Case Notes: Henry O’Keefe

Time allowed: 40 minutes

Today’s Date 19/3/12

Read the case notes below and complete the writing task which follows:

You are a nurse with the Blue Skies Home Nursing Centre. You visited this patient at home following a referral from the Spirit Public Hospital. He was discharged from hospital on 17/03/12.

Name: Henry O’Keefe

Address: 12 Donaldson Street, Greenslopes 4121

Phone: (07) 3941 2267

Date of Birth: 2 February 1929

Admitted: 14/3/12

Diagnosis: Malignant Melanoma Left Shoulder

Medical History: Large lesion successfully removed 14/3/12

Discharged 17/3/12

Needs assistance with showering and to dress wound prior to removal of sutures at Mater Public Hospital on 24/3/12

Family History: Married aged pensioner. Lives in housing commission home with wife Dorothy also an aged pensioner. No children

18/3/12 1st Home visit

Showered patient. Wound dressed – healing satisfactory no sign of infection Balance a little shaky – complaining of increased arthritic pains in hands and legs. Currently taking Glucosamine & Chondroitin Supplement recommended by GP. Pain relieved with 2 Panadol 3 times daily. Confused about why he had operation. Dorothy concerned about future. Tells you she will be 83 in August. Says Henry has not been himself since the surgery. Keeps forgetting things. She finds it difficult to manage the house and garden. Neighbours are helping with shopping. Kitchen and bathroom disordered – trouble finding clean towels dishes piled in sink, bed unmade.

19/3/12

Henry is showered and wound dressed. Still a little unbalanced. Rests most of the day. Does not remember being showered yesterday. House still disorganised, washing piled up in bathroom. Dorothy says she would be lost without help from neighbours who also appear to be cooking meals for the couple.

Concerns: Provided there are not complications with the wound healing, your role in providing nursing care ends when sutures are removed on 24 March. You consider that Henry and Dorothy need to be assessed for further on-going assistance in managing the house and garden and with shopping and the preparation of cooking.

Plan: Request a home visit by the Aged Care Assessment Team as soon as possible to fully assess their needs and to arrange for appropriate further assistance to be provided.

WRITING TASK Using the information in the case notes, write a letter to The Director, Aged Care Assessment Team, Brisbane South Region, 78 Masterson St. Acacia Ridge, Brisbane 4110. Explain why you are writing and what types of assistance may be required.

Sample answer by Lifestyle Training Centre

19 March 2012

I am writing to request a home visit for Mr O’Keefe and his wife, Dorothy, in order to assess their living condition and to provide on-going assistance in managing their home. Mr O’Keefe underwent a large lesion removal on 14/3/12 secondary to Malignant Melanoma of left shoulder and is currently under our care.

At present, his wound is healing well and has no signs of infection. However, he complains of excess arthritic pains in his hands and legs. He complies with his medication. During home visits, he is assisted with shower, and his wound is dressed daily. His balance is slightly unbalanced.

The couple lives on old-age pension and has no children. They suffer from impaired memory and find it difficult to manage their home and garden. Their house is totally disorganised and is piled up with unwashed cloths and dishes. However, their neighbours seem to be helping them with cooking and shopping.

Based on the above description, please visit the couple at their residence promptly in order to fully assess their needs and to provide assistance with cooking, gardening, shopping and managing the house. Our nursing care will come to an end at the removal of O’Keefe’s sutures on 24 March in Mater Public Hospital. Their home address is attached with this letter.

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