Interprofessional Consults & Discharge Referrals
Right after the c-section, the anesthesiologist will manage the patients pain
for the next 24 hours (ATI Nursing, 2016). The obstetrician is the only one
permitted to change the patients first pad after surgery after that the nurses
take over (AT...
Concept Map
Student Name: Janet Fofie Erickson’s Developmental Stage Related to pt. & Cite Admitting Dx (Cite References) Medical, Surgical, Social History
Instructor: Lourdes Jamison References (1) and OB History
Patient is at intimacy vs. isolation. This stage occurs from young adulthood H.S. is a 33-year-old Caucasian female who was admitted to Palm
from ages 18 to 40 years. The major conflict in this stage includes forming
loving relationships with other beings. In this stage, people will share their Desert Regional Hospital on February 29, 2020 at 1903 for a
Interprofessional Consults & Discharge Referrals selves more intimately with others and want to explore relationships that are scheduled cesarean delivery due to pregnancy induced hypertension
long-term. Successful completion of this stage is characterized as happy (PIH). The neonatal ICU is what brought her to this particular
Right after the c-section, the anesthesiologist will manage the patients pain relationships and sense of commitment, care, and safety within a relationship.
hospital. Patient is G6P3. Patient is 38 weeks and 1-day gestational
Keeping away from intimacy, fearing of commitment and relationships will
for the next 24 hours (ATI Nursing, 2016). The obstetrician is the only one lead to loneliness, isolation, and depression. Success of cultivating an intimacy age according to last menstrual period (LMP) is May/30/2019. Her
permitted to change the patients first pad after surgery after that the nurses relationship will lead to the virtue of love (McLeod, 2018). I would say that this estimated date of confinement (EDC) is MAR/5/2020. Patient has had
take over (ATI Nursing, 2016). The patient will also have consultation with patient meets success in this stage because she has developed a close committed
2 previous c-sections in the past and had complications with the first
relationship with her boyfriend for over 5 years. I say this because she has 2
the obstetrician doctor to discuss any complications that can occur after other children with him. The age of the children are 5 and 2 years old. Patient one (infection at the lining at the uterus), but not the second. All of
discharge and what needs to be reported to the doctor immediately. The stated that her boyfriend was there throughout the entire pregnancy and delivery her births have been premature. Her first born, who is a boy was
doctor will also go over types of contraception and if the mother is willing to process of all 3 children. During postpartum, the patients father came to visit
premature at 35 weeks and 3 days. The other, a girl was premature at
and seemed overjoyed to have another grandchild. He seemed eager and
adhere to it. Nutrition is a huge part of postpartum care, especially if the enthusiastic when it came to taking care of the baby. I add this because it shows 37 weeks and 5 days. This may be due to her being a smoker and/or
mother decides to breastfeed. Having a consultation with the dietician can be that the type of relationship, she has with her father is a positive and loving one. poor nutrition either before and/or during pregnancy. The patient’s
beneficial because the dietician can inform the patient on how many extra pre-pregnancy weight was 120 lbs. and gained a total of 40 lbs.
calories she will need to consume, what types of foods to eat to ensure a throughout her pregnancy. In the past, patient has had 2 spontaneous
balanced diet, and how many calories to consume to remain healthy. The Cultural considerations, ethnicity, occupation, religion, abortions and 1 termination. The first miscarriage happened at
patient can also see a lactation consultant who can help her if she is having family support, insurance. (1) (14) 10-week gestation, the second occurred at 18-week gestation. Patient
difficulties with latching, pain during breastfeeding and low milk *Caucasian *Education is unknown had termination at 6 weeks. Patient was tested for syphilis and the
production. The nurse will continue to care for the patient and baby by * Lives with 2 children (2 and 5 years) of her own and results came back as non-reactive. She was also tested for rubella,
completing assessments, providing education, and providing comfort boyfriend *Religion is unknown hepatis B, HIV, gonorrhea, chlamydia, and a toxicology screen all
measures. *Not employed which came back negative. Patient tested positive for human
papillomavirus (HPV). Patients group B streptococcus (GBS) status is
Chief Complaint
Patient came in with chief complaint of pregnancy
unknown. Patient seems to be healthy and has no other known illness
Patient Information induced hypertension (PIH). PIH is also called toxemia or diseases. Patient does not have any history of postpartum
(1)
or preeclampsia. This type of hypertension is only seen depression. Patient will be discharged two days after delivery.
