OB Concept Map – Assignment 1 Solution
OB Concept Map
History of Present Illness (HPI)
History needs to include Patients age, Gravida, Para, gestational age, EDC and how EDC is determined with citation. Reason for coming to the hospital , what the patient was complaining about that brought her to come into the hospital and then admitting Diagnosis
Pathophysiology is explained in complete detail with accurate and in-depth understanding of Admitting diagnosis. and presenting signs/symptoms supported by diagnostic tests and proposed treatment plan; with APA references.
Medical History
Complete details given of other health problems (includes explanation of all relevant medical history) with full understanding as to its relation to the patient’s/ client’s present health problem(s). with APA references .Including prenatal care identify what happens in 1st trimester, 2nd trimester and 3rd trimester with APA references. inducing labs and diagnostic test, with APA references.
Surgical History
Complete details given of all surgeries patho (includes explanation of all relevant surgical history) with full understanding as to its relation to the patient’s/ client’s present health problem(s). and past surgeries. with APA references.
Social History
social issues include family outings, patient hobbies, Work
Patient Information
Name: Age: Gender: Code Status: EDC: EGA:
Chief Complaint
Admitting Diagnosis
OB History
GTPAL
Need to identify previous pregnancies year , and type of delivery
Prenatal Panel
Blood Type/Rh: GBS: Hep B: HIV: Rubella: RPR: Chlamydia: Gonorrhea: HSV:
Delivery Summary
Delivery Type & Time: Placenta Delivery Time: Lacerations/Episiotomy: EBL: Hemorrhage Medications Given: APGAR Score:1 minute____ 5 minute______
Patient Education (Inpatient) & Discharge Planning
Teaching Assessment: Identify primary language, learning style, support system and tools needed to teach
Consults
Need to explain consult
1.
2.
3.
Patient Education (Inpatient)
All in patient teaching required
Discharge Planning
Need to have discharge teaching based on patient and newborn and follow up teaching for both patient and newborn.
Erickson’s Developmental Stage Related to Patient & Cite References
Need to explain how the patient fits in the stage
Cultural Considerations; Ethnicity; Occupation; Religion; Family Support; Insurance; Socioeconomic
Ethnicity: Occupation: Religion: Family Support: Insurance: Socioeconomic:
Need to explain how each area effects the patients’ health care practice in wellness and in illness with evidenced based support, Reference /citation APA
Diagnostic Tests/ Lab Results with Dates and Normal Ranges
Test
Date
Norms
Current Value
Clearly and accurately identifies and explains abnormal findings for pertinent current laboratory and diagnostics test results related to patient’s/client’s disease process.
CBC, Type and Screen
Glucose screening
ALT, AST, Platelets, Protein
GBS
Ferning
Ultrasound
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Psychosocial Concerns with Rationales
1.
Rationale:
2.
Rationale:
3.
Rationale:
Medical Management/Orders/Medications and Allergies
Name
Dose
Route
Freq.
MOA
RN Considerations
Lists all MAR medications (Routine and PRN) including name; ordered dose; route; MD ordered indication; mechanism of action; relevant side effects and nursing considerations relevant to the patient/client.
Cardiovascular
Color: Cap Refill: Tele Rhythm: Peripheral Edema: Heart Sounds: Pulses:
Neurological
LOC: PMS: PERRLA: Vision: Face: Strength:
Vital Signs
Temperature: Pulse: Respirations: Blood Pressure: Pain Level:
Respiratory
Lung Fields: Breathing Pattern: Sputum: Cough: Suctioning: Pulse Oximetry: Supplemental O2:
Emotional
Bonding: Support: Emotional State: Maternal Phase:
Homan’s Sign
Redness: Tenderness: Pain: Swelling: Homan’s:
Episiotomy/Laceration
Location: Stitches: Edema: Redness: Approximation:
Lochia
Amount: Odor: Color: Clots: Pad Changes: EBL:
Bowel
Bowel Sounds: Abdomen: Last BM: Incontinence: Bedpan: Abd. Pain: Ostomy: Drains:
Bladder
BR: Incontinence: Indwelling Catheter: Urine Color/Consistency: Urine Output:
Uterus
Location: Midline: Firm/Boggy: Contractions:
Breasts
Size: Nipple: Shape: Engorgement: Colostrum:
Priority Nursing Dx #1
All nursing diagnoses are accurate and prioritized per format with clear etiology and data to support the diagnosis. Nursing Diagnoses are consistent and present a correlation from the assessment data.
