A patient is admitted with the diagnosis of sickle-cell crisis. What should the nurse do first based on these clinical findings: temperature 102°F, O2 saturation 89%, and complaints of severe abdominal pain?

Question

1. give Tylenol (acetaminophen) grains X (650 mg)
2. administer oxygen as prescribed
3. administer morphine sulfate grain IM
4. assess and document peripheral pulses

Answer 1

Correct Answer: 2
Hypoxia is often the cause of sickling crisis from the clumping of damaged RBCs, which creates an obstruction and hypoxia distal to the clumping. Administering oxygen will improve the pain and increase the oxygen saturation of body tissues. Applying the oxygen should be the nurse's first action. Although the temperature is elevated and will increase oxygen demands in the body by increased basal metabolic activity, this is not the first action the nurse should take, because sickling crisis is caused by oxygen deprivation in tissues, not by the fever. Morphine sulfate is a narcotic for pain, but it should be given after another intervention to address the hypoxia present in sickle-cell crisis. A full-body assessment, including peripheral pulses, is important to identify the location of the potential obstruction, but this is secondary to treating the hypoxia that is known to be present in sickle-cell crisis.