West Coast NURS 316L OB Nursing Concept Map
West Coast NURS 316L OB Nursing Concept Map
Case study provided in order to fill out the OB concept map.
Case Scenario 2
History of Present Problem:
Maria Sanchez is a 24-year-old prima gravida who delivered Juan, a baby boy by cesarean section two weeks ago. She has been breastfeeding with no problems since he was born.
She developed increasing firmness and swelling in her left breast that is causing increasing pain and noticed that her nipples developed cracks two days ago. She made an appointment to see her obstetrician because she had a fever and chills that began this morning and had breast pain that became “unbearable” whenever she tried to breastfeed.
Personal/Social History:
Maria is newly married and motivated to be a good mom. Before her pregnancy, she had an occasional glass of wine with her meals but has abstained since she found out she was pregnant.
She has six weeks off before she has return to work. Her parents do not live close by and she has few friends because she moved from a different state because of her husband’s job transfer.
| Current VS: | P-Q-R-S-T Pain Assessment: | ||||
| T: 101.1 F/38.4 C (oral) | Provoking/Palliative: | When infant breastfeeds, patient experiences pain in left breast | |||
| P: 98 (regular) | Quality: | Sharp | |||
| R: 18 (regular) | Region/Radiation: | Left breast and left nipple | |||
| BP: 134/86 | Severity: | 9/10 on 0-10 pain scale | |||
| O2 sat: 98% room air | Timing: | Especially when infant nurses, but painful to touch at all times | |||
| Current Assessment: | |||||
| GENERAL APPEARANCE: | Calm and cooperative. Winces in pain when left breast is touched. Low transverse abdominal incision healing. Edges well approximated. | ||||
| RESP: | Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort | ||||
| CARDIAC: | Pink, warm & dry, no edema, heart sounds regular, tachycardic, with no abnormal beats, pulses strong, equal to palpation at radial/pedal/post-tibial landmarks, brisk cap refill | ||||
| NEURO: | Alert and oriented to person, place, time, and situation (x4) | ||||
| BUBBLE-HE | |||||
| BREAST: | Lactating; right breast soft, non-tender with evidence of breastmilk. Left breast reddened, warm, painful to touch, small 1 cm fissure present on left nipple | ||||
| UTERUS: | No longer palpable | ||||
| BLADDER: | Voiding without difficulty | ||||
| BOWELS: | Abdomen round, soft/nontender, bowel sounds audible per auscultation in all four quadrants | ||||
| LOCHIA: | Alba | ||||
| HOMANS: | Negative | ||||
| EPISIOTOMY: | Perineum intact | ||||
| Diagnostic Results: Complete Blood Count (CBC) | |||||||||
| WBC | HGB | PLTs | % Neuts | Bands | |||||
| Current: | 14.6 | 11.4 | 152 | 92 | 0 | ||||
| Most Recent: | 10.7 | 12.5 | 188 | 79 | 0 | ||||
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