Indicated: Intravenous fluids, serum type and screen, administration of prescribed pain medication.
Not Indicated: Chest percussion therapy, insertion of a nasogastric (NG) tube.
In the case of the 17-year-old male client with a diagnosed splenic laceration and left-sided hemothorax, the potential orders should be evaluated based on the presented clinical information.
Intravenous fluids: Indicated.
Given the client's condition, intravenous fluids would likely be indicated to maintain adequate blood volume and support hemodynamic stability, especially if there is ongoing bleeding.
Serum type and screen: Indicated.
This order is appropriate to determine the client's blood type and screen for potential blood transfusions, which may be necessary in the case of significant bleeding.
Chest percussion therapy: Not Indicated.
Chest percussion therapy is typically used for respiratory conditions such as pneumonia or atelectasis.
In this case, the primary focus should be on addressing the splenic laceration and hemothorax.
Insertion of a nasogastric (NG) tube: Not Indicated. While an NG tube may be indicated in certain abdominal conditions, its use should be carefully considered in the context of a splenic laceration.
The focus should be on the abdominal injury and associated complications.
Administration of prescribed pain medication: Indicated. Pain management is important for the client's comfort, and the administration of prescribed pain medication is appropriate, considering the traumatic injuries and associated pain.
Intravenous fluids, serum type and screen, and administration of prescribed pain medication are indicated, while chest percussion therapy and insertion of an NG tube are not indicated based on the provided information.
Question
The nurse in the emergency department (ED) is caring for a 17-year-old male client. History and Physical Nurses’ Notes Vital Signs Laboratory Results Emergency Department Day 1 0900: 1000: Client appears pale and slightly diaphoretic. Large amount of bruising noted along the left torso and over the left upper quadrant (LUQ) of the abdomen. Tenderness, guarding, and dullness to percussion noted on abdominal assessment. Slightly diminished breath sounds noted in the left lung fields on auscultation; client has a productive cough. Electrocardiogram (ECG) shows normal sinus rhythm. Client diagnosed with a splenic laceration and a left-sided hemothorax per the physician. The nurse has reviewed the Nurses’ Notes from 1000. For each potential order, click to specify whether the potential order is indicated or not indicated for the client. Potential Orders Indicated Not Indicated intravenous fluids serum type and screen chest percussion therapy insertion of a nasogastric (NG) tube administration of prescribed pain medication Note: Each row must have 1 response option selected