Nursing diagnosis: ineffective tissue Perfusion related to Vaso-occlusive nature of sickling, inflammatory response, Arteriovenous (AV) shunts in both pulmonary and peripheral circulation, Myocardial damage from small infarcts, iron deposits, and fibrosis
Possibly evidenced by
Changes in vital signs, diminished peripheral pulses and capillary refill, general pallor
Decreased mentation, restlessness
Tingling in extremities, intermittent claudication, bone pain
Transient visual disturbances
Ulcerations of lower extremities, delayed healing
Desired Outcomes/Evaluation Criteria—Client Will
Demonstrate improved tissue perfusion as evidenced by stabilized vital signs, strong and palpable peripheral pulses, adequate urine output, absence of pain; usual mentation; normal capillary refill; skin warm and dry; nailbeds and lips of natural pale, pink color; and absence of paresthesias.
Nursing intervention with rationale:
1. Monitor vital signs carefully. Assess pulses for rate, rhythm, and volume. Note hypotension; rapid, weak, thready pulse; and tachypnea with shallow respirations.
Rationale: Sludging and sickling in peripheral vessels may lead to complete or partial obliteration of a vessel with diminished perfusion to surrounding tissues. Sudden massive splenic sequestration of cells can lead to shock.
2. Assess skin for coolness, pallor, cyanosis, diaphoresis, and delayed capillary refill.
Rationale: Changes reflect diminished circulation and hypoxia potentiating capillary occlusion. (Refer to ND: Impaired Gas Exchange.)
3. Note changes in LOC; reports of headaches, dizziness; development of sensory or motor deficits, such as hemiparesis or paralysis; and seizure activity.
Rationale: Changes may reflect diminished perfusion to the CNS due to ischemia or infarction (stroke).
4. Maintain adequate fluid intake. (Refer to ND: Risk for Deficient Fluid Volume.) Monitor urine output.
Rationale: Dehydration not only causes hypovolemia but increases sickling and occlusion of capillaries. Decreased renal perfusion and failure may occur because of vascular occlusion.
5. Assess lower extremities for skin texture, edema, and ulcerations, especially of internal and external ankles.
Rationale: Reduced peripheral circulation often leads to skin and underlying tissue changes and delayed healing.
6. Investigate reports of change in character of pain, or development of bone pain, angina, tingling of extremities, and eye pain or vision disturbances.
Rationale: Changes may reflect increased sickling of cells and impaired circulation with further involvement of organs, such as myocardial infarction (MI), pulmonary infarction, or occlusion of vasculature of the eye.
7. Maintain environmental temperature and body warmth without overheating. Avoid hypothermia.
Rationale: Prevents vasoconstriction, aids in maintaining circulation and perfusion. Excessive body heat may cause diaphoresis, adding to insensible fluid losses and risk of dehydration. Hypothermia may exacerbate cardiovascular compromise with severe anemia.
8. Evaluate for developing edema—including genitals in men.
Rationale: Vaso-occlusion or circulatory stasis may lead to edema of extremities and priapism in men, potentiating risk of tissue ischemia and necrosis.
9. Monitor laboratory studies, such as the following: Blood gases, liver and kidney function tests
Rationale: Decreased tissue perfusion may lead to gradual infarction of organ tissues, such as the brain, liver, spleen, kidney, skeletal muscle, and so forth, with consequent release of intracellular enzymes.
10. Administer hydroxyurea (Droxia) or experimental antisickling agents, such as sodium cyanate, carefully and observe for possible lethal side effects.
Rationale: Hydroxyurea, a cytotoxic agent, dramatically decreases the number of sickle cell episodes, and is given to prevent crises. Antisickling agents currently under investigational use are aimed at prolonging erythrocyte survival and preventing sickling by affecting cell membrane changes.