Running Head: SICKLE CELL ANEMIA
Sickle Cell Anemia
Jack Green
Liberty University
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SICKLE CELL ANEMIA
A. Personal Information
Room #: 451 Gender : M Ethnicity Black Age if < 90; 30
Place of Residence Lynchburg MD: Gabrielle Jackson
Emergency Contact: Mother Marital Status: Single
Admitting Diagnosis: Sickle cell crisis
Co-Morbidities:
Date of Admission: 11/08/2016 Date of Surgery: none Allergies: Seafood, and Bee stings
Code Status full code Mental Status oriented x4
B. Activity and Nutrition
Diet order Regular Route/Rate oral every meal Last Wt 67.1kg
Level of Activity (bedrest, up ad lib, BRP, turning) Bedrest
Level of self-care cares for self
C. Nursing Care:
Drainage devices (foley, NGT, JPs, T-tube, etc.): none
Wound care/Dressing (be specific) none
IV access (peripheral, central, location, care): Left forearm 22 guage
IVF: N/A Saline Lock? TPN? Yes
Frequency of vital signs (including pulse oximetry): Q4HR
Frequency of Glucometer: N/A Supplemental oxygen: none OSA:
Falls Risk: Low risk
Precautions: The patient has a low falls risk
Patient Profile Worksheet
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SICKLE CELL ANEMIA
Most Recent Labs (include date of labs):
Common Hematology/Chemistries/RFTs
Lab Normal range Patient value Date/time Out of range?
WBC 5,000-10,00 14,000 – 15,000 11/08 – 11/11 High
Hb 14-18 7.5 – 8.0 11/08 – 11/11 Low
Hct 41-51% 21.8 – 23.5 11/08 – 11/11 Low
Plts 150-450 521 11/08 – 11/11 High
Na+ 136-145 138 11/08 – 11/11 -
K+ 3.5-5.1 4.2 11/08 – 11/11 -
Cl- 98-110 107 11/08 – 11/11 -
HC03 - - - -
BUN 5-23 10 11/08 – 11/11 -
Cr 0.5 -1.3 0.9 11/08 – 11/11 -
Glucose 70-100 92 11/08 – 11/11 -
Other Pertinent Labs (make sure to document important trends):
The patient’s bilirubin was 8.6 on 11/8 and was 5.4 on 11/11. Although the normal range for
bilirubin is 0-1.0, the normal range for the patient is 5-6. The patient also had a reticulocyte
count of 271. The the normal range for reticulocytes is 35-124.
Patient History Worksheet:
Chief Complaint: Sickle cell crisis
History of Present Illness (discuss clinical course from admission until current date):
Mr. Jefferson is a 30 year old black male who experiences chronic pain due to sickle cell
anemia. 2 days before the patient was admitted, he report he began to have acute joint pain. The
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pain started at his knees and then moved to his ankle. He also reported shortness of breath that
worsened during episodes of acute pain. The patient takes medication daily to manage his
chronic pain. After the patient was admitted to the emergency room an peripheral IV catheter
was placed in his left forearm and he was administered 1 unit of pack RBCs. Then was given
NS20KCL at 125mL/hr. On the second day after admission, the patient developed nasal
congestion and shortness of breath most likely due to fluid overload. He was then given one dose
of IV Lasix and his IV fluid was moved to 75 mL/hr
Past Medical History:
The patient has a past medical history of asthma, allergic rhinitis, gall stones, sickle cell,
and polysubstance abuse.
Past Surgical History:
The patient has a past surgical history of a cholecystectomy
Family History:
The patient’s family history includes hypertension and diabetes.
Tobacco none
Alcohol: none
Illegal Drugs: past history but but denies current use
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Occupational Status: not listed
Religious Preference: none
Cultural Support Needs: none
Pathophysiology
Sickle Cell Anemia
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SICKLE CELL ANEMIA
Mr. Jefferson is a 30 year-old black male who admitted to the hospital due to acute pain
related to sickle cell anemia. Two days before the patient was admitted he reported the start of
the acute pain. He reported that the pain was widespread across his body but the most severe pain
started in his knees and then moved down to his ankles. Shortly after the patient was admitted to
the emergency room, a peripheral IV was placed in the patients left forearm and he was
immediately administered one unit of packed RBCs. Following the blood transfusion, the patient
was given an infusion NS20KCL at 125 mL/hr. On the second day after being in the hospital, the
patient reported shortness of breathe and nasal congestion, this is most likely a result of fluid
overload, so the patient was given IV Lasix and his IV fluids were moved down to 75 mL/hr. To
help control the patient’s pain, he was given a PCA pump that gave the patient hydromorphone
(Dilaudid). The patients first set of lab values showed a Hbg of 7.5 and a Hct of 21.8%. The
normal range Hbg is 14-18 and the normal range for a Hct is 41-51 %. The patients reticulocyte
count was 271 and the normal range is 24 The patient’s platelet count was also 531. The normal
range for platelets is 150-450. The patient’s blood was also tested for bilirubin levels which
revealed a bilirubin level of 8.6 on the first blood test. The normal range for bilirubin is 0.0-1.0.
