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