Nursing Students Student Assist
Published
I`m completely new to ED in this rotation and i`m very nervous.. now I have a bunch of paperwork too and I`m stuck on this:
I had a patient who was pregnant, 15 wks, and fell down the stairs. she was feeling "cramps", with 2-5/10 pain, normal vitals (with the exception of her HR, which was a little high- 118 and 140/90 BP but she was anxious). I`m having a hard time thinking of a MEDICAL DIAGNOSIS/impression for this.. anyone have any ideas? -- for some reason it is asking for that, and I didn`t see it on their chart.
I have already filled out a assessment form for this- where i wrote down things like what meds i gave and her vitals, neuro, resp, and GI/GU assessment, so I`m lost about what to include in the progress note since I assumed that I already have everything..
what do i include in the progress note?
i wrote " pt fell down 6 stairs onto carpeted surface. Has not had prenatal exams. has hx of miscarriage. c/o sharp "menstrual crampish" pain. She was given Zofran and Ns 0.9%. Has had ultrasound- results to be determined. Pt appears to be less anxious and stated that the cramping has gone down.
I`m also supposed to think of a nursing diagnosis.. i supposed risk for fall/ safety.. and then i`ll make up some interventions.
Please.. ANYONE.. i know my progress note is a mess.. if someone can guide me through this I would SO appreciate it!!