the patient also has a history of gall stones.
Sickle cell anemia is an inherited disorder in which genetically altered hemoglobin causes
chronic hemolytic anemia. This condition often causes vessel occlusion because of the sickle
shaped RBCs which manifest’s as severe joint pain and can even lead to infarction. To
understand how sickle cell affects the body, one first needs to understand the normal structure
and function of a RBC (Grossman, 2014).
A red blood cell’s function is to carry oxygen and supply it to the tissues in the body.
They are 500-1000 times more common than any other blood cells. The structure of the RBC
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compliments it’s function very well. A RBC is shaped like a biconcave disc which provides a
greater amount of surface area for oxygen to diffuse tan a spherical cell, of the same volume
would. This thin, flexible disc also has a purpose in transportation through the body. This shape
allows it to move easier through small capillaries and supply all of the peripheral tissues with
oxygen. A fibrous network of proteins, called spectrin, surround the cell and help maintain the
biconcave disc shape. The function and and oxygen carrying capacity of the red blood cells is
controlled by the hemoglobin molecule. This molecule is composed of two pairs of structurally
unique alpha and beta polypeptide chain. These four polypeptide chains all contain a protein
portion and a heme unit. The heme unit contains one molecule of iron and is portion that binds to
the oxygen molecule. Each one of these polypeptide chains and heme units can carry molecule of
oxygen. Therefore, one hemoglobin molecule can carry four oxygen molecules (Grossman,
2014).
When sickle cell anemia occurs, there is an increased production of defective hemoglobin
molecules called hemoglobin S (HbS). The molecule results from a point mutation in the beta
polypeptide chain of the hemoglobin molecule. It results from an abnormal substitution of valine
for glutamic acid. The The concentration of HbS in a RBC determines the risk of sickling in that
cell. In somebody with with sickle cell disease the HbS will sickle the the red blood cell when it
becomes deoxygenated. As the the hemoglobin releases the oxygen, it begins to aggregate and
polymerize in the the cytoplasm of the cell. This changes the shape and deformability of the cell.
Although this shape of the shape of the cell changes, it will usually change back to a normal
shape after it becomes oxygenated again. This means the cells are reversibly sickled. Although,
after repeated episodes of deoxygenation the cells can become irreversibly sickled. When the
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half-moon shaped cell doesn’t return to normal to shaped after oxygenation, it’s irreversibly
sickled (Grossman, 2014).
There are two main consequences that result from sickle cell disease. The first is
occlusion of the blood vessels. This occurs as a results of many different factor. First off the rigid
non-flexible shape of the sickled cells make it difficult to pass through small arterioles and
capillaries with ease (Grossman, 2014). They can also damage the endothelial walls which leads
to the clotting cascade. The clotting cascade starts with the damage to the endothelial wall. This
damage initiates the contraction of smooth muscle that surrounds the the vessel. After the vessel
becomes contracted platelets are activated by cytokines. These platelets begin to aggregate
around the damaged area, forming a sticky platelet plug that attracts more platelets. The patient
had an elevated platelet count of 521. Although it is not known why those with sickle cell disease
have an elevated platelet count, it could be a result of intravascular damage widespread across
the body, which increases the demand for more platelet cells (Grossman S. , 2014). After the
platelet plug forms, fibrinogen is converted into fibrin which forms a clot with platelets and red
blood cells. Because of the rigid shaped of the sickled cells. They stick to the clot and to each
other. This process of hyper coagulation in the capillaries and arterioles facilitates vaso-occlusion
(Grossman, 2014). The patient is taking heparin. cOne of the main functions of heparin is
preventing the conversion of fibrinogen to fibrin, this inhibits the clotting process and prevalence
of vaso-occlusion (staff, 2016).
