Sickle Cell All Solution Fall-2021 Latest Answers

Part I: Recognizing RELEVANT Clinical Data History of Present Problem: Anthony Perkins is a 15-year-old African American male who was at a medically monitored summer camp and participated in several sports activities when the outside temperature was greater than 90 degrees. He began having pain in his knees and was evaluated by the camp nurse. After evaluation, he was transported to his primary care provider and evaluated. Anthony was transferred as a direct admit to the pediatric floor of the community hospital where you are the primary nurse responsible for his care. He weighs 154 lbs or 70 kg. Personal/Social History: Anthony was diagnosed with sickle cell anemia at birth during a routine newborn screening. He was a term newborn with normal childhood illnesses. He has been hospitalized with pneumonia four times – at age 8, 9, 11, and 14. He is up to date on childhood immunizations, and recently received his pneumococcal and influenza vaccines. Anthony has had multiple hospitalizations for sickle cell crises and transfusions. He lives with his parents and two siblings, a younger brother (9 years old), and sister (4 years old). His family lives in a three-bedroom, two-bath home. Anthony’s father is an accountant and the sole financial provider of the family. Anthony’s mom stays home, raising the children. The family is covered by a private medical insurance PPO through Anthony’s father’s employer. Personal/Social History: What data from the histories are important and RELEVANT and have clinical significance for the nurse? RELEVANT Data from Present Problem: Clinical Significance: RELEVANT Data from Social History: Clinical Significance: Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 99.4 F. (37.5 C.) (oral) Provoking/Palliative: Movement and weight bearing/Rest, elevation, warm compresses P: 92 (regular) Quality: “My knees are really hurting…deep ache” R: 20 (regular) Region/Radiation: Bilateral knees BP: 102/74 Severity: 8/10 O2 sat: 96 Timing: Constant since around noon today The nurse recognizes the need to validate concern about fluid volume deficit, performs a set of orthostatic VS and obtains the following: Position: HR: BP: Lying 92 102/74 Standing 132 92/42 What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: Current Assessment: GENERAL APPEARANCE: Uneasy in bed, changing position frequently, cooperative and responds to questions appropriately. RESP: Breath sounds clear with equal aeration bilaterally, increased respiratory effort; mild nasal flaring noted; no tracheal tugging, no retractions. CARDIAC: Pink, warm and dry, no edema, heart sounds regular with no abnormal beats, no murmur noted, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, denies chest pain. NEURO: Alert and oriented to person, place, time, and situation (x4). GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants. GU: Voiding without difficulty, urine clear/dark amber in color, no priaprism present. SKIN: Skin integrity intact. MUSKULOSKELETAL: Knees swollen bilaterally, erythemic, warm to touch, decreased ROM of knees, pain reported with movement.