Writing Test: Nurses

Time allowed: 40 minutes

Red the case notes below and compete the writing task which follows. Notes:

Ms. Amy Vineyard is a patient in your care at the St Kilda Women’s Refuge Centre. She is 6 weeks pregnant with her first child. She presented two days ago, requesting help for her substance abuse problems. She reports a desire to reduce or cease her alcohol consumption and a desire to reduce a cease her drug use. No desire has been indicated to decrease or stop cigarette use. She now wishes to be discharged but will require ongoing support throughout her pregnancy.

Discharge summary: Name: Ms. Amy Vineyard Age: 21

Admission: 6/1/09

Diagnosis: pregnant substance abuse

Discharge: 8/1/09

Plan:

• Community mental Health Nursing required daily next 2 weeks minimum.
• Pt wishes to continue living with a friend on her sofa.
• Psychiatric support needed for depression.
• Methadone program Alcoholics Anonymous meetings
• 1 Trimester Ultrasound at 2 weeks;
• maternal health clinic appointment needed.

Reason for admission:

• Pt. self admitted due to concern about pregnancy. Confirmed pregnancy test the days before (5/1/09)
• Reported pain in lower back
• weight loss (6kg over 2 months)
• some memory loss
• tingling in feet, difficulty sleeping, excessive worry and hallucinations
• feeling depressed-history of depression
• no pain in hips or joints
• no decrease in appetite
• no double vision

Treatment

• pt. monitored and blood tests for HIV/AIDS and STDs
• counseled re nutrition and pregnancy
• counseled re HIV/AIDS and STDs risk
• discussed possibility of rehabilitation clinic for ‘driving out’

Lifestyle:

• Nicotine daily 30-40 cigarettes
• started smoking at 15 y. o.
• Drugs used cannabis, amphetamines, cocaine, heroin
• started all above at 16 y. o.
• injects heroin, occasionally shares infecting equipment
• Alcohol  8 units/day      max. units/day- 15
• started drinking at 16 y. o.
• lives with a friend, Sophie, on her sofa.
• no contact with parents

History:

• suicidal thoughts, self harm in past
• never seen a psychiatrist

Writing Task

Using the notes, write a letter about Ms. Vineyard’s situation and history to new community health nurse. Address your letter to Ms. Lucy Ban, Registered Nurse, Community Health Centre, St Kilda.

Sample letter by Lifestyle Training Centre

Ms. Lucy Ban
Registered Nurse
Community Health Centre St Kilda.

08/01/09

Dear Ms Ban,
Re: Ms Amy Vineyard, aged 21 years.

I am writing to refer Ms Vineyard, a primigravida of 6 weeks, who requires antenatal care, following her discharge today. She was self-admitted to our facility due to pregnant substance abuse.

Ms Vineyard has history of suicidal thoughts, depression, and self-assault. She struggles with minor memory loss, lower back pain, tingling in feet, sleep disorders, hallucinations, and excessive worry; therefore, psychiatric support is essential.

During hospitalisation, Ms Vineyard underwent blood tests for HIV/AIDS and STDs as she shares infecting equipment to inject heroin; she was counselled on the same. She also was counselled on pregnancy and nutritious diet as she reports weight loss, 6kgs just over the last 2 months.

At present, Ms Vineyard desires to quit her alcohol consumption, 8-15 units a day; and drug uses such as cannabis, amphetamines, cocaine, and heroin. She smokes up to 40 cigarettes a day, and these habits are from her mid-teen; therefore, she is advised to attend Methadone program Alcoholics Anonymous meetings and to undergo rehabilitation.

Ms Vineyard stays at her friend’s place on a sofa, where she plans to continue her stay. She has no contact with her parents.

Based on the information provided, I kindly request the provision of community mental health nursing for Ms. Vineyard, along with daily monitoring for a minimum of the next 2 weeks. Additionally, please schedule a 1st-trimester ultrasound for her at a maternal clinic within the next 2 weeks. Should you have any further inquiries, please do not hesitate to contact me.

Your sincerely,
Charge nurse.                                                                                                    

(Words used: 230)

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