Question

Need SBAR

Dx: Miscarriage (patient admitted for abdominal pain)

admitted: abdominal pain.

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

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

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

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

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

assessment : sharp and constant, radiations: lower abdomen, lower back

does: changed O2 NC to venti mask, fluid making wide open, fundal massage, The doctor ordered to me that notify miscarriage to the patient.

Answer 1

SBAR

SITUATION(S):

Female patient name _______, Age _______ ,of parity ____ ,gestational age ________came with complaint of pain abdomen since today morning(date and time to be mentioned) and admitted in hospital for further evaluation and management.

Diagnosis: Miscarriage

BACKGROUND(B):

History of presenting illness-

• Her presenting complaint started early morning,when she woke up with pain and menstrual cramping.
• Pain is constant and sharp which is radiating to lower abdomen and lower back.
• Now pain is associated with bleeding.
• She had no similar complaints in the past.

ASSESSMENT(A):

On General examination :

• General condition - conscious and coherent or not ??
• Examine tongue and conjunctiva - pallor or not ?(to assess anaemia status)
• Vital signs - First : BP :130/89 , HR : 125 , RR : 16 , O2 : 97% ; Second :BP : 76/50 , HR : 59 , RR : 20 ,O2 : 83 %.

Local examination:

• Per abdomen examination : Abdomen soft or not, any distension ,height of the fundus , uterus retracted well or not.
• Per vaginal examination : Assess the size of the uterus and amount of bleeding(active or minimal)
• Based on history and examination diagnosis - miscarriage.

Deterioration in her vital status indicates that patient is going into hypovolemic shock due to blood loss.

Treatment given : Changed O2 NC to venti mask,fluid making wide open ,fundal massage.

RECOMMENDATIONS(R):

• Patient should be treated in intensive care unit on mechanical ventilation.
• Baseline investigations to be done(CBC , LFT , RFT , Coagulation profile etc).
• 2 wide bore iv cannulas to be secured or central line if needed for fluid management and blood transfusion(units depend on amount of blood loss and patients condition) should be started immediately.
• To maintain her vitals she should be started on ionotropes.
• Medical management for vaginal bleeding should be given along with iv antibiotics.
• After stabilising her get a bed side ultrasound scan done to see for any retained products of conception and to rule out uterine rupture.
• After ruling out uterine rupture , if still bleeding continues : Advise gentle uterine curettage under anaesthesia along with blood on flow.