OB concept map.docx

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Admitting Dx (Cite References) Medical, Surgical, Social History and OB History (1). 29yo G1P0 @ 41W1D EGA presents at L&D 7/14 for a scheduled induction. Pt reports good fetal movement, and denies r... upture of membranes, contractions or vaginal bleeding. Labor induction is also known as inducing labor. It is the artificial way stimulation of uterine contractions during pregnancy before labor begins on its own to achieve a vaginal birth ("Labor induction - Mayo Clinic", 2019). Medical History /Surgical History-none Social History M.V. has been married for the past 5 years and this was a planned pregnancy. Tobacco-never /EtOH- occasional use before pregnancy – denies any use during pregnancy /Drugs- past use of marijuana denies uses during pregnancy. Obstetric History GTPAL G1, T0, P0, A0, L0 LMP: 09/30/2018 Blood type O+ Estimated date of confinement (EDC):07/07/2019 M.V confirmed pregnancy 12/01/2018. Pt maintained adequate prenatal care throughout pregnancy. No complications throughout pregnancy. Ultrasound at 36weeeks estimated fetal weigh at 3600grams. An ultrasound must be done to elevate fetal weight and presentation before an induction ("UpToDate", 2019) M.V is who is postpartum day #1 status post vaginal delivery on 07/13/2019 0900 at 41.1 weeks of an 8lb 3fetal weight oz boy without laceration or other complication. She has minimal lochia, no pain symptoms, is breast feeding well. She denies mood symptoms. BUBBLE-HE ASSESMENT B-normal: soft or filling no cracking or bleeding nipples erect with stimulation colostrum present (milk) U-firm fundus, midline, at umbilicus B-soft and nondistended normal bowel sounds in all quads passing flatus. BM 7/12 B-nondistended, non-palpable. Adequate voiding Urine clear yellow. L-Rubra/Dark red, no clots present, mod amount with no foul smell. E-Mild edema, no laceration H-no pain in calves, redness or swelling E- see psychosocial box Chief Complaint Contractions, rupture of membrane or bleeding. “I am here for a Scheduled induction”. Admitting Diagnosis NSVD, or C-Section Scheduled induction -NVD Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) Socioeconomic /Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns: include the following Social Determinants of Health M.V lives at home with her husband. She works at a skilled nursing facility as an LVN. She has good family support from both her family and husbands. Her mother in law lives nearby and will care for the baby when pt. returns to work in 12 weeks. M.V states she is not very religious but is Christian. M.V’s husband plans to return to work full-time in 1 week which would leave the patient at home alone with baby. Social Concerns 1)Patient may face challenges finding time personal care needs such as bathing, eating, and sleeping These are the most common needs that become a challenge for postpartum mothers also placed cleaning and cooking in the same category of importance 2)Lack of support from partner due to him working full time. 3)With family members living so close, M.V may be faced with unwanted visits Erickson’s Developmental Stage Related to pt. & Cite References (1) M.V is at a stage during her life were most people fall in love, get married and start building their own family. It’s the stage of intimacy vs isolation. This is the early adulthood stage, in this stage love and intimacy is very important (Mcleod, 2019). The young adult must develop intimate relationships or suffer feelings of isolation. M.V seems as she will have successful completion of this stage and result in happy relationships and a sense of commitment, safety, and care within her relationship. Patient Information (1) Name: M.V Age:29 Height/Weight:5ft5 209lbs Code Status: full code Allergies: NKDA Gestational Weeks: 41.1 Concept Map Student Name: Christina Scialdone Instructor: Karie Herber This study source was downloaded by 100000844708667 from CourseHero.com on 09-16-2022 15:59:47 GMT -05:00 Your text here 1 (VM-V4) Patient Education (In Pt.) & Discharge Planning (home needs) After delivery, M.V begin to shed the mucous membrane that lined the uterus during pregnancy. M.V will have vaginal discharge consisting of this membrane and blood (lochia) for weeks. Blood will be bright red for the first few days and then it will taper, becoming watery and change from pinkish brown to yellowish white. M.V might feel occasional contractions after delivery this is caused by the uterus contracting to shrink down to per pregnancy size. Inform the nurse if pain medications are needed. Performing Kegel exercises are an important component of strengthening the perineal muscles after delivery and may be begun as soon as it is comfortable to do so. -Provide pt. with contact numbers to make postpartum care appointment, provide pediatrician information. call the healthcare provider if the patient experiences any of the following: Fever, foul-smelling lochia, Large blood clots (golf ball–sized or bigger) or bleeding that saturates a pad in one hour,Discharge, erythema, or severe pain from incisions or stitched areas, Hot, red, painful areas on the breasts or Bleeding and/or severe pain in the nipples or breasts,Severe headaches and/or blurred vision,Frequent, painful urination and Signs of depression (Berens,2016). -lactation consult- M.V has chosen to breast feed and be a first-time mom she can benefit from the extra support and assistance when she may have breastfeeding concerns. -Information about WIC provided. Pt expressed concerns about not having an adequate breast pump for when she returns to work. The WIC program may be able to provide M.V with assistance. - Nutrition consult provided. M.V gained 50lbs during this pregnancy and expressed concerns about losing the weight. A dietician can also determine the patient’s daily requirements of specific nutrients to promote sufficient nutritional intake. Medical Management/ Orders/ Medications & Allergies (2) NKA Name Dose RT Freq. MOA RN Considerations Onset/Peak/Duration (Insulin) Colace (docusate) Stool softener 100mg QD PO QD increasing the amount of water the stool absorbs in the gut, making the stool softer and easier to pass. Side effects may include stomach pain, diarrhea and dependence. Electrolyte imbalance may occur with excessive use. Assess for abdominal distention, bowel sounds, amount of stool and consistency 24hr 72 Ibuprofen (Motrin) NSIDS for pain 800mg PO [Show More]

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