Question

Need SBAR and discharge teaching

Dx: Miscarriage (patient admitted for abdominal pain)

History:    Patient presents with abdominal pain, bleeding and lower back pain.

                Patient woke up this morning with pain and menstrual cramping and now bleeding.

Symptoms: Abdominal pain, bleeding/discharge, lower back pain

OPQRST assessment

1. onset of symptoms: getting ready for work
2. provocation/provokes: when she gets up and tries to walk
3. quality of pain: sharp and constant
4. radiations: lower abdomen, lower back
5. the severity of pain: 8-9
6. time: this morning around 6 a.m. woke up with pain and menstrual cramping and then bleeding.

first vital sign: BP: 130/89, HR: 125, RR: 16, O2: 97%

second vital sign: BP:76/50, Hr:59, RR:20, Ox: 83%

1. change O2 NC to venti mask

2. fluid making wide open

3. fundal massage

4. The doctor ordered to me that notify miscarriage to the patient.

Answer 1

S	Todays Date ,---------,patient Room - ----------- Patient Name - ----------- Age- ------,gender - Female Admitting Diagnosis - Miscarriage Admit Date - ------, attending Physician - --------- Reason For admisssion -Abdominal pain,bleeding and back pain Current Condition - sharp and constant pain ,radiating to lower back BP: 130/89, HR: 125, RR: 16, O2: 97% second vital sign: BP:76/50, Hr:59, RR:20, Ox: 83%
B	No relevent past medical history
A	The proble may be micarriage. Patient goes in shock
R	Inform the patient about condition. 1. changed O2 NC to venti mask 2. fluid making wide open 3. fundal massage

Discahrge teaching

- Advise to take rest

- Don't do any strenous excersise right away ,such as aerobics or running.

-Dont have sex or use tampones until the provider says