ISBAR Plan of Care | Pain and Loss of Blood
Added on 2020-04-21
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1ISBAR – Plan of CareIdentificationISBAR Plan of CarePatient name:UR:Age/Date of Birth:Gender:Jasmina Tehrani32 yearsFemaleSituation: Pain in right lower abdomen with small loss of blood per vagina (PV).Pain and loss of blood increased moderately by evening. Ultrasound scan has confirmed right ectopic pregnancy. Jasmina had been transferred to the critical care unit, where she had undergone a laparotomy. Jasmina is having prolonged pain even after the surgery.Background: Had chicken pox as a child. Endometriosis, Left wrist fracture, surgical abration of endometriosis, dilatation and curettage for miscarriage, Iron deficiency and G3P1 (Gravida 3 Parity 1).Assessment:Objective DataSubjective dataJasmina's wound after the laparotomy is cleanand dry.Jasmina’s bowels have opened today.As per Jasmina”s condition it is necessary to remove the PCA and start oral medications forrelieving pain.According to her it is very tender to touch and even hurts while turning around.Jasmina feels that she is constipated.Jasmina is not very sure about the effectiveness of the medications.
Problems (actual or potential): Results of the transvaginal ultrasound scan shows that she is having a right ectopic pregnancy. A rupture can be predicted by haemiperitoneum.Priority of Problems: After the laparotomy for the ruptured right ectopic, she complains that it is hurting when she moves around. Her stool is hard. Jasmina is very anemic which requires to be addressed. She is allergic to tetracycline. Jasmina had been teary all day as she already had a past history of endometriosis.
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