TASK 79:
Patient: Mrs Beryl Casey (DOB: 21/11/1941) is a 72-year-old woman who is being discharged from hospital to a rehabilitation centre.
Marital status: Widowed (recently)
Family: 2 children – son lives locally & daughter interstate.
Social: Lives alone in 2-bedroom house with stairs to entrance. Son (married, 2 children –6 & 8) lives 20 minutes away – visits twice a week. Enjoys gardening.
Medications: Anti-hypertensive (Ramipril) 10mg
Admission date: 4/02/14 at 1200hrs
Fainted getting out of bed & fell to the loor. Found by son 2 hours later.
Diagnosis: X-ray – fractured left neck of femur (# L NOF) post fall
Treatment: Left hemiarthroplasty (Austin Moore hip replacement); general anaesthesia Incision closed with staples & 2x Exudrain
Post operation: Intravenous (IV) therapy: 3 units packed cells – with IV Lasix (furosemide) 40mg therapy after each unit (intraoperative & post op)
Maintained IV therapy for 36hrs, then ceased and oral luids encouraged
Intravenous antibiotics (IVABs) – Cephazolin 1g t.d.s. for 3/7 – course completed
Vital signs: BP hypotensive – 95/60, other obs. within normal limits
Anti-hypertensive medication reviewd by Dr – Dose ! now Ramipril 5mg daily
Pain management: Patient-controlled analgesia (PCA) with Fentanyl for 36hrs – pain relief – satisfactory. Commenced oral analgesia 36hrs post op -+ Panadeine or Panadol 4/24 prn, Max 4 doses/24hrs
Wound management: Dressing V
Total of 600ml haemoserous luid discharge from Exudrains over 24hrs
Drain tubes removed 48hrs post op (Day 2). Alternate staples removed Day 5 and dressing changed
Mobility & activities of daily living (ADLs):
Day 2 Sitting out of bed (SOOB) short periods, full assistance
Day 3 Mobilising with pick-up frame (PUF) & 2-person assist
Day 4 Uneventful
Day 5 Mobilising short distances with PUF & 1-person assist Abduction pillow when resting in bed (RIB)
Anti-embolic stockings in situ for 14 days ADLs – full assistance
Day 6 Uneventful day Preparing for discharge
Discharge plan:
Day 7 (1100hrs) Discharge to the Rehabilitation Centre
Discharge medications – Ramipril 5mg daily, paracetamol 1g qid prn
Family to be notified of transfer. Hospital transport arranged for 1100hrs
Day 8 Repeat check of hemoglobin (Hb) levels
Monitor BP b.d., for 3/7, due to adjustment in anti-hypertensive meds Assess for rehab therapy (inpatient & on return home)
Day 10 Removal of remaining staples, wound can remain exposed afterwards
Writing Task: Using the information given in the case notes, write a discharge letter to the Nursing Unit Manager, The Rehabilitation Centre, Waterford.
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