TASK 46 You are the registered nurse on the Cardiology Unit at St Luke’s Hospital, Adelaide. Ms. Kylie Weiss is a patient in your care.
Today’s date: 09/07/2017 Patient details
Name: Ms. Kylie Weiss DOB: 21/05/1952
Address: 8758, pulteney Street, Adelaide, SA, 5000
Telephone: (04)7649 5748
Date of Admission: 07/07/2017
Presenting complaint: BIBA – brought in by ambulance
2-hours history of intermittent discomfort in jaw and heaviness in both forearms constant discomfort-pale, clammy, nauseated IV access in ambulance, 10mg IV. Morphine on route, Aspirin 300 mg chewed, Glytrin spray x 3 ECG showing ST elevation
Diagnosis: Myocardial infarction Medical History
Weigh: 85kg Height: 10cm
Diet: Rarely cooks at home-eats muffins or pancakes for breakfast
Like eating fast foods – fries, hamburgers, sausages, lobster, onion rings, ice cream, steak
Ex-smoker-1994 Non drinker
Medical History: Mild osteoarthritis.
Mid asthma – no exacerbations within last 5 years Dyslipidaemia – (Raised cholesterol) – not treated
Medications: NIL
Family history: Brother CABG 70 years Sister MI 60 years
Mother angina
Social history:
Married with one daughter
Husband-Peter Weiss, 67 years, retired, aged pensioner Daughter, Ryena Weiss, lives in London
Occupation: Works as a taxi driver,Mixed shifts
Medical treatment: Blood tests – Troponin 1 (indicative of damage to heart muscle in most instances) performed by nursing staff along with CBC- Hs TNI> 50000(N˃16 female)
ECG- ECG on arrival to ED by nurse, shows ST elevation -Leads V1, V2, V3, V4 Elevation,Anterior Mi Emergency Medication– IV Morphine, Oxygen Clexane, loading dose of Ticegralor,Emergency Angioplasty – Due to presentation of pain, ST elevation on ECG-Direct stenting proximal LAD
Echocardiogram – to indicate damage to heart muscle and treatment.Ejection fraction 35%.Pain/Discomfort – managed. Fluids encouraged to flesh dye decrease risk of AKI (Acute Kidney Injury)
Fasting blood (lipids, Diabetes TNI, CBC, Biochem) – High cholesterol levels identified
Commenced on Atorvastatin 40mg OD, Ticegralor 90 mg BD, Glytrin spray for chest pain
Nil further pain/discomfort cardiac status stable Radial site, nil ooze, swelling, pain discomfort
Pt seemed Confused regarding diagnosis, reality of near-death experience
Educated re event, MI diagnosis and modifications to risk factors (Cholesterol, wt. loss)
R/V by dietician – diet to promote weight loss and lower cholesterol levels Concerned about being unable to manage home on her husband’s pens- S/W (social worker) input required for this
09/07/2017: preparing for discharge
Discharge Medications: Commenced on Atorvastatin 40 mg OD metoprolol 23.75 mg OD
Cilazipril 0.5 mg OD, Aspirin 100 mg OD,Ticegralor 90 mg BD Glytrin spray PRN for chest pain
Discharge plan: No driving motor vehicle for 6 weeks.
Writing Tasks Using the information given in the case notes write a referral letter to Ms. Nina Gill, Cardiac Rehabilitation Nurse Specialist, Cardiac Rehabilitation- Compliance with risk factor management (wt. loss, low cholesterol diet), medications, education re about MI and its management.
Using the information in the case notes, write a referral letter to Mr. Barney Dyer, Occupational Therapist, Home Occupational Therapy services, 85 Flinders Street, Adelaide requesting him to visit Ms. Weiss at home and provide guidelines for returning to work, driving and normal daily activities.
Refer to social worker-due to inability to work for 6 weeks, 6weeks recovery from MI, assess eligibility for sickness allowance /benefits from the Australian Government Department of Human Service.
Submit your OET letters for correction: (for a minimal fee)
https://goltc.in/oet-writing-correction/