NURS 316L OB Nursing Concept Map Discussion

Concept Map Student Name: Instructor: Erickson’s Developmental Stage Related to pt. & Cite References (1) Patient Education (In Pt.) & Discharge Planning (home needs) Admitting Dx (Cite References) Medical, Surgical, Social History and OB History Medical History Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) Surgical History Social History Patient Information Chief Complaint Contractions, rupture of membrane or bleeding. (1) Diagnostic Test/ Lab Results with dates and Normal Ranges (3) Name: Age: Test Norms Date Height/Weight: Current Value Admitting Diagnosis NSVD, or C-Section Medical Conditions Allergies: Gestational Age: Medical Management/ Orders/ Medications & Allergies (2) Name Dose RT Freq. MOA RN Considerations Onset/Peak/ Duration (Insulin) Obstetric History GTPAL Priority nursing diagnosis #1 Vital Signs (4) Neurological (5) Cardiovascular (6) Respiratory (7) Nutrition/Hydration (8) GI (9) GU (10) Rest/ Exercise (11) Outcome/Goal #1 Outcome/Goal #2 Integumentary (12) Endocrine (13) Psychosocial (14) Misc. (Ht/Wt) Interventions # 2 Interventions #1 Assessment/ Evaluation #2 Assessment/ Evaluation #1 PC Outcomes/Goal Potential Complications/ at risk for Priority nursing diagnosis #2 PC Interventions PC Evaluation Plan Case Scenario 2 History of Present Problem: Maria Sanchez is a 24-year-old prima gravida who delivered Juan, a baby boy by cesarean section two weeks ago. She has been breastfeeding with no problems since he was born. She developed increasing firmness and swelling in her left breast that is causing increasing pain and noticed that her nipples developed cracks two days ago. She made an appointment to see her obstetrician because she had a fever and chills that began this morning and had breast pain that became “unbearable” whenever she tried to breastfeed. Personal/Social History: Maria is newly married and motivated to be a good mom. Before her pregnancy, she had an occasional glass of wine with her meals but has abstained since she found out she was pregnant. She has six weeks off before she has return to work. Her parents do not live close by and she has few friends because she moved from a different state because of her husband’s job transfer. Current VS: T: 101.1 F/38.4 C (oral) P: 98 (regular) R: 18 (regular) BP: 134/86 O2 sat: 98% room air P-Q-R-S-T Pain Assessment: Provoking/Palliative: When infant breastfeeds, patient experiences pain in left breast Quality: Sharp Region/Radiation: Left breast and left nipple Severity: 9/10 on 0-10 pain scale Timing: Especially when infant nurses, but painful to touch at all times Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: BUBBLE-HE BREAST: UTERUS: BLADDER: BOWELS: LOCHIA: HOMANS: EPISIOTOMY: Diagnostic Results: Complete Blood Count (CBC) WBC HGB Current: 14.6 11.4 Most Recent: 10.7 12.5 Calm and cooperative. Winces in pain when left breast is touched. Low transverse abdominal incision healing. Edges well approximated. Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort Pink, warm & dry, no edema, heart sounds regular, tachycardic, with no abnormal beats, pulses strong, equal to palpation at radial/pedal/post-tibial landmarks, brisk cap refill Alert and oriented to person, place, time, and situation (x4) Lactating; right breast soft, non-tender with evidence of breastmilk. Left breast reddened, warm, painful to touch, small 1 cm fissure present on left nipple No longer palpable Voiding without difficulty Abdomen round, soft/nontender, bowel sounds audible per auscultation in all four quadrants Alba Negative Perineum intact PLTs 152 188 % Neuts 92 79 Bands 0 0 …