Concept Map

Name: C.D

Age: 30 year old Female

Height/Weight: 198 lb (86.1 kg)

Allergies:

Gestational Age: 40 3/7 weeks

Medical Management/ Orders/ Medications & Allergies (2)

Name

Dose

RT

Freq.

MOA

RN Considerations

Side Effects

Sertraline

50 mg

PO

Daily

Increase amount of serotonin in the brain, maintain psychic balance

Assess for allergies

Assess for history of seizures, suicidal thoughts

Monitor renal and liver function test while taking this medication

Decreased sexual ability

Drowsiness

Mood or behavioral changes

Acetaminophen

325 mg

PO

PRN for pain

Reduces levels of prostaglandin metabolites in urine. Potent antipyretic and analgesic actions but weak anti-inflammatory activity.

Assess allergies

Assess pain level

Monitor for sign of hepatotoxicity

Educate patient about taking this medication while breastfeeding.

Black, tarry stools

Pinpoint red spots on the skin

Sore throat

Unusual bleeding or bruising

Ibuprofen

600 mg

PO

PRN

It works by reducing hormones that cause inflammation and pain in the body

Instruct patient to take it with food or milk

Avoid Ibuprofen if history of asthma

Hypersensitivity

Heartburn

Indigestion

Belching

SOB

Admitting Dx (Cite References)

C.D came in for a follow up after a having a c-section 48 hours ago. Patient was doing fine, no complications from the c-section. When asked how she was adjusting to motherhood, patient started to cry, she looked restless, tired and had an unkempt appearance. She was diagnosed with Anxiety related to stress as evidence by expressing feelings of being a horrible wife and mother. Health care provider decided to call her husband in and ask them some questions.

Medical History

Celine’s blood type is B positive and she was GBS negative. She has a history of depression and was taking Sertraline but quit taking it when she got pregnant. According to American Psychiatric Association depression is a medical illness that affects how people feel, the way they think and how they act.

Surgical History

Patient has a surgical history of a c-section done 48 hours ago. Patient had not complications during nor after the procedure.

Social History

Celine is a 30-year-old female that recently gave birth to a beautiful healthy baby boy. She has been with her partner for four years and are planning to get married in the next six months. She is attending college and is not working her partner works as a loan officer at a local bank. Celine’s family lives close about 1 hour away and Steve’s family lives three hours away. As I mentioned patient has a history of depression and was taking Sertraline before getting pregnant. According to Mayoclinic sertraline is a medication used to treat depression, OCD, panic disorder, PTSD, it works by increasing the levels of serotonin in the brain.

Obstetric History

GTPAL

Celine is a 30-year-old female G1 P1. Delivered a healthy baby boy 24 hours ago via a primary cesarean section due to the baby being in a breech position. Patient was 40 3/7 weeks gestation and had an uneventful pregnancy. She weighs 198 pounds and has a pre-pregnancy BMI of 32.6.

Diagnostic Test/ Lab Results

Test

Norms

Date

Current Value

WBC

4,000- 10,000 cells/mm3

5/7/20

14.1

HGB

Male: 14.0- 17.5 g/dL

Female: 12.3- 15.3 g/dL

5/7/2020

10.6

PLTs

150,000 up to 450,000

5/7/2020

302

%Neuts

1,500 to 8,000

5/7/2020

70

Cultural considerations, ethnicity, occupation, religion, family support, insurance

Celine is a Caucasian female that has been living with her boyfriend for four years already. They are planning on getting married. Her side of the family lives closed to them but, his side of the family lives 3 hours away. Steve is working at a local bank and Celine was going to college before getting pregnant. After giving birth Celine’s mom is at home helping her with the newborn as well as her husband Steve.

Erickson’s Developmental Stage

According to Erickson Developmental Stage Celine is in the Intimacy vs. Isolation stage. During this stage people begin to share themselves more intimately. They explore relationships which leads to long-term commitments. Isolation happens to those that are afraid of being committed to a relationship, they end up alone and depress (McLeod,S).

Patient Education & Discharge Planning

In patient

- Educate patient about sign and symptoms of infection

· - Provide information about medications, procedure and first test done to the baby

· -Teach patient to report pain and bleeding.

·

·

· Discharge

· - Teach patient about coping skills, relaxation techniques

· - Develop a plan to provide frequent rest periods throughout the day.

· - Discuss with the couple the role of being new parents.

· - Teach patient about hormone influences on sleep and lack of energy.

·

Chief Complaint

Patient came to the office for a regular check up after having a C-section 48 hours ago with no complication. When asked about how she was adjusting to motherhood, patient started to cry, stated that all she wanted was to sleep. She looked unkempt, poor hygiene and appeared very exhausted.

