Admitting Dx (Cite References) Medical, Surgical, Social History and OB History (1).
29yo G1P0 @ 41W1D EGA presents at L&D 7/14 for a scheduled induction. Pt reports good fetal movement, and denies rupture of membranes, contractions
or vaginal bleeding. Labor induction is also known as inducing l...
Concept Map
Admitting Dx (Cite References) Medical, Surgical, Social History and OB History (1).
Student Name: Christina Scialdone
Instructor: Karie Herber 29yo G1P0 @ 41W1D EGA presents at L&D 7/14 for a scheduled induction. Pt reports good fetal movement, and denies rupture of membranes, contractions
or vaginal bleeding. Labor induction is also known as inducing labor. It is the artificial way stimulation of uterine contractions during pregnancy before labor begins on
its own to achieve a vaginal birth ("Labor induction - Mayo Clinic", 2019).
Medical History /Surgical History-none
Patient Information Social History
(1)
Name: M.V M.V. has been married for the past 5 years and this was a planned pregnancy. Tobacco-never /EtOH- occasional use before pregnancy
– denies any use during pregnancy /Drugs- past use of marijuana denies uses during pregnancy.
Age:29
Height/Weight:5ft5 209lbs
Code Status: full code
Obstetric History
Your text here 1
GTPAL
Allergies: NKDA
G1, T0, P0, A0, L0
Gestational Weeks: 41.1 LMP: 09/30/2018
Blood type O+
Estimated date of confinement (EDC):07/07/2019
M.V confirmed pregnancy 12/01/2018. Pt maintained adequate prenatal care throughout pregnancy. No complications throughout pregnancy.
Ultrasound at 36weeeks estimated fetal weigh at 3600grams. An ultrasound must be done to elevate fetal weight and presentation before an induction
Chief Complaint ("UpToDate", 2019) M.V is who is postpartum day #1 status post vaginal delivery on 07/13/2019 0900 at 41.1 weeks of an 8lb 3fetal weight oz boy
Contractions, rupture of membrane or without laceration or other complication. She has minimal lochia, no pain symptoms, is breast feeding well. She denies mood symptoms.
bleeding. BUBBLE-HE ASSESMENT
B-normal: soft or filling no cracking or bleeding nipples erect with stimulation colostrum
“I am here for a Scheduled present (milk)
induction”. U-firm fundus, midline, at umbilicus
B-soft and nondistended normal bowel sounds in all quads passing flatus. BM 7/12
B-nondistended, non-palpable. Adequate voiding Urine clear yellow.
L-Rubra/Dark red, no clots present, mod amount with no foul smell.
Admitting Diagnosis E-Mild edema, no laceration
NSVD, or C-Section H-no pain in calves, redness or swelling
E- see psychosocial box
Scheduled induction -NVD
Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14)
Erickson’s Developmental Stage Related to pt. & Cite References (1)
Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns: include the
following Social Determinants of Health M.V is at a stage during her life were most people fall in love, get married
M.V lives at home with her husband. She works at a skilled nursing facility as an LVN. She has good family and start building their own family. It’s the stage of intimacy vs isolation.
support from both her family and husbands. Her mother in law lives nearby and will care for the baby when pt. This is the early adulthood stage, in this stage love and intimacy is very
returns to work in 12 weeks. M.V states she is not very religious but is Christian. M.V’s husband plans to important (Mcleod, 2019). The young adult must develop intimate
return to work full-time in 1 week which would leave the patient at home alone with baby. relationships or suffer feelings of isolation. M.V seems as she will have
Social Concerns successful completion of this stage and result in happy relationships and a
1)Patient may face challenges finding time personal care needs such as bathing, eating, and sleeping These are sense of commitment, safety, and care within her relationship.
the most common needs that become a challenge for postpartum mothers also placed cleaning and cooking in
the same category of importance
2)Lack of support from partner due to him working full time.
3)With family members living so close, M.V may be faced with unwanted visits
(VM-V4)
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