Health Medical Homework Help

East Los Angeles College Patient Teaching on Diet and Exercise Paper

 

please follow rubric attached for directions…attached you will find instructions as well as the patient information. APA FORMAT

Laura Lopez
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.
Medications:
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

TEACHING EXPERIENCE RUBRIC

TEACHING EXPERIENCE RUBRIC

Criteria Ratings Pts

This criterion is linked to a Learning OutcomeComprehensive<br>Assessment

3.84 pts

Clear and concise discussion of patient’s admission diagnosis, demographic data, and anticipated learning needs,Clear and comprehensive patient assessment data to support a deficient knowledge nursing diagnosis.

2.92 pts

Vague and incomplete discussion of patient’s admission diagnosis, demographic data, and anticipated learning needs.Vague and incomplete patient assessment data to support deficient knowledge nursing diagnosis.

1.92 pts

Vague and incomplete discussion of patient’s admission diagnosis, demographic data, and anticipated learning needs.

0.96 pts

No discussion of patient’s admission diagnosis, demographic data and anticipated learning needs.No comprehensive patient assessment data to support deficient knowledge.

3.84 pts

This criterion is linked to a Learning OutcomePatient Learning<br>Needs<br>Assessment

3.84 pts

Clear and complete assessment of learner (patient /family), teaching needs, and special learning needs, if present.Clear identification of patient’s strengths and weaknesses relevant to learning needs.

2.92 pts

Incomplete assessment of learner (patient and/or family), teaching needs, and special learning needs, if present.Incomplete identification of patient’s strengths and weaknesses relevant to learning needs.

1.92 pts

Incomplete assessment of learner (patient and/or family), teaching needs, and special learning needs, if present.

0.96 pts

No assessment of learner (patient and/or family), teaching needs, and special learning needs, if present.No discussion of patient’s strengths and weaknesses relevant to learning needs

3.84 pts

This criterion is linked to a Learning OutcomeOrganization/<br>Evidence-based<br>Information

4.08 pts

Open and closing remarks that capture patient’s attention.Clear and correct statement of 2 teaching objectives.Clear and organized presentation of evidence-based patient teaching.

3.1 pts

Open or closing remarks displayed.Vague/incorrect teaching objectives.Vague/disorganized presentation of evidence-based patient teaching

2.04 pts

Open or closing remarks displayed.Vague/incorrect teaching objectives

1.02 pts

No open or closing remarks displayed.No teaching objective stated.Poor or disorganized presentation of teaching from inappropriate sources.

4.08 pts

This criterion is linked to a Learning OutcomeBody Language

4.08 pts

Direct eye contact and appropriate gestures/movements during teaching.Relaxed, self-confident nature and no mistake during teaching.

3.1 pts

Minimal eye contact and little movement or descriptive gesture during teaching.Mild tension, lack of self-confidence and difficulty recovering from mistakes.

2.04 pts

Minimal eye contact and little movement or descriptive gesture during teaching.

1.02 pts

No eye contact and inappropriate gestures during teaching.Tension and nervousness obvious, trouble recovering from mistakes.

4.08 pts

This criterion is linked to a Learning OutcomeVoice

4.08 pts

Use of clear speech and inflection, maintains the interest of the learner.

3.1 pts

Some level of inflection and clarity during delivery.

2.04 pts

Monotone voice with some inflection of delivery

1.02 pts

Monotone voice consistently.

4.08 pts

This criterion is linked to a Learning OutcomeLearning <br>Evaluation

4.08 pts

Clear/appropriate evaluation of patient’s response and effectiveness/ineffective ness of teaching.Reflective analysis of teaching including discussion of strengths and weaknesses.

3.1 pts

Vague/inappropriate evaluation of patient’s response and effectiveness/ ineffectiveness of teaching.Vague reflective analysis of teaching including discussion of strengths and weaknesses.

2.04 pts

Vague/inappropriate evaluation of patient’s response and effectiveness/ ineffectiveness of teaching.

1.02 pts

Vague/inappropriate evaluation of patient’s response and effectiveness/ ineffectiveness of teaching. Vague reflective analysis of teaching including discussion of strengths and weaknesses.Absent reflective

4.08 pts

Total Points: 24