Nursing care of Acute Adult Sickle Crisis

Nursing of Adult Sickle Cell Crisis

Click on the links below to see each section about Nursing Management

• Types of Pain
• Nursing observations for patients receiving opiate via PCA
• Immediate Nursing Management of Vaso-occlusive Crisis
• Aims for Admission
• Nursing care of Vaso-occlusive Crisis
• Infection
• Acute chest syndrome
• Management of Acute chest syndrome
• Chronic Pain Management
• Psychological Aspect
• Discharge information
• Lecture on Nursing Care and Management of an acutely ill adult with Sickle Cell Crisis (focussing on vaso occlusion)

 

Types of Pain

The type of pain felt varies for the patient, the below give an idea of these types of pain and their interventions

Mild pain
This can be managed through Non-opioid analgesics +/- adjuvant

Moderate pain
Weak opioid (or low dose strong opioid) +/- non-opioid +/- adjuvant

Severe pain
Strong opioid +/- non-opioid +/- adjuvant
• Morphine or diamorphine or (oxycodone)
• 0.1mg/kg iv/sc repeated every 20 minutes until controlled
• Then 0.05-0.1mg/kg every 2-4 hours iv/sc/(po)
• Patient Controlled Analgesia (PCA) speak to team first

Other medications:
Naloxone
Adjuvants: paracetamol, ibuprofen, naproxen, (ketamine)
Laxative: movicol, senna, docusate
Thromboprophylaxis: clexane 40mg daily
Anti-itching: chlorpheniramine, hydroxyzine
Antiemetic: cyclizine (avoid IV), prochlorperazine, levomepromazine

 

Nursing observations for patients receiving opiate via PCA

 

Timing	Observations required	Frequency
Base line observation-prior to commencing PCA.	Temperature, Blood pressure, Pulse, Respiratory rate Oxygen sat, Pain score, Sedation score, Nausea and Vomiting Score.	Baseline
1st- 6th hour	Temperature, Blood pressure, Pulse, Respiratory rate Oxygen sat, Pain score, Sedation score, Nausea and Vomiting Score.	Every 30 minutes until pain is controlled or responding. (pain score reduced by 2 from admission) Then every hour to a total of 6 hrs
7thhour until the PCA is stopped.	Temperature, Blood pressure, Pulse, Respiratory rate Oxygen sat, Pain score, Sedation score, Nausea and Vomiting Score.	Every 2 hours.
Following any change to the chosen pre-set protocol	Temperature, Blood pressure, Pulse, Respiratory rate Oxygen sat, Pain score, Sedation score, Nausea and Vomiting Score.	Restart frequency from the 1st hour as outlined above

 

Immediate Nursing Management of Vaso-occlusive Crisis

• The patient will need analgesia within 30 mins of arrival in hospital (NICE 2015)
• Commence observation chart and perform pain assessment using pain-scoring tools
• Encourage oral fluids, but if patient is unable to tolerate oral commence IV fluids
• Keep the patient warm and comfortable
• Reassurance given to the patient is key and very vital

Aims for Admission

Prompt assessment of needs and diagnosis within 30 mins of presenting
Immediate admission for e.g.: severe painful crisis, increased pallor, infection, acute chest syndrome, acute abdominal pain or distension, diarrhoea or vomiting, neurological complications or priapism.
A&E to ring Haematology team /CNS-Haemoglobinopathies to inform of admission or transfer.

Nursing care of Vaso-occlusive Crisis

• Document all observations and actions accurately
• Reporting and acting on abnormal observations
• Understanding the potential side effects of medications, especially opioids
• Encourage patient to drink fluids, if patients is unable to drink then start IV fluids for 1st 24 hours.
• Importance of fluid balance and strict recording of input and output
• All sickle cell disease patients should have a carefully maintained fluid balance chart for the WHOLE duration of their admission.
• Discuss with team if admission is necessary when in A&E.
• Bloods to be checked: FBC, HB Electrophoresis (always in new patients), reticulocytes, liver function, urea and electrolytes, bone profile, CRP and a group and screen. Blood cultures if infection is suspected.
• All patients should be started on prophylactic anti-coagulation; Tinzaparin/Clexane (treatment dose for pulmonary emboli patients) and tens stockings

Other possible nursing interventions

• Red blood cell exchange (Manual or automated) if automated exchange is unavailable please find this video from NHSBT on how to set-up a manual exchange:

 

 

• Top up blood transfusions
• Hydroxycarbamide

 

Infection

• Sickle cell disease is associated with an ill defined immune defect due to being hypo-splenic.
• Main causes; pneumococcal, gram negative, lower respiratory tract, urinary tract, osteomyelitis or parvovirus.
• If the patient’s temperature is above 38⁰C start IV antibiotics (follow local Trust Guideline and Policy)
• Take a septic screen and order a baseline chest x-ray.
• Discontinue prophylactic antibiotic e.g. penicillin V 250mg BD or alternative.
• Gain suitable venous access early to prevent infection developing into a sickling crisis.

Acute chest syndrome

• The pathology of acute chest syndrome is rapidly increasing red cell sequestration in peripheral pulmonary capillaries interfering with gas exchange, causing hypoxia.
• Establish early diagnoses of acute chest syndrome by doing chest x-ray and blood gases. Or pulmonary emboli early intervention improves recovery.
• Symptoms; new infiltrates on chest x-ray, fever, chest pain or hypoxia %<92 and pO2 <8. Shallow breathing and semi-conscious GCS below 12/15.
• Causes; Fat emboli from necrotic marrow, chlamydia pneumonia, mycoplasma, s.pneumo, staph aureus or parvovirus.

Management of Acute chest syndrome

• Give the patient blood gases as soon as possible and repeat frequently.
• Consider Antibiotics – follow your local Trust’s clinical protocol & policy
• Think of Incentive Spiro meter/CPAP as treatment options
• Transfusion therapy give Exchange transfusion within 24 hours via vascath/femoral line. If available (if automated exchange is unavailable please find this video from NHSBT on how to set-up a manual exchange: https://www.youtube.com/watch?v=5QFiLziDxbc)
• Frequent oxygen saturations need to be taken on air and then on oxygen therapy.
• Suitable can pain management be achieved by following individualised patient analgesia protocol or local pain management protocol

 

Chronic Pain Management

• Chronic pain usually from sickle cell bone damage- (e.g. hip & femoral necrosis). Physiotherapy, weight loss and NSAIDs may help
• Chronic nerve pain management can be used please discuss with clinicians- e.g. Pregabalin
• Referral to chronic pain team if avaible should be considered
• Consider orthopaedics team for assessment and possible treatment

Psychological Aspect

• Remember patients often describe a feeling of helplessness against the disease
• Use a holistic approach to managing pain as both a physical and emotional experience. Remember patients have lived with Sickle Cell for many years.
• Stress can be a precipitant of sickle cell crises
• Show empathy and understanding
• Social and community support is extremely important try and involve supportive friends and family
• Consider referral to Clinical Psychologist

Discharge information

Before discharge, provide the patient (and/or their carer) with information on how to continue to manage the current episode and preventive measures, to include:
• how to obtain community and other specialist support
• how to obtain additional medication
• how to manage any potential side effects of the treatment they have received in hospital.
• how to prevent future illness and possible complications

Encourage the patient to take all recommended prevention medications and treatments

 

Lecture on Nursing Care and Management of an acutely ill adult with Sickle Cell Crisis (focussing on vaso occlusion)