Question

A nurse is caring for a client in the emergency department (ED)

Complete the diagram for 2 actions, 1 potential condition, and 2 parameters.

Client presents to the ED with upper abdominal pain that radiates to the right shoulder. Client rates pain as 7 on a scale of 0 to 10. Client also reports nausea, vomiting, and dyspepsia.

AST 45 units/L (0-35)
ALT 39 international units/L (4-36)
LDH 200 units/L (100-190)
WBC count 12,000 (5,000-10,000)

1) Actions to take
Ensure the client is NPO
Maintain the client in semi-Fowler's position
Insert an NG tube
Administer morphine IV
Place the client on bed rest

2) Potential conditions
Cholecystitis
Peritonitis
Appendicitis
Ulcerative colitis

3) Parameters to Monitor
Monitor the client for a rigid, board-like abdomen
Monitor for pain at McBurney's point
Monitor the color of the client's stools
Monitor the client for dark urine

Answer 1

The nursing actions to take for a client with upper abdominal pain that radiates to the right shoulder in the emergency department include ensuring the client is NPO, maintaining them in semi-Fowler's position, inserting an NG tube, administering morphine IV, and placing the client on bed rest. The potential conditions to consider are cholecystitis, peritonitis, appendicitis, and ulcerative colitis. Parameters to monitor include a rigid, board-like abdomen, pain at McBurney's point, color of stools, and presence of dark urine.

Step-by-step explanation:

The diagram for the nursing actions, potential condition, and parameters for the client presenting with upper abdominal pain that radiates to the right shoulder in the emergency department (ED) is as follows:

Actions to take:

Ensure the client is NPO

Maintain the client in semi-Fowler's position

Insert an NG tube

Administer morphine IV

Place the client on bed rest

Potential conditions:

Cholecystitis

Peritonitis

Appendicitis

Ulcerative colitis

Parameters to monitor:

Monitor the client for a rigid, board-like abdomen

• Monitor for pain at McBurney's point
• Monitor the color of the client's stools
• Monitor the client for dark urine