Admitting Diagnosis

Anxiety related to stress as evidence by expressing feelings of being a horrible wife and mother.

Student Name: Camelia Labrador

Instructor: Claudia Barriel-Goslin

Cardiovascular (6)

Pink, warm & dry, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill, 1+ pitting edema in lower extremities bilaterally

Vital Signs (4)

T: 98.5 F/36.9 C (orally)

P: 84 (regular)

R: 18 (regular)

BP: 120/80

O2 sat:98% room air

PC Outcomes/Goal

Patient does not experienced bleeding by the end of a 12 hour shift

Priority nursing diagnosis #2

Acute pain related to procedure as evidence by patient reporting having a 7/10 burning pain in the incisional site.

Respiratory (7)

Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort

Interventions # 2

· Assess pain characteristics

· Provide rest periods to promote relief, sleep and relaxation

· Administer analgesics as per doctor order

· Apply heat or cold compress

· Teach relaxation techniques such as, music, breathing exercise.

Assessment/ Evaluation #1

After the doctor’s visit patient had no sign and symptom of anxiety, she was calm and happy.

Assessment/ Evaluation #2

By the end of my shift patient reported a decreased in pain to less than 2 on a pain scale of 0-10.

PC Evaluation Plan

Patient showed no sign and symptoms of bleeding by the end of my 12 hour shift.

PC Interventions

Monitor patient’s vital signs including BP and HR

Look for signs of orthostatic hypotension

Review lab test results for coagulation, platelet count, PT/INR

Assess stool and urine for signs of bleeding

Assess skin and mucous membrane for signs of petechiae, bruising and hematoma.

Psychosocial (14)

Quiet, appears fatigued, currently not interacting with baby, EPDS 8.

Endocrine (13)

Trachea is midline

No sign and symptom of hyperthyroidism or hypothyroidism

Misc. (Ht/Wt)

Wt: 198 pounds (86.1 kg)

Ht: 5.6 ft

GU (10)

Fundus firm 1 cm below umbilicus and midline

Voiding without difficulty. Denies any burning with urination

GI (9)

Abdomen soft/tender at incision, bowel sounds audible per auscultation in all four quadrants, positive flatus, no BM since delivery

Nutrition/Hydration

(8)

No sign of dehydration

Skin turgor

Regular diet

Rest/ Exercise (11)

Active, able to ambulate by herself

Neurological (5)

Alert and oriented to person, place, time, and situation (x4)

Outcome/Goal #1

Patient has no sign of anxiety, is calm by the end of the doctor’s visit

Priority nursing diagnosis #1

Anxiety related to stress as evidence by expressing feelings of being a horrible mother, wife, patient was crying and overwhelmed.

Outcome/Goal #2

Patient report a decrease in pain less than 2 on a rating scale of 0-10 by the end of my shift

Integumentary (12)

Low abdominal incision intact with surgical glue and open to air. No drainage noted. Skin slightly pink surrounding entire incision. No temperature change in skin and no edema surrounding incision.

Interventions #1

· Teach patient relaxation techniques

· Explain to the patients the role of being a new mother.

· Advise the patient to take some time for herself every day so she can have a break from her baby car.

· Encourage the patient to keep in touch with her friends, they are a great support system.

· Teach patient to plan for daily activities such as, exercise, nutrition plan and sleep.

Potential Complications/ at risk for

At risk for bleeding related to post-partum complication

Reference

Belleza, Marianne, and Marianne. “Postpartum Depression: More Common Than You Think!” Nurseslabs, 18 Jan. 2017,

nurseslabs.com/postpartum-depression/.

Durham, R. F., & Chapman, L. (2019). Maternal-newborn nursing: the critical components of nursing care. Philadelphia, PA: F.A

Davis Company.

McLeod, S. A. (2018, May 03). Erik erikson's stages of psychosocial development. Simply Psychology.

https://www.simplypsychology.org/Erik-Erikson.html.

“Sertraline (Oral Route) Description and Brand Names.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 1

Apr.2020, www.mayoclinic.org/drugs-supplements/sertraline-oral-route/description/drg-20065940.

Wayne, Gil, and Wayne. “Acute Pain – Nursing Diagnosis & Care Plan.” Nurseslabs, 30 Apr. 2020, nurseslabs.com/acute-pain/.

Wayne, Gil, et al. “Anxiety – Nursing Diagnosis & Care Plan.” Nurseslabs, 20 Mar. 2019, nurseslabs.com/anxiety/.

Wayne, Gil, and Wayne. “Risk for Bleeding – Nursing Diagnosis & Care Plan.” Nurseslabs, 23 Sept. 2017, nurseslabs.com/risk-

for-bleeding/.

What Is Depression?, www.psychiatry.org/patients-families/depression/what-is-depression.