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West Coast University
Concept Map
Student Name: NURS 316L
Instructor: Evans
Erickson’s Developmental Stage Related to pt. & Cite
Professor Evans
References (1)
S.S. falls under Intimacy vs. Isolation which is the 6th stage
of Erikson’s developmental stages which ranges from 19-40
Patient Education (In Pt.) & Discharge Planning (home needs)
When Ms. Susie smith was brought into mother-baby unit she was given an
years of age. TheJuly
major10, 2021
conflict at this stage is forming
intimate loving relationships with other people. In this stage
orientation of her room and how to use her call light button. Report said that a person is trying to share themselves with others, this is
S.S. had a previous diagnosis of hypertension with her last blood pressure evidenced by S.S having been pregnant twice and now she History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite
reading at 141/90, while on her way up to the floor she was told patient just delivered a beautiful baby boy. On the other hand, this References) Medical, Surgical, Social History (1).
education will be given for hypertension. Dr. Martins while doing his rounds stage is also the isolation portion, this is when a person is Ms. Susie Smith is a 33-year-old Caucasian female who delivered a 3.6kg
went into her room and told her labs will be drawn, her intake and output avoiding intimacy due to personal reasons or fearing baby boy on August 20, 2021, at 1300 via cesarean section. Smith and her
will be documented, and he advised her to maintain a low sodium diet. A opening to others in any inmate way, S.S. is currently not baby boy who she named Maverick are going to be transferred to mother
follow up appointment after she is discharged was created that way she does married and has lost one child she could move onward into baby unit on 8/21/2021 at 1000 both mom and baby are doing well and are
not have to worry. Dr. Martins looked at her incisions and gave her a healthy intimacy relationship if she had family or spousal stable to be transferred. While performing kick counts the night before she
education on how to care for the incisions. support, if the birth of her baby boy had gone wrong this started to notice decreased fetal movement causing her to become worried
would have sent her into isolation. (Taylor, Lynn, & so the next day first day in the morning she drove to her OB/GYN provider
The patient chose to breastfeed her baby, so a lactation consultation was Bartlett, 2018). office where her doctor, Dr. Martin did a NST test which came back
scheduled before discharge. Human milk is the preferred source of infant nonreactive. Dr. Martins told her she needs to be admitted immediately
nutrition and provides all the nutrients the baby needs (Durham,2019). The following the results, she then placed an order of Oxytocin-stimulated CST.
lactation specialist will go over feeding schedules, positions comfortable to The results showed a category 3 fetal heart tracing with recurrent late decals
breastfeed in, breast engorgement, and nipple soreness. The patient stated and minimal variability. Baby Maverick was born via unscheduled c-section
she is a visual learner, so information was printed to help her follow while and had an APGAR score performed, Apgar is a quick test that is done
receiving information. while the baby is on the moms skin it is done 1 and minutes after birth, A 1
minute score determines how well the baby tolerated the birthing process, a
A pediatrician who accepts her insurance was also scheduled so that she 5-minute score tells the doctor how well the baby is doing outside the
can take her newborn for a checkup, newborn appointments are important mothers’ womb (U.S. National Library of Medicine,2021). Baby Maverick
because they will check if the infant is growing how, they should and if they had a 1-minute Apgar score of 8 and with a 5 Apgar score of 10, he was
are hitting the grown percentile according to their age. Patient Information tolerating extrauterine life nicely so there was no need for him to be sent to
Chief(1)
Complaint the NICU.
Due to S.S being a single new mom and has reported she does not have a lot Patient isName: Ms.
a direct SusietoSmith
admit labor and delivery
of family support a social worker will help assist her while she is in the from her HCPAge: 33 y/o42 weeks gestation
as G2P0 Medical History
hospital and will schedule a home visit after she is discharged to follow up with complainsGender: Female fetal movement
of decreased
Code Status: Full Code Ms. Susie Smith has a history of hypertension and a previous pregnancy
on how she is adjusting to being a new mom while also offering community post Non-Reactive (NST). loss at 18 weeks’ gestation. Stage 1 hypertension is described as systolic
resources brochures. EDC: July 11,2021
EGA:42 weeks pressure of 140 mm Hg or a diastolic pressure of 90 mm Hg (Copstead &
Admitting Diagnosis Banasik,2013). Hypertension is the second leading cause of maternal death
Ms. Susie Smith 33-year-old Caucasian and a significant contributor to neonatal morbidity and mortality.
female, she is 42 weeks’ gestation G2P0 with Hypertension is responsible for 17.6% of maternal death affecting 10
history of chronic hypertension with percent of pregnant woman in the United States and has increased more
, Diagnostic Test/ Lab Results with dates and Normal Ranges (3)
Test Norms Date Current Value Cultural considerations, ethnicity, occupation, religion,
family support, insurance. (1) (14)
Non-Stress Test Reactive 8/20/21 Nonreactive
(NST) Socioeconomic Status:
Contraction Stress Cat 1 8/20/21 Cat 3 Ms. Susie Smith is a single Caucasian 33 year-year-old
Test (CST)
Medical Management/ Orders/ Medications & Allergies (2) female. She states she has limited support system and
Admission
currently lives in a 1-bedroom apartment in Anaheim, CA.
BP 120/80 144/90 Further explained below page 9 She was let go from her job when the pandemic lockdown
RR 12-20 22 started and has been struggling to find a job.
Temp 98.6 F 8/20/21 98.3 F
O2 93-100% 98% Employment Status:
Pulse 60-100 88 Before the lockdown started, she was working full time at a
cooperation since being let go she started doing part time
Postpartum
Instacart and a part time lyft driver. Patient states although
BP 20/80 140/90
RR 12-20 8/20/21 20 this has been a hard time for her, she has been able to bond
Temp 98.6 F 98.5 F with her infant.
O2 93-100% 98%
Pulse 60-100 72 Religion:
S.S. reported that she was raised in a strict catholic
CBC/CMP household, but after moving out she stopped attending
WBC 9-15k 15 church.
RBC 3.61-5.11 5.0
Hgb 9.5-11 8/20/21 15 H
Hct 28-33 29 Culture:
Plt 140-400 300 S.S. was born and raised in Anaheim, CA. she is an only
Glucose 90-140 99 child. Her parents worked as business owners, there job had
AST 5-40 38 them working long hours and S.S. was left in the care of
ALT 7-56 42 nannies, growing up she attended the best school and went to
Na 135-145 139 UCLA college where she studies business following her
parents’ footsteps.
Type and screen ABO-Rh 8/20/21 O+
Family Support:
PTT 30-40 8/20/21 30 S.S. family support comes from her cousin, who tries to help
Creatinine 0.6-1.2 0.7 her as much as she can. S.S. reported ever since her parents
Protein negative 8/20/21 negative passed away a few years ago, then her miscarriage her cousin
(Grunebaum,2021) has the one person who she can lean on and speak freely on
Fetal Heart Tracing explained below page (4) how she feels.
Insurance:
S.S. has HMO insurance which stands for health maintenance
organization, HMO allows a member to pick their own
doctor, but will need a referral to see specialist, the only
exception is for pregnant woman they are able to see an
OB/GYN without a referral. HMO members must stay inside
the same network to avoid extra outside cost that insurance
will not cover (Hayes, 2021).
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