NUR 3480 Module 6 Sickle Cell Pain Paper: Timely Analgesia, Bias and an Individualized Plan Example

Two Hours to the First Dose: Timely Pain Care for a Sickle Cell Crisis in New Brunswick

Student Name

B.S.N., Accelerated Second Degree, Thomas Edison State University

NUR-3480: Nursing Care of Clients with Acute and Chronic Conditions

Mentor Name

Month Day, Year

Two Hours to the First Dose: Timely Pain Care for a Sickle Cell Crisis in New Brunswick

The Patient

Ms. Mensah is a fictional patient in a fictional New Brunswick hospital. Ms. Mensah, 27, a graduate student, has sickle cell anemia and has two or three crises a year. She arrived at the emergency department with pain across her lower back and thighs, a 9 on the scale, following a week of exams and short nights. She told the student that she waited two hours for her first dose and that a staff member asked whether she really needed that much medication. By the time she reached the medical unit, she had received one dose of intravenous opioid and was still in severe pain.

The Guideline

Yawn et al. (2014) summarized the federal expert panel's evidence-based report on sickle cell care. For vaso-occlusive crises, they recommended rapid assessment and starting analgesia within thirty minutes of triage or sixty minutes of registration, using parenteral opioids for severe pain, reassessing pain every fifteen to thirty minutes and giving additional doses as needed, considering patient-controlled analgesia and using an individualized prescribing and monitoring plan when available. They also advised hydroxyurea for adults having three or more significant crises a year and incentive spirometry to help prevent acute chest syndrome in hospitalized patients.

Waiting Longer

Haywood et al. (2013) analyzed national emergency department data and showed that people with sickle cell disease waited longer than other emergency patients to be seen, about 25 percent longer, even when they reported severe pain. The authors suggested that the delay reflected both the stigma attached to the disease and the race of most patients, and called for systems that ensure timely care.

The Stakes

Lanzkron et al. (2013) examined U.S. death certificate data and found that people with sickle cell disease died decades sooner than other Americans, the median age at death being in the late thirties to early forties. Although childhood mortality had fallen, adult mortality had not improved in the same way. The study reminds nurses that sickle cell disease is a serious, life-shortening illness and that each crisis carries risks, including acute chest syndrome.

Nursing Diagnoses

Her diagnoses were acute pain from blocked small vessels, a risk of poor gas exchange if acute chest syndrome developed, deficient fluid volume and risk for impaired trust related to past delays in care.

Implementation

On the unit, the nurse started patient-controlled analgesia as ordered, and the student reassessed pain every fifteen to thirty minutes, along with sedation and respiratory rate. Ms. Mensah's pain fell to 6 within two hours and to 4 by evening. Intravenous fluids were given at the ordered rate, without overloading. Every waking hour, the student had her take ten breaths on the incentive spirometer, and checked her oxygen saturation and breathing, since chest pain, fever or new breathing difficulty can signal acute chest syndrome. Warm packs were applied to her legs, and she was helped to change position.

Believing the Patient

The student accepted Ms. Mensah's pain reports and treated her as the expert on her disease. She acknowledged the delay and the question about her medication, and with Ms. Mensah's permission reported the experience to the nurse manager, who reviewed it with the emergency department.

Preventing Complications

The student watched for acute chest syndrome every four hours, listening to Ms. Mensah's lungs and checking for fever, chest pain or a falling oxygen saturation, and encouraged her to walk short distances as pain allowed. She avoided overhydration, since too much fluid can contribute to acute chest syndrome, and recorded intake and output. Ms. Mensah's oxygen saturation stayed above 95 percent and her lungs remained clear.

Listening to the Patient

Ms. Mensah knew which doses had worked for her in the past and how her pain usually progressed. The student asked her and shared what she said with the nurse, who passed it to the provider. Treating the patient as a partner in planning, rather than a recipient of orders, shortened the time to effective relief.

An Individualized Plan

Ms. Mensah did not have an individualized emergency care plan. The student and nurse asked the hematology team to create one listing her usual effective opioid and dose, so that future visits could start treatment quickly. The hematologist also discussed hydroxyurea, which she had stopped during a busy semester.

Evaluation

By day three, her pain was controlled with oral medication, her lungs were clear and she was discharged with her care plan, a hydroxyurea refill and a follow-up appointment.

What the Student Learned

The student had not known that patients with sickle cell disease face long waits and disbelief in emergency departments. Hearing Ms. Mensah's experience and reading the evidence changed how she thinks about pain reports from patients whose disease she does not share. She now asks every patient in a pain crisis what has worked for them before.

Discharge Teaching

Before discharge, the student reviewed hydration, rest during exam periods, when to take her home medicine and the warning signs that need the emergency department, such as chest pain, fever or trouble breathing.

Limits

The emergency wait study used national survey data and could not measure every cause of delay. Guideline recommendations rest partly on expert consensus. A student administers opioids only under supervision.

Conclusion

Ms. Mensah waited two hours for relief that guidelines say should come within thirty to sixty minutes. The expert panel guideline set the standard, research showed longer waits for these patients and mortality data showed what is at stake. Prompt reassessment, spirometry, respect and an individualized plan improved this admission and should shorten the next wait.

References

Haywood, C., Jr., Tanabe, P., Naik, R., Beach, M. C., & Lanzkron, S. (2013). The impact of race and disease on sickle cell patient wait times in the emergency department. The American Journal of Emergency Medicine, 31(4), 651-656. https://doi.org/10.1016/j.ajem.2012.11.005

Lanzkron, S., Carroll, C. P., & Haywood, C., Jr. (2013). Mortality rates and age at death from sickle cell disease: U.S., 1979-2005. Public Health Reports, 128(2), 110-116. https://doi.org/10.1177/003335491312800206

Yawn, B. P., Buchanan, G. R., Afenyi-Annan, A. N., Ballas, S. K., Hassell, K. L., James, A. H., Jordan, L., Lanzkron, S. M., Lottenberg, R., Savage, W. J., Tanabe, P. J., Ware, R. E., Murad, M. H., Goldsmith, J. C., Ortiz, E., Fulwood, R., Horton, A., & John-Sowah, J. (2014). Management of sickle cell disease: Summary of the 2014 evidence-based report by expert panel members. JAMA, 312(10), 1033-1048. https://doi.org/10.1001/jama.2014.10517