do grand rounds, which were educational. Call to see if they have a Fellow (MD) willing to answer your questions.

    As for over-sedation---that is why the patient required 24 hr nursing care and Narcan close by. You give them as much as is needed to control the pain. Sometimes you have to titrate doses. Otherwise, the patient could be at home on PO meds. Sounds like the other nurse does not comprehend that concept.
  14. by   Dave ARNP
    This patient needs to be be on a Morphine PCA.
    Large basal rate, and a good size PCA dose.

    No excuse for not providing that.

    Dave

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