Concept map nursing Discussion
Concept map nursing Discussion
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.
ORDER CUSTOM, PLAGIARISM-FREE PAPER
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)
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| 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
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| Diagnostic Results: Complete Blood Count (CBC) | ||||
| WBC | HGB WBC | PLTs | % Neuts | |
| Current: | 10.2 | 11.2 | 240 | 62 |
| MISC. | ||||
| Blood Type | ||||
| Current: | A-
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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.
Concept map nursing Discussion.
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