Sickle Cell Crisis question

[memphispanda]

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.

[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

[renerian, BSN, RN]

Good thread.

renerian :)

[Rapheal]

I think you did a great job. The acute chest sydrome post was very interesting. I will keep it in mind next time I care for a ss patient.

[suzanne4, RN]

You did the right thing by giving him that does of MS. If you think back to your nursing text, treatment in acute stage is IV fluids and opiates, usually in high dosages. The pain that they get during a crisis is quite severe. Usually the patient gets dehydrated because it hurts so much to move. The first pain that they usually present with is in the joint areas because of the shape of the cells. If you can rehydrate them, you can help diminish their pain, also. So, don't forget the fluids.

[memphispanda, RN]

He had fluids...I *think* it was NS at 150cc/hour, but it might have been something else. Thanks for all the great info...I wish I'd had better orders to help deal with the pt's pain. He came in with no primary care doc, and the doc he was assigned is notorious for poor pain control, thus no PCA...the initial order was for demerol 25 and phenergan Q4. Right. Morphine was only ordered after a call.

[suzanne4, RN]

First, they should hide the narcotics when that physician comes in with a kidney stone, or just lose the keys for awhile.

We always give fluids wide open initially. sometimes you need to give them about 400/ hr, etc. to get their volume up to norm. Remember that when most patients come in during a crisis they have been bed-ridden usually for a few days, not even getting up for a drink or going to the bathroom because of increased pain. So replacing fluids also needs to be be a priority.

[Dave ARNP]

200cc/HR of NS is usually my standard order.

Demerol 25? Let's just give him a tylenol and sing a happy song!

-Dave

[Aneroo, LPN]

Student nurse here. We actually just went over sickle cell disease, test on it tomorrow. :uhoh21: One of the main things they've drilled into our heads is just how fast a sickle cell pt can change on you. Instructor was telling us about an experience she had where she had charted pt was fine, acyanotic, skin warm, etc...15 mintues later another RN went in and pt was clammy, sweating, etc... Second RN thought my instructor had lied in her charting, but a doctor was in there with her during first (pt fine) visit, so he was able to vouch for her. -A

[NurseDixie]

I just had a SS pt last Tues. evening. She was in severe pain. She was on morphine 2mg q 30 min. basal rate PCA, then she could get .5mg q 10 min. by pushing the button. She was getting NS at 200/hr, and was on O2 at 2L/nc. Also she got 3 tylenol q 4 hrs for temp/pain.This is the first pt we've had on our unit for a long time. I've only been there 3 months, but the RNs who have been there for years couldn't remember ever having a SS pt. (I work in rural WV).

[renerian, BSN, RN]

A sickle cell patient will never forget your kindness as a nurse. You will forever be in their mind if you can help their pain. I had quite a few ask for me when they were direct admits from ER. I am not saying that because I think I am great or anything. I just made their comfort a stat priority.

renerian

[EmeraldNYL, BSN, RN]

I think you did the right thing. We have had several sickle cell patients go bad and end up intubated in our ICU; they are very difficult patients to work with sometimes. My unit does a lot of plasmapheresis with sickle cell patients. I agree, this is an interesting thread. Lots of good info.!!

[jaimealmostRN]

Another student here: Can't you not give demerol for SS pain? I forget why as my text books are hidden away until June 1st. Anyone know or am I thinking of something else? OP, I think you did a great job judging from your post. You trusted you instinct and stayed close to this pt., and responded quickly when things wen't wrong. :)