Case notes:

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 fluids 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 reviewed 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 fluid 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.

Sample letter by Lifestyle Training Centre

10/02/2014

Dear Sir/Madam,

Re: Mrs Beryl Casey, aged 72 years.

Mrs. Casey requires rehabilitative care and management, following her discharge today. She is recovering from a recent left hemiarthroplasty due to a fall at home on 4/02/14.

Currently, Mrs. Casey shows good improvement but still requires full assistance with daily activities and can only walk short distances with assistance and a pick-up frame.

During hospitalization, Mrs. Casey received 3 units of packed cells through transfusion. Initially, she was on IV therapy and IV antibiotics. As her condition improved, she transitioned to an oral and liquid diet. Her alternative staples were removed, and dressing changes were performed on day 5. She will continue wearing anti-embolic stockings for the next 2 weeks. Her current medication includes Ramipril, 5mg, and Paracetamol, 1g, four times a day, as needed.

Mrs Casey is a widow and has a daughter and a son, the later visits her often. She lives alone and is hypertensive.

Based on the above, please continue monitoring her. Please check her haemoglobin level tomorrow and her BP, twice, three times a week. The remaining staples are to be removed on 13/02/2014, and the wound can be left exposed. If you have further queries, please do not hesitate to contact me.

Yours faithfully,

Registered nurse.

(words count: 198)

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