TASK 25
Read the case notes and complete writing task which follows Name: Mrs Jane Lapaglia Age: 71
Culture & religion data: Italian & Catholic, speaks functional English Admission Date :4th March 2011- Prince Albert Hospital Discharge Date : 28th April 2011
Diagnosis :Renal failure 2˚ to dehydration, mild dementia, pneumonia
Social /Medical Family :Lives with 80 yr old husband /carer, Joe, in a 4 bdrm unit
Joe not coping with pt’s or his own care needs. House filthy, both have poor hygiene and nutrition
One son, Andrew, a mechanic, visits Tuesday and Sunday. Interests include classical music, ballet and AFL
Medical History and Medications: See Dr’s notes (to be forwarded)
Management and Progress during Hospitalisation: Initially comatose, ventilated in ICU 7/7
Given dialysis 3/52 which ↓ urea & creatinine, stable now
Hospital acquired pneumonia 2/24 chest physio for 2/52, still requiring O2 2 litres via nasal prongs but non infective for 3/52
↑confusion post ICU but now back to usual mild level and is quite settled. Needs prompting to eat, drink, dress, walk, toilet & tend to personal hygiene but can independently do these
Family conference 25/3/11. Consensus decision: pt will move to nursing home & Joe will live in adjoining hostel-nil beds for either till 28/4/11
Discharge Plan: Transfer to nursing home
Husband will live in hostel next door, both accepting of this Continue 02 therapy as per 02 sats
Encourage independence, pt capable of self-care with ++prompting Ensure adequate hydration to prevent ↓ renal function; Repeat electrolyte, urea & creatinine blood test weekly
Writing task You are the Charge Nurse on the medical ward where Ms LaPaglia has spent most of her hospital stay as a patient. Using the information in the case notes, write a referral letter to the Charge Nurse at Boronia
Nursing Home, Coogee where Mrs Jane LaPaglia will be discharged to from your ward.
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