The occlusion of blood vessels is the cause of most of the severe complications
associated with sickle cell disease. The main symptom associated with vessel occlusion is acute
pain that is widespread throughout the body. This is caused by tissues not receiving enough
oxygen which can lead to ischemia and infarction. The most common areas with this occurs is
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usually the bones and joints, which explains why the patient was having severe pain in his knees
and ankles (Grossman, 2014).
To help control the patients severe pain, he was given a patient controlled analgesic
(PCA) pump. This pump allows the patient to decide when they can receive a dose of the pain
medicine instead of calling for a care provider such as a nurse. This allows the patient to give
himself more doses of pain medication at a smaller dose. This is the most preferred method of
severe pain management because it allows the patient to keep the drug in the bloodstream at an
effective level without overdosing. It is also a very safe method of administration because the
machine will only allow the patient to administer a dose every ten minutes and the machine will
lock out if the machine begins to approach an unsafe range (Johns Hopkins Medicine, n.d.). The
medication that the patient was taking through the PCA pump was Hydromorphone (Dilaudid).
Dilaudid is a Mu opioid agonist that inhibits the ascending pain pathways and alters the patients
response to pain. One of the main side effects that comes with taking dilaudid is itching all over
the body (Medscape, n.d.). Because of the itching, the patient was also given Diphenhydramine
(Benadryll) to help with the patients itching. Diphenhydramine is is a Histamine H-1 receptor
antagonist that blocks the release of histamine and and reduces allergic reactions such as the
itching (Medscape, diphenhydramine, n.d.).
The second complication that occurs with sickle cell disease is hemolysis of red blood
cells. The premature destruction of the sickled RBCs is a result of the rigid, non-deformable
membrane. The process of cell destruction is facilitated by a group of large phagocytic cells
found in the spleen, and the liver. They recognize old and defective cells such as sickled cells and
absorb and destroy them. When the cells are destroyed the amino acids from the polypeptide
chains and the iron from the hemoglobin are reused. The excess elements from the heme are
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digested and turned into bilirubin which is substance that is processed by the liver and excreted
into the GI tract during bile secretion (Grossman, 2014).
The patients high bilirubin levels are due to the excess amounts of defective red blood
cells in the body that have been broken down to create bilirubin. Since bilirubin is excreted
through the gall bladder during bile secretion. An excess excretion of bilirubin over an extended
period of time can cause gallstones. This explains why the patient has a history of gallstones. The
increased destruction of RBCs in the spleen and liver are also a result of the patients low Hbg
count and Hct. The Hbg count measures the amount of hemoglobin in the blood and the Hct
measure the percentage of healthy RBCs in the blood stream. Another important test that the
patient had was his reticulocyte count. Reticulocytes are immature RBCs that have not
differentiated fully yet. This test measures the rate at which new RBCs are being produced. The
patients reticulocyte count was high because his body was trying to produce new RBCs to
replace the cells lost because of hemolysis (Grossman, 2014).
To help with the production of new and healthy RBCs, the patient was given
hydroxyurea. This drug inhibits the synthesis of DNA without inhibiting the synthesis of
ribonucleic acids or protein. This medication can have many positive effects on someone with
sickle cell anemia including an increased production of normal hemoglobin, It also increases the
water content and flexibility of RBCs while decreasing the adhesion of the RBCs to the
endothelial wall. This prevents the likely hood of vaso-occlusion and also helps reduce the
patients pain due to hypoxia (Medscape, hydroxyurea, n.d.).
When treating treating a patient during an acute episode of sickle cell anemia, The
number one treatment for that patient is maintaining adequate hydration. A decrease in
intravascular problems can increase the risk of the sickling cells occluding the vessel. So to avoid
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this, it is important the nurse keeps the patient well hydrated during the stay at the hospital, and
teaches the patient the importance of hydration (Grossman, 2014). When the patient first came in
the the hosptital, following his transfusion, he was given fluids at a rate of 125 mL/hr. After two
days of receiving fluids, the patient started to develop shortness of breath. Because of the
exetreme increase of fuild in the vascular space the hearts pre load increased to a hight level that
the heart could not keep up with the intravascular fluid volume. This caused the fluid to build in
the lungs which is similar to left sided heart failure. To treat the his excess fluid the patient was
given a single dose of Lasix. Lasix is a Potassium wasting loop diuretic that’s main function is
increase the rate of filtration and decrease the amount of intravascular volume. After the patient
reported shortness of breath, his fluids were also bumped down to 75ml/hr.