Diagnostic Test/ Lab Results with dates Name: H.S. Surgical History
during pregnancy. It develops after 20th weeks of
and Normal Ranges (3) Age: 33 years old
pregnancy and can be a serious problem for both mother Patient has had no other surgical history besides the 2 previous
All labs were collected on Height: 5 foot 3 inches cesarean sections. Patient states that she had difficulties and
and fetus because it can lead to death (MOD, 2017).
02/31/2020 Pregnancy Weight: 160 lbs. complications with her first c-section and developed an infection at
Patient will have increased blood pressure in the 140-
Test Current Value Pre-pregnancy Weight: 120 lbs.
150/90. Patients lab values will also change. Changes the lining of her uterus. Patient had anesthesia and an epidural prior to
Allergies: NKA
can be seen in complete blood count (CBC), a decrease her surgeries. Her other c-section went as planned with no medical
RPR/VDRL Non-reactive (NR) Gestational Age: 38 weeks
in platelets and red blood cells (RBC’s) (MOD, 2017). complications.
And 1 day
Rubella immune Liver enzymes will be increased. A urine analysis will Social History
show 3+ to 5+ protein in the urine (MOD, 2017). Patient is very social. States that she goes out often. Smokes daily,
HbsAg negative about ½ to 1 pack of cigarettes a day. Patient is a non-drinker.
Admitting Diagnosis (see pg. 3) Obstetric History
GBS unknown
GTPAL
HIV negative Medical Management/ Orders/ Medications & Allergies (2) Gravidity: 6 Term Births: 3 Preterm births: 2 Abortion: 3 Living: 3
GC negative Name Dose RT Freq. MOA RN Considerations
Chlm negative
Tox negative Cephalexin 400 mg IV Q12h Cephalexin is a semisynthetic cephalosporin antibacterial drug Continued CBC testing. Ensure patient
used to treat bacterial infections (Nurses Handbook, 2019). finishes dosage. Assess for adverse side
HPV Positive effects.
Patient was tested positive for human papillomavirus (HPV). HPV
is a sexually transmitted infection (STI). HPV can spread by having Metronidazole 50 mg PO Q6h Metronidazole belongs to a drug class called nitroimidazole Assess for serious side effects such as
vaginal, anal, or oral sex with a partner who has the virus (Deeksha antimicrobials. This medication relieves infection by killing seizures, encephalopathy, dizziness,
et al., 2019). Patients with HVP can remain asymptomatic and may
not even be aware that they have the infection. Often times, the the bacteria and or other organisms that can cause an infection headache, confusion, and ataxia. Ensure
infection can go away by itself but when it does not, it can cause
several types of cancers. The infection can cause cancers of the
(Nurses Handbook, 2019). patient completes prescribed dosage.
cervix, vagina, and vulva in women and penis in men (Deeksha et
al., 2019). It can also cause anal and throat cancer (Deeksha et al.,
2019). HPV can also cause genital warts. The affected patient
should can tell her health care provider to remove the warts to
reduce discomfort and decrease bleeding during a vaginal birth
(Deeksha et al., 2019). It is very rare for women to transmit genital
warts to the fetus during a vaginal birth but if it does happen serious
Colace 100 mg PO PRN Colace is a stool softener and aids the bowel in passage of Assess for stomach cramps. Ensure
medical conditions such as respiratory distress and developmental feces (Nurses Handbook, 2019). patient is well hydrated. Increase
disabilities can occur (Deeksha et al., 2019). It has been tested that
women with HPV have a higher incidence of having preterm patient’s intake in fiber and roughage.
prelabor rupture of membranes (PROM) (Deeksha et al., 2019). The
best protection is to get the HPV vaccine and get annual Pap test.
