TASK 22 Today’s Date: 21/03/12.
Patient Details: Name: Ms. Nina Sharman,
DOB: 09/02/1951
New resident of Dementia Specific Unit, Westside Aged Care Facility, Single; Under the Australian Guardianship and Administration Council protection
Medical History: Ischemic heart disease (IHD) since 2005, takes Nitroglycerine patch, daily
Stroke May 2011, after stroke- unsteady gait
In 2011 – diagnosed with severe dementia – able to understand simple instructions only, confused and disorientated
Diabetes mellitus (type 2) since 2000 – on a diabetic diet
Osteoarthritis of both knees 20 yrs. Voltaren Gel to both knees BD
Weight gain 10 kg over the last 5 months, current weight 106kg (BMI of 30)
Chronic constipation, takes Laxatives PRN, No allergies to medication or food
No teeth – has entire upper or lower dentures, sometimes refuses to wear dentures due to confusion and disorientation
Increased appetite – usually eats full portion of offered meals x 3 times daily and, also, goes into other residents’ rooms and eats their food as bananas, biscuits or lollies
Social History No friends
Lack of interests, but likes colouring and watching TV; ↑ emotional dependence on nursing staff
Non- smoker, no use of alcohol or illegal drugs
Recent Nursing Notes
15/02/12: Chest infection. Keflex 500mg QID x 7 days
26/02/12: Occasional cough & episodes of SOB with ↑RR
27/02/12: Sporadic throat clearing after eating yoghurt
20/03/12: 17:00 hrs: Episode of choking on a piece of food (? Food not chewed properly). She suddenly turned blue, grabbed the throat with both hand and coughed. The piece of solid food was removed.
17:10 hrs: Nursing assessment after treatment
Pulse 110 BPM, BP 120/70 mmHg; RR – 22/min; T – 37.1° C; BSL – 6.0 mmol/L
18:00 hrs: No complaints, Pulse – 88 BPM, BP – 115/70 mmHg, RR – 16/min, T – 37.0 ° C
Skin: normal colour, Hospital visit not required
WRITING TASK: You are a Registered Nurse at the Dementia Specific Unit. Using the information in the case notes, write a letter to Dietician, at Department of Nutrition and Dietetics, Spirit Hospital, Prayertown, NSW 2175. In your letter explain relevant social and medical histories and request the dietician to visit and assess Ms. Sharman’s swallowing function and nutritional status urgently due to a high risk of aspiration
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