Help me with ED progress note.. I`m so lost! -- and diagnosis

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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!!

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Risk for injury is what comes to mind. Damage to the baby from the fall.

Did she hit her head? What caused the fall? Any weakness or dizziness?

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I think your progress note needs more info ab the fall. What caused her to fall? Did she land on her hands, her belly??

Any bleeding? Did you get fetal heart tones to see how the baby is doing? Blood work to see if mom is Rh negative and may need a Rhogam shot??

Is she reporting pain?

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Sorry, I keep reading and thinking of more!

Is nausea better following Zofran? 0-10 for pain?

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She did not hit her head. she said that she became dizzy- and tripped on the carpet. she said shes become ridiculously clumsy since becoming pregnant. I already know what nursing diagnosis i would put for this, but does anyone have any ideas about MEDICAL diagnosis/impression? .. its asking for that.. and progress note.. which i wrote above but I know is a very rough copy.

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wow lots of great things there!! great thinking

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Specializes in ICU.

Is pregnancy a medical diagnosis? Just throwing things out there...

If you found no significant medical history of illness in her chart then maybe you could put "Admitted for observation" as your "medical diagnosis?"

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Specializes in ICU.

Also, if she has a history of miscarriage, high blood pressure (may or may not be an isolated incident) and complaints of dizziness (the reason for her fall) did you ask about vision disturbances? Did she have any prenatal records in her chart where you could trend her blood pressure from prenatal visits? I'd be wondering about pre-eclampsia/eclampsia.

Edit: Did her blood pressure improve after her anxiety subsided?

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Also, if she has a history of miscarriage, high blood pressure (may or may not be an isolated incident) and complaints of dizziness (the reason for her fall) did you ask about vision disturbances? Did she have any prenatal records in her chart where you could trend her blood pressure from prenatal visits? I'd be wondering about pre-eclampsia/eclampsia.

Edit: Did her blood pressure improve after her anxiety subsided?

no visual disturbances were reported. she did not have any prenatal records- she has not gone to the doctor at all since finding out she was pregnant. i was wondering about blood pressure-- but its not terribly high, -- i was more concerned (later on-- ugh.. i was only with her for 2 hours and could not think about this at all until later) about blood sugar.. since it was early in the morning, she just got up and did not eat anything.. but i looked at her labs and everything was normal, so if they did BS there has nothing wrong there ...

Blood pressure did go down after she calmed down.

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Specializes in ICU.

Also, if she has a history of miscarriage, high blood pressure (may or may not be an isolated incident) and complaints of dizziness (the reason for her fall) did you ask about vision disturbances? Did she have any prenatal records in her chart where you could trend her blood pressure from prenatal visits? I'd be wondering about pre-eclampsia/eclampsia.

Edit: Did her blood pressure improve after her anxiety subsided?

no visual disturbances were reported. she did not have any prenatal records- she has not gone to the doctor at all since finding out she was pregnant. i was wondering about blood pressure-- but its not terribly high, -- i was more concerned (later on-- ugh.. i was only with her for 2 hours and could not think about this at all until later) about blood sugar.. since it was early in the morning, she just got up and did not eat anything.. but i looked at her labs and everything was normal, so if they did BS there has nothing wrong there ...

Blood pressure did go down after she calmed down.

A note on, "no visual disturbances were reported..."

While no visual disturbances were reported in the past, that doesn't necessarily mean that she experienced none. It may have been that she was simply never asked about it before or that she didn't think it was a big enough deal to mention. That's where your nursing assessment comes in. Patients come to us in a variety of states. It isn't uncommon to see a patient who hasn't been to see a doctor in over a decade (especially in the ED). In order to provide appropriate care, we have to develop as clear a snapshot of the patient as we can in the here and now.

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good call. i definitely need to work on getting a more thorough assessment... today was just a big blurr so i`m glad i`m able to sit down and figure out things that I "should have done".. haha.

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Specializes in ICU.
good call. i definitely need to work on getting a more thorough assessment... today was just a big blurr so i`m glad i`m able to sit down and figure out things that I "should have done".. haha.

I remember those days. It should clear in about 10 years, maybe sooner. =P

Seriously though, it does get better. With time, you get more accustomed to your new responsibilities and develop a routine.

Hang in there.

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