Before the end of the shift, the patients pain was slightly improving. His hemoglobin and
hematocrit count were also rising. The patient also reported no more shortness of breath. He will
continue to receive fluids and Dilaudid.
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SICKLE CELL ANEMIA
PICO Question of Patient or Patient Population
P= Patient or population: Sickle cell Anemia
I = Intervention (something is done): Adequate hydration
C= Comparison (there may or may not be a comparison):
O = Outcome (must be measurable): reduced pain
Question:
How does hydration effect pain in patients with sickle cell anemia?
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SICKLE CELL ANEMIA
II. Medications
Student should also have medication cards or book available on clinical.
Include PRNs that have been administered with the last 24 hours.
Medication
Generic & Trade
Route Dosage &
Frequ
ency
Category/Mechanism
of Action
Contraindications /
Cautions
Side Effects Use for
this patient
Morphine SR IV 60 mg BID Opioid analgesic;
depresses pain impulse
transmission at the spinal
cord level by interacting
with opioid receptors
(Skidmore-Roth, 2011,
p.744)
Hypersensitivity,
addiction (opioid),
hemorrhage, bronchial
asthma, increased
intracranial pressure
(Skidmore-Roth, 2011)
Seizures, bradycardia,
shock, cardiac arrest,
tachycardia,
thrombocytopenia,
respiratory
depression,
respiratory arrest,
apnea (Skidmore-
Roth, 2011)
To relieve
moderate to
severe pain
Docusate sodium
(Colace)
PO 100 mg/BID Laxative, emollient, stool
softener; increases water,
fat penetration in
intestine, allows for easier
passage of stool
(Skidmore-Roth, 2011, p.
406)
Hypersensitivity,
obstruction, fecal
impaction,
nausea/vomiting
(Skidmore-Roth, 2011)
Bitter taste, throat
irritation, nausea,
anorexia, cramps,
diarrhea, rash
(Skidmore-Roth,
2011)
This
medication
makes it
easier for the
patient to
pass stool.
Folic acid (Vit.
B9)
PO 1 mg
Daily
Vitamin B complex group,
water-soluble vitamin;
needed for erythropoiesis;
increases RBC, WBC,
platelet formation in
megaloblastic anemias
(Skidmore-Roth, 2011, p.
526)
Hypersensitivity,
anemias other than
megaloblastic/macrocytic
anemia, vit B12
deficiency anemia,
uncorrected pernicious
anemia (Skidmore-Roth,
2011)
Flushing,
bronchospasm
(Skidmore-Roth,
2011)
Used as
supplement
to reduce the
risk of heart
disease and
stroke, as
well as
managing
anemia
Fluticasone
Drop
Nasal 2 app.
Daily
Corticosteroids,
inhalation, antiasthmatic,
Pregnancy category C;
Hypersensitivity to this
product or milk protein,
primary treatment in
Fever, headache,
nervousness,
dizziness, migraines,
Used to treat
the patients
nasal
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SICKLE CELL ANEMIA
Decreases inflammation
by inhibiting mast cells,
macrophages, and
leukotrienes; anti-
inflammatory and
vasoconstrictor properties
(Skidmore-Roth, 2013, p.
