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Adult Health
문제

A nurse is caring for a 28-year-old African American client with sickle cell anemia who is experiencing a vaso-occlusive crisis. The client reports severe pain in the chest and back, rated 9/10, and has been receiving morphine IV every 2 hours for the past 12 hours. Which nursing intervention should be the priority at this time?

The client appears restless, has shallow breathing, and oxygen saturation has dropped from 98% to 92% on room air. Vital signs show: BP 110/70 mmHg, HR 110 bpm, RR 28/min, Temperature 99.2°F (37.3°C).
해설
Priority is administering oxygen and preparing for acute chest syndrome evaluation due to hypoxemia (O2 saturation 92%) and respiratory distress. Other options address pain or circulation but do not manage the immediate respiratory threat.
같은 주제 다음 문제A nurse is assessing a 35-year-old Hispanic client with sickle cell anemia who presents to…

심화 해설


Clinical Reasoning and Priority Setting

The client's presentation during a vaso-occlusive crisis (VOC) has shifted from isolated pain to a respiratory emergency. The combination of severe chest pain, a significant drop in oxygen saturation from 98% to 92% on room air, tachypnea with a respiratory rate of 28/min, and shallow, splinted breathing points directly to the development of acute chest syndrome (ACS). ACS is a leading cause of death in sickle cell disease and requires immediate intervention to prevent rapid progression to respiratory failure [1,2].

The pathophysiology of ACS involves a vicious triad: pulmonary infection or fat embolism triggers inflammation, which leads to alveolar hypoxia. Hypoxia causes further pulmonary capillary sickling and vaso-occlusion, which worsens the ventilation-perfusion mismatch and drives oxygen saturation downward. The client's restlessness is a classic early sign of hypoxemia, and the tachycardia (heart rate 110 bpm) reflects the heart's attempt to compensate for reduced oxygen delivery. Administering supplemental oxygen is the priority to break the cycle of hypoxia-driven sickling and to stabilize the client while preparing for a chest X-ray and further evaluation for ACS [1,2].

While pain is the precipitating factor for the crisis, increasing morphine frequency (Option 2) without addressing the hypoxemia could lead to respiratory depression, further compromising an already vulnerable pulmonary status. Encouraging deep breathing and ambulation (Option 3) is contraindicated during an acute drop in oxygen saturation and severe pain; deep breathing may be encouraged after stabilization, but ambulation is not appropriate. Applying heat packs (Option 4) is a supportive comfort measure that can promote local vasodilation, but it does not address the life-threatening decline in oxygenation and is therefore not the priority intervention.

임상 시나리오

Acute Chest Syndrome (ACS) RecognitionPriority Response to Respiratory Decline in Sickle Cell Crisis

A drop in SpO2 (e.g., 98% to 92%), new chest pain, tachypnea, and shallow breathing during a vaso-occlusive crisis signal possible Acute Chest Syndrome (ACS), a leading cause of death. The immediate priority is supplemental oxygen to break hypoxia-driven sickling and preparation for a chest X-ray and further evaluation.

Caution

Do not increase opioid frequency before addressing hypoxemia; this can precipitate respiratory depression in a client with already compromised pulmonary function. Ambulation and deep breathing exercises are contraindicated in the acute phase of suspected ACS.

핵심 개념

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