Concept map nursing
Case Scenario 6
History of Present Problem:
Jennifer Lopez is a 25-year-old female patient G1P0 who is currently 39 3/7 weeks gestation. She is admitted to the hospital to be induced for being post-date. She is positive for Group Beta streptococcus and receiving IV antibiotics per protocol. She is 65 inches (162.5 cm). Her pre-pregnancy weight was 115 pounds (52.3 kg). She gained 18 pounds (6.8 kg) during this pregnancy. She just had spontaneous rupture of membranes with a moderate amount of thick meconium fluid at 9 pm. The nurse performed a vaginal check, and her cervix is dilated to 4 cm, 8 percent effaced and -1 station. Pitocin is infusing at 8 mU/minute intravenously.
Personal/Social History:
Jennifer lives with a roommate and is no longer involved with the father of her baby. Her family support is limited to her older brother, Sal. She smokes one pack of cigarettes a day and has not had a job for over a year and states money is tight. She admits to not eating very healthy during the pregnancy because it is easier to grab hamburger and coke than cook. She missed a few of her prenatal visits due to transportation issues and did not attend any prenatal classes. Her sister is present as her support person during labor and delivery.
Patient Care Begins: Current VS:
P-Q-R-S-T Pain Assessment:
T: 99.9 F/37.7 C (oral)
Provoking/Palliative:
Uterine contractions
P: 92 (regular)
Quality:
Severe cramping; moderate to palpation
R: 18 (regular)
Region/Radiation:
Low pelvis
BP: 128/68
Severity:
6/10
O2 sat: 99 % LA
Timing:
With uterine contractions
GENERAL APPEARANCE:
Calm and appears to be resting between contractions. Using breathing techniques during contractions appropriately
RESP:
Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort
CARDIAC:
Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, brisk cap refill, 1+ bilateral pedal edema
NEURO:
Alert and oriented to person, place, time, and situation (x4)
Maternal/Fetal
FHT’s:
140s regular
Variability:
See monitoring strip to address
Accelerations:
See monitoring strip to address
Decelerations:
See monitoring strip to address
Contractions:
Yes
Frequency:
Every 3-4 minutes
Duration:
60-70 seconds
Intensity:
Moderate to palpation
Diagnostic Results: Complete Blood Count (CBC)
WBC
HGB WBC
PLTs
% Neuts
Current:
10.2
11.2
240
62
MISC.
Blood Type
Current:
A-
Over the past hour, fetal heart tones (FHT) have remained at 140 with
Minimal variability and no accelerations. She has had three more variable decelerations lasting 30-40 seconds. You position Jennifer on her left side, and she receives an IV bolus of 1000 mL LR and O2 is applied via non-rebreather mask at 10 liters. You are in the room trying to help her breathe through her contractions when she has a prolonged late deceleration lasting three minutes with FHTs in the 70s before returning to 120 bpm.
Medical Management
Consent for C-section
Stop Pitocin
Terbutaline 0.25 mg subcutaneous x1
dose
0.9% NS 1000 mL IV bolus
Foley indwelling catheter
O2 at 10 L via mask
Chief Complaint
Contractions, rupture of membrane or bleeding.
Admitting Diagnosis
NSVD, or C-Section
Medical Conditions
Patient Information
(1)
Name:
Age:
Height/Weight:
Allergies:
Gestational Age:
Admitting Dx (Cite References) Medical, Surgical, Social History and OB History
Medical History
Surgical History
Social History
Obstetric History
GTPAL
Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14)
Medical Management/ Orders/ Medications & Allergies (2)
Erickson’s Developmental Stage Related to pt. & Cite References (1)
Patient Education (In Pt.) & Discharge Planning (home needs)
Diagnostic Test/ Lab Results with dates and Normal Ranges (3)
Concept Map
Student Name:
Instructor:
PC Outcomes/Goal
Priority nursing diagnosis #2
Respiratory (7)
Vital Signs (4)
Integumentary (12)
Interventions # 2
Assessment/ Evaluation #1
Assessment/ Evaluation #2
PC Evaluation Plan
Potential Complications/ at risk for
PC Interventions
Psychosocial (14)
Cardiovascular (6)
Endocrine (13)
Misc. (Ht/Wt)
GU (10)
GI (9)
Nutrition/Hydration
(8)
Rest/ Exercise (11)
Neurological (5)
Outcome/Goal #1
Priority nursing diagnosis #1
Outcome/Goal #2
Interventions #1
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