Nursing Diagnosis R/T medical diagnosis or condition, AEB pertinent S/S, diagnostics and supporting data
Priority Nursing Dx #2
All nursing diagnoses are accurate and prioritized per format with clear etiology and data to support the diagnosis. Nursing Diagnoses are consistent and present a correlation from the assessment data.
Nursing Diagnosis R/T medical diagnosis or condition, AEB pertinent S/S, diagnostics and supporting data
Assessment/Evaluation #1
Evaluates effectiveness of interventions and measures goal completion.
Modifies, revises and recommends alternative interventions.
Assessment/Evaluation #2
Evaluates effectiveness of interventions and measures goal completion.
Modifies, revises and recommends alternative interventions.
Outcome/Goal #2
The goal clearly supports the nursing diagnosis and plan of care. The goals are specific, measurable, attainable, realistic and timed.
Time for your clinical day
Outcome/Goal #1
The goal clearly supports the nursing diagnosis and plan of care. The goals are specific, measurable, attainable, realistic and timed.
Interventions #2
Clearly and accurately Identifies nursing/ collaborative interventions. Interventions are always individualized, prioritized, organized, specific and realistic. Nursing actions are always aimed at the patient’s/client’s goals and directed at the stated health deviation.
Your interventions are the interventions and task you provided to the patient all day during your clinical. This is what you actually did at the bedside during your clinical day.
Intervention should be from beginning to end to meet the task step by step
Interventions #1
Clearly and accurately Identifies nursing/ collaborative interventions. Interventions are always individualized, prioritized, organized, specific and realistic. Nursing actions are always aimed at the patient’s/client’s goals and directed at the stated health deviation.
Your interventions are the interventions and task you provided to the patient all day during your clinical. This is what you actually did at the bedside during your clinical day.
Intervention should be from beginning to end to meet the task step by step.
Potential Complication #1
Risk for Nursing Diagnosis R/T medical diagnosis or condition
Potential Complication #2
Risk for Nursing Diagnosis R/T medical diagnosis or condition
PC Outcome/Goal #2
The goal clearly supports the nursing diagnosis and plan of care. The goals are specific, measurable, attainable, realistic and timed.
PC Outcome/Goal #1
The goal clearly supports the nursing diagnosis and plan of care. The goals are specific, measurable, attainable, realistic and timed.
PC Interventions #2
Clearly and accurately Identifies nursing/ collaborative interventions. Interventions are always individualized, prioritized, organized, specific and realistic. Nursing actions are always aimed at the patient’s/client’s goals and directed at the stated health deviation.
Your interventions are the interventions and task you provided to the patient all day during your clinical. This is what you actually did at the bedside during your clinical day.
Intervention should be from beginning to end to meet the task step by step
PC Interventions #1
Clearly and accurately Identifies nursing/ collaborative interventions. Interventions are always individualized, prioritized, organized, specific and realistic. Nursing actions are always aimed at the patient’s/client’s goals and directed at the stated health deviation.
Your interventions are the interventions and task you provided to the patient all day during your clinical. This is what you actually did at the bedside during your clinical day.
Intervention should be from beginning to end to meet the task step by step
Head-to-Toe Assessment
Documents full Head-to-Toe physical assessment – relevant to the patient/client as performed by the student. Utilizes an organized format and appropriate terms to describe both normal and abnormal assessment findings.
Respiratory
Cardiovascular
Neurological
Vital Signs
Nutrition
GI
Rest/Exercise
GU
Misc/Ht/Wt
Psychosocial
Integumentary
Endocrine
Fetal Heart Rate Tracing
Fetal Heart Rate Tracing
Heart Rate:
Variability:
Acceleration:
Deceleration:
Category:
Contractions
Frequency: ________ ___________
Duration: ________ ___________
Fetal Heart Rate Tracing
Heart Rate:
Variability:
Acceleration:
Deceleration:
Category:
Contractions
Frequency: ________ ___________
Duration: ________ ___________
Reference
Accurate APA format; Appropriate citations and references; No spelling or grammar errors.
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All the Best,
Cathy, CS