Mr Gerald Baker is a 79-year-old patient on the ward of a hospital in which you are Charge Nurse.
Patient Details:
Marital Status: Widower (8 years)
Admission Date: 3 September 2010 (City Hospital)
Discharge Date: 7 September 2010
Diagnosis: Left Total Hip Replacement (THR) Ongoing high blood pressure
Social Background:
- Lives at Greywalls Nursing Home (GNH) (4 years) No children
- Employed as a radio engineer until retirement aged 65 Now aged-pensioner
- Hobbies: chess, ham radio operator
- Sister, Dawn Mason (66), visits regularly; v supportive – plays chess with Mr Baker on her visits
- No signs of dementia observed
Medications:
- Aspirin 100mg mane (recommenced post-operatively)
- Ramipril 5mg mane
- Panadeine Forte (co-codamol) 2 qid prn
Medical Background: 2008 – Osteoarthritis requiring total hip replacement surgery
Nursing Management and Progress:
- 1989 – Hypertension (ongoing management)
- 1985 – Colles fracture, ORIF
- daily dressings surgery incision site
- Range of motion, stretching and strengthening exercises
- Occupational therapy
- Staples to be removed in two wks (21/9)
- Also, follow-up FBE and UEC tests at City Hospital Clinic
- Good mobility post-operation
Assessment:
- Weight-bearing with use of wheelie-walker; walks length of ward without difficulty
- Post-operative disoriention re time and place during recovery, possibly relating to anaesthetic – continued observation recommended
- Dropped Hb post-operatively (to 72) requiring transfusion of 3 units packed red blood cells; Hb stable
- (112) on discharge – ongoing monitoring required for anaemia
Discharge Plan:
- Monitor medications (Panadeine Forte)
- Preserve skin integrity
- Continue exercise program
- Equipment required: wheelie-walker, wedge pillow, toilet raiser. Hospital to provide walker and pillow. Hospital social worker organised 2-wk hire of raiser from local medical supplier.
Writing task:
Using the information in the case notes, write a letter to Ms Samantha Bruin, Senior Nurse at Greywalls Nursing Home, 27 Station Road, Greywalls, who will be responsible for Mr Baker’s continued care at the Nursing Home.
In your answer:
expand the relevant notes into complete sentences
do not use note form
use letter format
The body of the letter should be approximately 180-200 words.
Sample answer by Lifestyle Training Centre
Ms Samantha Bruin,
Senior Nurse Greywalls Nursing Home
27 Station Road, Greywalls.
7/9/2010
Dear Ms Bruin,
Re: Mr Gerald Baker, aged 79 years.
Mr Baker requires continuity of care and management, following his discharge today. He is currently recovering from a Left Total Hip Replacement surgery that he underwent in our hospital.
At present, Mr Baker shows good mobility, and he can walk short distances with the help of a wheeliewalker. Hospital is providing him a wheelie-walker, wedge pillow as well as a toilet raiser; the latter has to be returned after 2 weeks.
Post operatively, Mr Baker had felt disorientated, probably due to anaesthetic. In addition, his haemoglobin level had dropped temporarily; therefore, he should be watched as well as monitored for anaemia. He was commenced on occupational therapy: a range of motion, stretching and strengthening exercises, which needs to be continued.
Based on the above information, please continue the care for Mr Baker. Kindly monitor his medication regimen: Aspirin, 100mg in the morning and Panadeine Forte/co-codamol, 4 times, as required. Please maintain his skin integrity. On 21/9/2010, he needs to go for FBE and UEC follow-up tests at City Hospital Clinic, and his staples need to be removed.
Should you have further queries, please do not hesitate to contact me.
Yours sincerely,
Registered nurse
(Words count: 189)
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