6 Sickle Cell Anemia Crisis Nursing Care Plans

Impaired Gas Exchange

Impaired gas exchange can occur in patients with sickle cell disease due to the combined effects of decreased oxygen-carrying capacity of the blood, reduced red blood cell lifespan, and increased blood viscosity. The characteristic sickle-shaped red blood cells in sickle cell anemia have a shorter lifespan and are less able to deliver oxygen to the body’s tissues. In addition, patients with sickle cell anemia are more susceptible to bacterial pneumonia, which can further compromise gas exchange.

Nursing Diagnosis

• Impaired Gas Exchange

May be related to

• The decreased oxygen-carrying capacity of the blood, reduced RBC life span/premature destruction, abnormal RBC structure; sensitivity to low oxygen tension (strenuous exercise, increase in altitude)
• Increased blood viscosity (occlusions created by sickled cells packing together within the capillaries) and pulmonary congestion (impairment of surface phagocytosis)
• Predisposition to bacterial pneumonia, pulmonary infarcts

Possibly evidenced by

• Dyspnea
• Confusion
• Use of accessory muscles
• Restlessness
• Tachycardia
• Cyanosis (hypoxia)

Desired Outcomes

• The client will demonstrate improved ventilation/oxygenation as evidenced by respiratory rate within normal limits, absence of cyanosis and use of accessory muscles; clear breath sounds.
• The client will participate in ADLs without weakness and fatigue.
• The client will display improved/normal pulmonary function tests.

Nursing Assessment and Rationales

1. Monitor respiratory rate, depth, use of accessory muscles, and areas of cyanosis.
These are indicators of the adequacy of respiratory function or degree of compromise and the effectiveness or need for therapy.

2. Auscultate and note the presence or absence of breath sounds and adventitious sounds.
Development of atelectasis and stasis of secretions can impair gas exchange.

3. Monitor vital signs and note changes in cardiac rhythm.
Compensatory changes in vital signs and the development of dysrhythmias reflect the effects of hypoxia on the cardiovascular system.

4. Check thoroughly reports of chest pain and increasing fatigue. Monitor for signs of fever, cough, and adventitious breath sounds.
This may reflect the development of acute chest syndrome which increases the workload of the heart and oxygen demand. The crisis is a common complication in sickle-cell patients and can be associated with one or more symptoms including fever, cough, excruciating pain, sputum production, shortness of breath, or low oxygen levels.

5. Regularly assess the level of consciousness.
Brain tissue is very sensitive to decreases in oxygen. Doing the assessment may be an early indicator of developing hypoxia.

6. Monitor laboratory studies: CBC, ABGs, pulse oximetry, cultures, chest x-rays, and pulmonary function tests.
These tests can provide valuable information about the patient’s overall health status and help identify any underlying respiratory or infectious complications.

Nursing Interventions and Rationales

1. Assist the client in turning, coughing, and deep-breathing exercises.
Promote expansion of the chest optimally, mobilization of secretions, and aeration of all lung fields. This also reduces the risk of stasis of secretions and pneumonia.

2. Evaluate the patient’s tolerance to activity, and limit activities within the patient’s tolerance. Assist with ADLs and mobility as needed.
Reducing the metabolic requirements of the body would reduce the oxygen requirements.

3. Schedule rest periods and encourage the patient to alternate rests and activities.
To protect the patient from excessive fatigue and reduce oxygen demands.

4. Teach and demonstrate the use of relaxation techniques: guided imagery, deep breathing exercises, and visualization.
Relaxation decreases muscle tension and anxiety and hence the metabolic demand for oxygen.

5. Encourage adequate fluid intake (2 to 3 L/day) within cardiac tolerance.
Adequate intake is necessary to provide for the mobilization of secretions and prevent hyperviscosity of blood occlusion.

6. Screen the health status of patients’ visitors and staff. Use PPEs when necessary.
Protects from potential sources of respiratory infection.

7. Administer supplemental humidified oxygen as indicated.
Supplemental oxygen maximizes the transport of oxygen to the tissues. Oxygen should only be given in the presence of confirmed hypoxemia because oxygen can suppress erythropoietin levels, further reducing the production of RBCs.

8. Perform and assist with chest physiotherapy, intermittent positive-pressure breathing (IPPB), and incentive spirometry.
Patients with SSD are prone to pneumonia, which can be potentially fatal because of its hypoxic effect of increasing sickling. Mobilizes secretions and increases the aeration of lung fields.

9. Administer packed RBCs or exchange transfusion as ordered.
Increasing the number of oxygen-carrying cells dilutes the percentage of HbS to prevent sickling, improves circulation, and decreases the number of sickled cells. Plain red blood cells (PRCs) are usually used because they are less likely to create a circulatory overload. Partial transfusions are sometimes used prophylactically in high-risk situations (e.g., preparation for general anesthesia, third trimester of pregnancy.)

10. Administer medications as indicated:

• 10.1. Antipyretics: acetaminophen (Tylenol)
  Maintains normal temperature to reduce metabolic oxygen demands without affective serum pH, which may occur with aspirin.

• 10.2. Antibiotics
  A broad-spectrum antibiotic is started immediately pending culture results of suspected infections. This may change when the specific pathogen is identified.