Please complete a Problem Based Care Plan and Concept Map for Vaginal Delivery and also for Shoulder
Please complete a Problem Based Care Plan and Concept Map for Vaginal Delivery and also for Shoulder Dystocia.Last name: Garcia First name: LeticiaGender: Fe Age: 15 Ht: 5’2″ Wt: 158# Code Status: FullSpiritual Practice: Catholic Ethnicity: Puerto Rican Primary Language spoken:English/Spanish1. History of present illnessChief Complaint: Excruciating abdominal pain.Visiting from Florida visiting sister and in complete denial of pregnancy. Her parents are first generation Puerto Rican immigrants. Parents and sister are totally unaware she is pregnant. Because of her denial she has had no prenatal care. At her sister’s home at 0100 she begins to experience strong abdominal cramps. She does not tell her sister until 0700 and states she has a bad stomach ache. Her sister sees she is in a lot of pain and immediately takes her to the nearest hospital.Primary Medical Diagnosis Full-term pregnancy2. Review of SystemsCNS Alert, oriented, cooperative, fearfulCardiovascular Regular sinus rhythm, no gallops, rubs or murmurs, apical clear, pulses +4 radial and pedalPulmonary Clear to A&PRenal/Hepatic Voiding clear urine, no hepatomegaly feltGastrointestinal Distended, full-term pregnancyEndocrine Full-term pregnancyHeme/Coag No bruising or bleeding notedMusculoskeletal Moves all extremities well. Spine within normal limitsIntegument Clear without abrasionsDevelopmental Hx Normal Hispanic teenagerPsychiatric Hx None reportedSocial Hx Sexually active, no reported drug, smoking or alcohol historyAlternative/ Complementary Medicine Hx unknownMedication allergies: None reported Reaction:Food/other allergies: NKDA Reaction:Drug Dose Route Frequency3. Current medications4. Laboratory, Diagnostic Study ResultsNa: 142 K: 4.2 Cl: 102 HCO3: 2622 BUN: Cr:Ca: 9.3 Mg: 1.2 Phos: Glucose: HgA1C:Hgb: 13 Hct: 36.8 Plt: 265 WBC: 5.2 ABO Blood Type:PT: 11.5 PTT: 25 INR Troponin: BNP:Ammonia: Amylase: Lipase: Albumin: Lactate:ABG-pH: paO2: paCO2: HCO3/BE: SaO2:VDRL: neg GBS: pending Herpes: neg HIV: neg Chlamydia: negCXR: ECG:CT: MRI:9What’s New x Financial Aid | LakeWashington | X Pre-SIM: VaginalDelivery and Sh( X + V X &l… Show more… Show more9What’s New x Financial Aid | LakeWashington | X Pre-SIM: VaginalDelivery and Sh( X + V X &l… Show more… Show more9What’s New x Financial Aid | LakeWashington | X Pre-SIM: VaginalDelivery and Sh( x + V X &… Show more… Show more9What’s New x Financial Aid | LakeWashington | X Pre-SIM: VaginalDelivery and Sh( x + V X &… Show more… Show more Health Science Science Nursing NURSING 222 Share QuestionEmailCopy link Comments (0)
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