CONCEPT Map

please fill out everything in CONCEPT MAP using attached concept map also with attached info about patient down below. use references as well.

patient:

Laura Lopez

18yo G1P1 39.6 week gestational age

NKA Prepreg. Wt 130lb Admission wt 155lb Ht 5ft 3in

Admission date 3/16/20

Prenatal labs 8/4/19 A+, Rubella 7.4, Hepatitis B negative, , HIV nonreactive

RPR non reactive, Chlamydia negative, Gonorrhea Negative

2/15/20 GBS + , Pt given 2 doses of Ampicillin in labor

Drug screen + for Marijuana in pregnancy but negative at hospital

CBC 8/4/19 3/16/20 3/18/20

WBC 5.2 11.3 13.1

RBC 5.3 4.09 3.33

HGB 13,2 11.8 8.7

HCT 38 34.6 27.7

PLT 254 228 193

Pt came to hospital c/o contractions q5minutes for 2hrs and spotting

Admitting diagnosis: Term pregnancy at 39+wks in labor

Pt was in labor for 48 hrs with an epidural and on Pitocin for 18 hrs.

Had NSVD w/ 2nd degree perineal laceration and QBL 600cc

Baby: Male wt 4070kg, 20 in., Apgars 9-9

Immediately after delivery she was given Pitocin, Methergine.2mg IM, and Cytotec 1000mg PR

History of asthma and appendectomy

Spanish speaking only, FOB not involved, mother present and supportive. Hispanic, Christian, 9th grade education, Medical insurance

VS T 98.9 P 94 R 20 BP 100/68

Pt c/o pain 6/10 cramping and perineal pain. Lochia moderate w/ sm clots. Fundus firm at umbilicus, midline. Voids w/o difficulty. Last void 300cc 3 hrs ago

No IV. No edema, A/Ox4, Reflexes 2+, Cardiac wnl, Respiratory wnl. Regular diet. BM today and passing flatus. Skin warm and intact. Perineum swollen slightly.

Pt c/o some dizziness when she gets up to bathroom.

Pt holds baby and appears to be bonding but voices anxiety about infant care and breastfeeding. Breasts filling and nipples slightly cracking w/ pt c/o pain when breastfeeding.

Medications:

Motrin 600mg po q6

Adacel 0.5mg IM once(if needed)

Tucks pads prn

MMR II vaccine 0.5mg IM once(if needed)

Senokot-S po BID

Lanolin HPA topical prn

Norco3/325mg 1 po q4h prn mod pain

Tylenol 1000mg po q6h prn fever

Ambien 5mg po prn HS

Dermoplast spray prn

Hemabate 250mcg IM prn

Cytotec 1000mg PR prn

Methergine .2mg IM prn

Oxytocin 30u/LR 500ml IV prn