Role identification

_ CONCEPT MAP (ROLE SKITS) 

DIAGNOSIS:  Sickle cell anemia

Chief complaints: chest pain, pain in legs and back, fever, cough

PATIENT ASSESSMENT DATA: 

Patient: CZ

Subjective: (STATED) P/t stated pain is 7 out of 10 and has the chills and constant shivering. P/t is having difficult catching their breath 

Objective: (MEASURABLE) 

Temp: 102.0 F 

Respirations: 12 

BP: 144/78 

O2 saturation: 93% room air 

Cap refill: 3+ seconds and back Fever 

PRIORITY NURSING DIAGNOSIS STATEMENT: (MINIMUM 2) 

1. Impaired tissue perfusion A/E/B capillary refill lasting longer than 

2+ seconds & dyspnea. 2. Acute chest syndrome. A/E/B “pain reported” S/S fever & chills. 

DELEGATION OF INTERVENTIONS MINIMUM (4) 

RN: AZ 

1. Assess the p/t and notify team of baseline vitals. Delegate CNA to monitor and report vitals. 

2. Delegate CNA to monitor and report A&O. 

3. Administer hydroxyurea intravenously. Delegate the LVN to start IV fluids as they are IV certified. 

4. Educate the p/t on condition and managing pain, and lifestyle modifications. Delegate LVN reinforce education if needed. 

LVN: BC

1. Monitor the patient’s pain 

2. Start the I.V. fluid 

3. Reinforce education about pain management 

4. Report abnormal findings to the RN 

CNA: EA

1. Assist with activities to daily living such as personal hygiene 

2. Assist with repositioning every 2 hrs and as needed. 

3. Record vital signs & report to LVN 

4. Record A&O. 

DIAGNOSTICS TESTS:

-Chest X-ray 

-Blood pH 

-Arterial blood gas 

-CT scan 

-Bone Scan 

Labs: Hemoglobin electrophoresis, CBC, Iron, bilirubin, creatinine 

MEDICATIONS: Penicillin, hydroxyurea, oxygen, acetaminophen