468)
status asthmaticus,
Pregnancy C,
breastfeeding, active
infections, glaucoma,
diabetes,
immunocompromised
patients (Skidmore-Roth,
2013, p. 468)
numbness in fingers,
nausea, vomiting, oral
candidiasis,
gastroenteritis, UTI,
urticaria, dermatitis,
hyperglycemia,
growth retardation in
children, cushingoid
features, bone mineral
density reduction,
osteoporosis
(Skidmore-Roth,
2013, p. 468)
congestion
Diphenhydramine
(Benadryl)
PO 12.5mg Q6H Antihistamine; acts on
blood vessels, GI,
respiratory system by
competing with histamine
for H1-receptor site;
decreases allergic
response by blocking
histamine (Skidmore-
Roth, 2011, p.396)
Hypersensitivity to H1-
receptor antagonist, acute
asthma attack, lower
respiratory tract disease,
neonates (Skidmore-
Roth, 2011)
Dizziness,
drowsiness, seizures,
retention,
thrombocytopenia,
agranulocytosis,
hemolytic anemia,
anaphylaxis
(Skidmore-Roth,
2011)
This is an
anti-
histamine
that blocks
histamine
release and
reduces
inflammation
Furosemide
(Lasix)
IV Loop diuretic; inhibits
reabsorption of sodium
and chloride at proximal
and distal tubule and in
the loop of Henle
(Skidmore-Roth, 2011,
p.540)
Breastfeeding, infants,
hypersensitivity to
sulfonamides, anuria,
hypovolemia, electrolyte
depletion (Skidmore-
Roth, 2011)
Circulatory collapse,
hypokalemia,
hypochloremic
alkalosis,
hypomagnesemia,
hyperuricemia,
hypocalcemia,
hyponatremia,
hyperglycemia,
nausea, polyuria,
renal failure,
thrombocytopenia,
agranulocytosis,
leukopenia,
This is used
to reduce
intervascular
volume
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SICKLE CELL ANEMIA
neutropenia, anemia,
rash, pruritus,
Stevens-Johnson
syndrome (Skidmore-
Roth, 2011)
Deferasirox oral 1000mg AC/B Selective chelator of
trivalent iron; reduces
liver iron concentration
and serum ferritin levels
Hypersensitivity
CrCl <40 mL/min or
serum creatinine >2 x
ULN.
Poor performance status
and high-risk
myelodysplastic
syndromes or advanced
malignancies.
Platelet counts <50
x10^9/L
Serum creatinine
increase, Abdominal
pain, Nausea,
Vomiting, Diarrhea,
Proteinuria, Pyrexia,
Headache, Cough,
Nasopharyngitis,
Pharyngolaryngeal
pain, Influenza.
This is used
to reduce the
concentration
of iron in the
liver.
heparin Sub Q 5000 units
Q8H
Anticoagulant,
antithrombotic; prevents
conversion of fibrinogen
to fibrin and prothrombin
to thrombin by enhancing
inhibitory effects of
antithrombin II
(Skidmore-Roth, 2011,
p.570)
Hypersensitivity,
hemophilia, leukemia
with bleeding, peptic
ulcer disease, severe
thrombocytopenic
purpura, severe
renal/hepatic disease,
blood dyscrasias, severe
hypertension, subacute
bacterial endocarditis,
acute nephritis
(Skidmore-Roth, 2011)
Fever, hematuria,
hemorrhage,
thrombocytopenia,
anemia, rash,
anaphylaxis
(Skidmore-Roth,
2011)
This is used
to reduce
coagulation
because of
the high
platelet
count.
hydroxyurea oral 1500 mg daily causes an immediate
inhibition of DNA
synthesis by acting as a
ribonucleotide reductase
inhibitor, without
interfering with the
synthesis of ribonucleic
acid or of protein. Known
Hypersensitivity,
Severe anemia, bone
marrow depression,
WBC <2500/mm³,
platelets <100,000/mm³,
Pregnancy, and lactation
Nausea, Vomiting,
Constipation,
Diarrhea, Mucositis,
Acute pulmonary,
reactions (rare),
Genetic mutation
(long-term use),
Myelosuppression,
This is used
to treat the
patients
sickle cell
anemia.
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SICKLE CELL ANEMIA
pharmacologic effects of
hydroxyurea that may
contribute to its beneficial
effects include increasing
hemoglobin F levels in
red blood cells, decreasing
neutrophils, increasing the
water content of RBCs,
increasing deformability
of sickled cells, and
altering the adhesion of
RBCs to endothelium.
Secondary, leukemia
(long-term use).
Hydromorphone
(Dilaudid)
IV 30 mg PRN via
PCA pump
Opiate analgesic; inhibits
ascending pain pathways
in CNS, increases pain
threshold, alters pain
perception (Skidmore-
Roth, 2011, p.581)
Hypersensitivity
(Skidmore-Roth, 2011)
Drowsiness,
dizziness, confusion,
headache, sedation,
euphoria, seizures,
nausea, vomiting,
anorexia,
constipation, cramps,
rash, respiratory
depression
(Skidmore-Roth,
2011)
To relieve
moderate to
severe pain.
V. Top Three Prioritized Medical and Nursing Diagnosis
1. Sickle cell anemia: Ineffective tissue perfusion RT The sickle shape of the RBCs causing vaso-occlusion AEB A jaundice appearance,
severe joint pain, restlessness, capillary refill over 3 seconds.
2. Sickle cell anemia: Acute pain RT vaso-occlusion do to sickle shaped cells AEB facial grimacing, pain that was rated at a 9, an
increased respiratory rate, and a decreased mobility of joints.
