Please Help: Standing Order For Sickle Cell Crisis

[Olli]

Hi everyone,

I have my leadership rotation at the med surg unit at one of the hospitals in Chicago. They have some sickle cell patients on the floor but do not have a standing order for the sickle cell patients. The staff asked me to do my in-service about the the standing order for the sickle cell patients. For once, I do not even remember if I ever came across the standing order for sickle cell patients at other hospitals. Where can I get some information about this? What is usually included in the standing order for the sickle cell patients? How does the hospital implement the standing orders? Do you have any links to send?

Thanks a lot,

I really appreciate your help!!!

[Agnus]

To be honest I can not imagine standing orders for this disorder. It is so individual and each crisis is individual.

Pain is a HUGE issue that is what defines the crisis. PCA is usually ordered but this can not be a standing order because the med and dosage must be individualized.

Nursing measures are pretty standard such as encourage fluid intake but you do not need a standing order for any nursing measure. Again the ages of cycle cell patients varies from small child to adult. How can you possible consider standing orders when there is nothing uniform about the range of bodies that experience crisis. Minimize stress and activities but again this is nursing measure that you do not need orders for.

I see many cycle cell pts. never have I seen anything that resembles something that could be turned into standing orders other than common nursing measures that you do not need orders for.

Are you instead looking for a care plan? that would in my estimation make more sense.

[Olli]

To be honest I can not imagine standing orders for this disorder. It is so individual and each crisis is individual.

Pain is a HUGE issue that is what defines the crisis. PCA is usually ordered but this can not be a standing order because the med and dosage must be individualized.

Nursing measures are pretty standard such as encourage fluid intake but you do not need a standing order for any nursing measure. Again the ages of cycle cell patients varies from small child to adult. How can you possible consider standing orders when there is nothing uniform about the range of bodies that experience crisis. Minimize stress and activities but again this is nursing measure that you do not need orders for.

I see many cycle cell pts. never have I seen anything that resembles something that could be turned into standing orders other than common nursing measures that you do not need orders for.

Are you instead looking for a care plan? that would in my estimation make more sense.

The population I work with are adults and the staff wants a standing order for sickle cell crisis. I also work at the UICMC surg-oncology unit as a student RN but never came across this. Thank you a lot though! I will try to find something in the literature too

[birdgardner]

Oxygen?

[leslie :-D]

i would like to see a prn order for mso4, w/minimum dosing and preferred route by md.

pain is always an issue.

leslie

[Agnus]

I am in a unique situation where I care for both adults and kids in cycle cell crisis. Even then I don't see how you can do more that order PCA again the dose and med must be individulized and oxygen as someone mentioned. Most of what we do is supportive using nursing measures other than pain control. IV fluids might be on a standing order. I would love to be shown wrong here and expect to. I just can't think of what else we could do medically.

[locolorenzo22, BSN, RN]

as the instructors always say "HOP to it!" Hydration, Oxygenation, and Pain control.

[zenurse]

Just a student here--I am curious about a nursing student providing "standing orders"--wouldn't that be the role of the physician? Wouldn't the nurse provide more of a care map, that addressed such issues as pain management, hydration, monitoring I & O to ensure hydration, allowing for rest, grouping care activities to provide optimal rest, passive range of motion exercises to maintain joints...., and educating, educating, educating?

Let us know how it is going!

[Olli]

Thank you everyone. Here is an evidence based practice article that discusses "A special treatment program for patients with sickle cell crisis"

http://findarticles.com/p/articles/mi_m0FSW/is_3_20/ai_n18613814/pg_1 for those of you who are interested. My in service presentation is April 22 and hopefully I'll get a standing order put together and post it here afterwards too. The hospital is small and the RN manager even mentioned a possibility of this standing order to be implemented there. I think I'll consult with MDs at the unit too.

Thanks again!!!

[gonzo1, ASN, RN]

We take Sickle Cell crisis patients very seriously and usually get them back as quickly as possible. Most frequently we use oxygen, normal saline and morphine. We also give terbutaline for priaprism (hope I spelled that right) in our male patients when needed.

These interventions seem to work pretty well for our ED.

[ICRN2008, BSN, RN]

My facility has a database with the patient's usual doses for PCAs (based on weight). Narcotic doses are highly individualized, like others have said. A dose that is ineffective for one patient might be lethal for another. We have a standard order set for when PCAs are ordered (including continuous pulse oximeter, oxygen as needed, vital sign monitoring orders, benedryl for itching, and other monitoring parameters). We also have standardized care plans for a number of disorders including sickle cell.

I agree that a physician should be the one to come up with any standard order set. RNs simply do not have an adequate level of knowledge about pharmacology. RNs should be the ones to come up with nursing care plans as this is within our scope of practice.

[BlueRidgeHomeRN]

i would like to see a prn order for mso4, w/minimum dosing and preferred route by md.

pain is always an issue.

leslie

totally agree--

you need orders that include

hydration

oxygen

pain control

the last is the hardest to have a a standing order--different pts need different narcotics, and since they are rarely opiate naive, some of the doses can run high. used to have a pt who was labeled drug seeking because only demerol worked for him...