Nursing diagnosis: acute/chronic pain related to intravascular sickling with localized stasis, occlusion, infarction, and necrosis, activation of pain fibers due to deprivation of oxygen and nutrients, accumulation of noxious metabolites
Possibly evidenced by
Localized, migratory, or more generalized pain, described as throbbing, gnawing, or severe and incapacitating; affecting peripheral extremities, bones, joints, back, abdomen, or head, with headaches recurrent and transient
Decreased ROM, guarding of the affected areas
Facial grimacing, narrowed or self-focus
Desired Outcomes/Evaluation Criteria—Client Will
Verbalize relief or control of pain.
Demonstrate relaxed body posture, freedom of movement, and ability to sleep and rest appropriately.
Nursing intervention with rationale:
1. Assess reports of pain, including location, duration, and intensity (scale of 0 to 10). Have client help differentiate current pain from typical or usual pain problems.
Rationale: Vaso-occlusive pain is the most common manifestation of sickle cell crises, where sickling potentiates cellular hypoxia, resulting in severe pain. Typically, pain occurs deep in the bones and muscles of back, ribs, and limbs and lasts 5 to 7 days. However, client may also have acute pain from another cause (ulcers, appendicitis), chronic pain from sickle cell damage (usually bone pain that is present daily), chronic pain from other causes (old injuries, arthritis), and chronic nerve pain caused by damage from sickle cell blockage or other conditions, such as diabetes.
2. Observe nonverbal pain cues, such as gait disturbances, body positioning, reluctance to move, facial expressions; and physiological manifestations of acute pain—elevated BP, tachycardia, and increased respiratory rate. Explore discrepancies between verbal and nonverbal cues.
Rationale: Nonverbal cues may aid in evaluation of pain and effectiveness of therapy. Pain is unique to each client; therefore, one may encounter varying descriptions because of individualized perceptions.
3. Discuss with the client/SO what pain relief measures were effective in the past.
Rationale: Involves client/SO in care and allows for identification of remedies that have already been found to relieve pain. Helpful in establishing individualized treatment needs.
4. Explore alternative pain relief measures, such as relaxation techniques, biofeedback, yoga, meditation, and distraction—visual, auditory, tactile, kinesthetic, guided imagery, and breathing techniques.
Rationale: Cognitive-behavioral interventions may reduce reliance on pharmacological therapy and enhance client’s sense of control.
5. Provide support for and carefully position affected extremities.
Rationale: Reduces edema, discomfort, and risk of injury, especially if osteomyelitis is present.
6. Apply local massage gently to affected areas.
Rationale: Helps reduce muscle tension.
7. Apply warm, moist compresses to affected joints or other painful areas. Avoid use of ice or cold compresses.
Rationale: Warmth causes vasodilation and increases circulation to hypoxic areas. Cold causes vasoconstriction and compounds the crisis.
8. Administer medications, as indicated, for example: opioids, such as continuous infusion or around-the-clock morphine (Astramorph, Duramorph), hydromorphone (Dilaudid), and nalbuphine (Nubain); long-acting opiate combinations, such as morphine (MS Contin) and oxycodone (Oxycontin); nonopioid analgesics, such as acetaminophen (Tylenol); oral opiate combination analgesics, such as acetaminophen with codeine (Tylenol No. 3) and hydrocodone (Vicodin); and antiseizure medications, such as gabapentin (Neurontin).
Rationale: Various types of analgesics are needed to manage different types of pain. Opioids are the mainstay of pain control during crisis and are usually administered via patientcontrolled analgesia (PCA). Acetaminophen can be used for control of headache, pain, and fever. Aspirin should be avoided because it alters blood pH and can make cells sickle more easily. Note: Meperidine (Demerol) should not be used because its metabolite, normeperidine, can cause central nervous system (CNS) excitation—anxiety, tremors, and seizures.
9. Consult with or refer to physical therapy.
Rationale: Determines and provides appropriate therapies, such as massage, heat therapies, and guided exercise.
10. Administer and monitor RBC transfusion.
Rationale: Although transfusion does not halt the pain in an acute crisis, frequency of painful crises may be reduced by regular partial exchange transfusions to maintain population of normal RBCs.