(More information on page 3)
, Priority nursing diagnosis #1 Neurological (5) Cardiovascular (6) Respiratory (7) Priority nursing diagnosis #2
Vital Signs (4)
Patient displayed A&O Patients pulses were Patient has no difficulty Risk for fluid volume deficient
Pain 0/10
Risk for infection related to x4. Patient is oriented to palpable. All radial and pedal breathing. No evidence of related to maternal blood loss.
BP: 119/69 on left arm
invasive procedure (Cesarean person, time, situation, pulses were palpable and respiratory distress. Patient is
O2 Sat: 98%
delivery). and place. non-bounding. Pulses has not on supplemental
Resp: 16 BPM
regular rate and rhythm. S1, oxygenation. All lung sounds
Pulse: 77
S2, no S3, S4 noted upon heard on auscultation. No
Temp: 98.7 F
auscultation. +1 pitting crackles or wheezing noted. No
edema noticed on right leg. sign of productive cough noted.
Nutrition/Hydration GI (9) GU (10) Rest/ Exercise (11)
(8) Due to the meds given Patient has a foley Patient has received
Patient is on clear during c-section patient catheter inserted. Urine plenty of rest since c-
liquid until she passes is constipated. She has is light yellow in color. section. She has not
gas. She is well not passed gas or a No odor detected. received any exercise
hydrated. Has good bowel movement since No blood detected. due to the surgery and
skin turgor, no denting delivery. 600 mL output at 0900. being on magnesium Outcome/Goal #2
Outcome/Goal #1
noticed. Pt has history of previously. Patient will continue to avoid
Patient will explain
measures on how to prevent recurrent UTI’s. dehydration by increase fluid intake.
infection. Patient will explain measures to
Patient will agree to take prevent dehydration and describe
Integumentary (12) Endocrine (13) Misc. (Ht/Wt)
complete set of prescribed Psychosocial (14) symptoms that indicate a need to
Patients skin color is white, and Patient has no history BMI: 28.3
antibiotics. Patient lives with her two consult with healthcare professionals
consistent with ethnic of diabetes and has no
background. She has no children, one girl and one boy,
history of endocrine Family history of lung
pressure ulcers. Patient has a ages 5 and 2. She also lives with
issues or disorders. cancer
low transverse incision. Skin her boyfriend and father. Patient
integrity is in-tact where the s- is alert and oriented x4. Patient
is calm, attentive, and cheerful. Interventions # 2
Interventions #1 section happened. Patient has 1. Monitor and document
1. Assess for signs and symptoms of light to moderate adult acne on Patient is bonding well
newborn. patients’ vital signs, paying
an infection such as elevated face. close attention to blood
temperature, pulse, WBC, pressure and heart rate.
abnormal vaginal odor or change Assessment/ Evaluation #1 Assessment/ Evaluation #2 2. Assess patients skin turgor
in color of vaginal secretions, and and oral mucous membranes
fetal tachycardia. Goal was not met. Patient will have to complete another Goal was met. Patient has great skin turgor. No signs of for signs of dehydration.
2. Observe for fever, chills, pelvic complete blood count (CBC) to determine white blood cell orthostatic hypotension. Patient also had 600 mL urine output 3. Monitor for orthostatic
pain, anorexia, uterine (WBC). A high WBC count is indicative of an infection. which is well above the recommended. There were no signs of hypotension.
3. Provide antibiotic as prescribed alternations in mental status. 4. Assess for alterations in
4. Educate patient on perineal care – mentation such as confusion,
use bottle of water to clean and do agitation, slowed speech
not wipe but blot under area.
5. Change diaper every time after
using the restroom
PC Outcomes/Goal PC Interventions PC Evaluation Plan
1. Assess and record type, amount, and site of bleeding. Goal was met. Patient showed no signs of increased bleeding.
Patient will maintain a blood 2. Assess location of uterus
pressure of at least 100/60 mm Hg, a 3. Massage boggy uterus
pulse rate between 70-90 beats per 4. Monitor vital signs
Potential Complications/ at minute, have a balanced 24-hour 5. Check capillary refill
risk for intake and output. Patients cognitive 6. Measure 24-hour intake and output
Bleeding related to surgical status will be within expected range.
incision and postpartum Patient will have lochia flow of less
complications. than one saturated perineal pad per
hour.
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