..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 prnTEACHING EXPERIENCE RUBRIC
TEACHING EXPERIENCE RUBRIC
CriteriaRatingsPtsThis criterion is linked to a Learning OutcomeComprehensive
Assessment
3.84 ptsClear 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 ptsVague 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 ptsVague and incomplete discussion of patient’s admission diagnosis, demographic data, and anticipated learning needs.
0.96 ptsNo 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
Needs
Assessment
3.84 ptsClear 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 ptsIncomplete 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 ptsIncomplete assessment of learner (patient and/or family), teaching needs, and special learning needs, if present.
0.96 ptsNo 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/
Evidence-based
Information
4.08 ptsOpen 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 ptsOpen or closing remarks displayed.Vague/incorrect teaching objectives.Vague/disorganized presentation of evidence-based patient teaching
2.04 ptsOpen or closing remarks displayed.Vague/incorrect teaching objectives
1.02 ptsNo 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 ptsDirect eye contact and appropriate gestures/movements during teaching.Relaxed, self-confident nature and no mistake during teaching.
3.1 ptsMinimal eye contact and little movement or descriptive gesture during teaching.Mild tension, lack of self-confidence and difficulty recovering from mistakes.
2.04 ptsMinimal eye contact and little movement or descriptive gesture during teaching.
1.02 ptsNo 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 ptsUse of clear speech and inflection, maintains the interest of the learner.
3.1 ptsSome level of inflection and clarity during delivery.
2.04 ptsMonotone voice with some inflection of delivery
1.02 ptsMonotone voice consistently.
4.08 pts
This criterion is linked to a Learning OutcomeLearning
Evaluation
4.08 ptsClear/appropriate evaluation of patient’s response and effectiveness/ineffective ness of teaching.Reflective analysis of teaching including discussion of strengths and weaknesses.
3.1 ptsVague/inappropriate evaluation of patient’s response and effectiveness/ ineffectiveness of teaching.Vague reflective analysis of teaching including discussion of strengths and weaknesses.
2.04 ptsVague/inappropriate evaluation of patient’s response and effectiveness/ ineffectiveness of teaching.
1.02 ptsVague/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