3. Sickle cell anemia: Impaired gas exchange RT RBCs impaired ability to carry oxygen because of sickle shaped cells RT Restlessness,
shortness of breath, nasal congestion, use of accessory muscles.
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Care Plan
Medical & Nursing Dx Nursing Outcomes (NOC) Nursing Interventions (NIC) Evaluation
Sickle cell anemia: Ineffective
tissue perfusion RT The sickle
shape of the RBCs causing vaso-
occlusion AEB A jaundice
appearance, severe joint pain,
restlessness, capillary refill over 3
seconds.
1. At the end of the day the
patient will display
adequate perfusion AEB
Checking the patient’s
phalanges for capillary
refill, feeling for the
patients peripheral
pulses, and assessing for
proper mentation.
2. At the end of the day the
patient will rate his pain
below a 7 on a 0-10 scale
AEB an increased
respiratory rate, facial
grimacing, asking the
patient rate and describe
his pain.
1a. Maintain adequate fluid
intake and urine output.
Rationale: Dehydration causes
increased sickling and occlusion
in the capillaries and a decrease
in renal perfusion may also
indicate vascular occlusion.
1b. Maintain warm room
temperature without over-
heating.
Rationale: This prevents
vasoconstriction and allows
blood to flow and maintain
circulation.
1c. Monitor the patient’s
oxygen saturation carefully.
Rationale: A sickling occlusions
in the vessel may cause a
reduced oxygen saturation.
2a. Teach the patient the
technique of guided imagery.
Rationale: Guided imagery can
help relax the patient, and
distract them from the pain
that they’re experiencing.
2b. Encourage the patient to
1. At the end of the day, the
patient displayed
adequate perfusion
2. At the end of the day the
patient was not able to
achieve the pain goal of
7.
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SICKLE CELL ANEMIA
3. At the end of the day the
patient will demonstrate
a understanding of how
sickle cell affects tissue
perfusion and how to
manage their condition
AEB having the patient
repeat the information
back to a care provider,
asking the patient
questions about the
information that was
taught, having the
patient create a plan to
help manage sickle cell
use his PCA Dilaudid to help
manage his pain
Rationale: This pain medication
is administered in small doses
whenever the patient feels he
needs it. This maintains a
steady control of pain without
overdosing.
2c. Administer the patient’s
hydroxyurea.
Rationale: This medication is
cytotoxic agent that decreases
that decreases the number of
sickle cell episodes.
3a. Teach the client the
importance of staying hydrate
Rationale: hydration is a key
factor in preventing a sickle cell
crisis by decreasing
concentration of sickle cells in
the vessels
3b. Teach the importance of
getting adequate rest.
Rationale: This can reduce
fatigue and oxygen demands.
3c. Have the patient repeat
management techniques of their
condition
3. At the end of the day the
patient demonstrated a
good understanding of
how sickle cell affects
tissue perfusion.
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Rationale: If the patient
understands ways to reduce the
likelihood of a sickle cell crisis,
he will be able to better manage
his condition
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References
Grossman, S. (2014). Blood Cells and the Hematopoietic System. In C. P. Shelia Grossman, Porth Pathphysiology (pp. 639-687). Philadelphia,
PA: Wolters Kluwer.
Grossman, S. C. (2014). Disorders of Red Blood Cells. In C. M. Shelia C. Grossman, Porth's Pathophysiology (pp. 665-687). Philadelphia ,
PA: Wolters Kluwer.
Medscape. (n.d.). diphenhydramine. Retrieved from Medscape: http://reference.medscape.com/drug/benadryl-nytol-diphenhydramine-
343392#10
Medscape. (n.d.). hydromorphone. Retrieved from Medscape: http://reference.medscape.com/drug/dilaudid-hydromorphone-343313#10
Medscape. (n.d.). hydroxyurea. Retrieved from Mescape: http://reference.medscape.com/drug/droxia-hydrea-hydroxyurea-342100
Staff, J. H. (n.d.). Patient-Controlled analgesia pumps. Retrieved from Johns Hopkins Medicine:
http://www.hopkinsmedicine.org/healthlibrary/conditions/orthopaedic_disorders/patient-controlled_analgesia_pumps_134,96/
staff, M. (2016). Heparin. Retrieved from Medscape: http://reference.medscape.com/drug/calciparine-monoparin-heparin-342169#10
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