TASK 21.  Today’s Date 13/09/09

Ms. Nicole Smith is an 18 year old woman who has just given birth to her first child at the Spirit Mothers’ Hospital in Brisbane. You are the nurse looking after her.

Patient Details: Address: Flat 4, Matthews Street, West End 4101 Phone: (07) 3441 3257

Date of Birth: 4 September 1991 Admitted 9th September 2009 Discharged: 13th September 2009 Marital Status: Single                          Country of birth: Australia

Social Background: Nicole is single and has had no contact with father of child for six months. She does not know his current address.No family members in Brisbane. Parents and sister live in Rockhampton. Does not currently have contact with them. Lives in a rental share flat with one other woman. Currently receives sole parent benefits. Feels very isolated and insecure. Doubts her ability to be a good mother and has talked about offering the baby for adoption.

Medical History: General health goodHad appendicectomy at 15 years Non smoker

No alcohol or illicit drug use. No drug or other allergies

Obstetric History: First pregnancy,  Attended for first antenatal visit at 16 weeks gestation 8 antenatal visits in total. No antenatal complications.

Birth details: Presented to hospital at 19:00hrs on 9th September Contracting 1:10mins

1st stage of labour: 16 hrs.  Mode of delivery: Emergency Caesarean Section Reason: Fetal distress and failure to progress.

Baby Details: DOB: 10th September 2009 Time: 11:20hrs, Sex: Male Weight: 4.4 kg

Apgar score: 6 at 1 min, 9 at 5 mins Resuscitation: 02 only for few minutes

Postnatal Progress: Maternal post-partum hemorrhage of 800 ml Blood loss now: minimal

Wound: Clean and dry Hemoglobin on 12/09/08: 90g/L, Started on Fefol (Iron supplement) and Vitamin C

Started breast feeding but not confident. Prefers to change to bottle feeding. Not confident in bathing and caring for baby Baby weight at discharge: 4.1 kg Feeding well, No jaundice

Writing Task: Using the information in the case notes, write a letter to The Director, Community Child Health

Service, 41 Vulture Street, West End, Brisbane 4101 requesting a home visit to provide advice and assistance for Nicole and her baby.

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TASK 19 Patient        :           Kylie Swanston, 12 month old girl

Family            :  Moira Swanston (mother)/ Matt Swanston (father)

Family background : Lives at home with mother and 3 y.o. brother, Tom. Mother is experiencing financial difficulties following divorce six months ago. Family lives in a 3 bedroom home in public housing. Moira is receiving the Single Parent’s Pension. She is socially isolated- no car – with little money to spend on public transport. Has no friends. Grandparents lives in Sydney. Tom and his sister, Kylie, usually spend every second weekend with their father, Matt Swanston, who is living with his new partner.

Admitted         : Kylie was admitted six days ago. Is planned for discharge tomorrow. Admitted with 2^nd degree burns to R. trunk and R.arm following accidental scalding with hot water.

Treatment      :  Twice-daily Silvazine dressings to affected area.

IV fluids for 24 hours post-admission, then oral fluids. Medication: Prophylactic antibiotic cover and analgesia. Mother has been recommended to see Hospital’s social worker.

Discharge plan           :           Daily Silvazine dressings. No discharge medications. Monitor mother’s depressed mental state.  Introduce mother to local support groups, agencies, Mother’s Group, local childcare Centre, local financial counsellor and Hospital social worker.

WRITING TASK: Write a letter to the Community Nurse, Rosewall Healthcare Centre, Sharland Road, Corio,Vic 3214. Outline the treatment Kylie has had to date. Request that the Community Nurse: Change the Silvazine dressings daily- until no longer required; Monitor Mrs. Swanston’s mental state;

Make appointments for Mrs. Swanston to go along to the local Mother’s Group for some social activities; Community Nurse to arrange for free childcare one morning a week(for Tom); Community Nurse should also make an appointment with the local Bank for Mrs. Swanston to get some financial management counselling.

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TASK 18: You are a Maternal and Child Health Nurse working at the Romaville Community Child Health Service. Today’s date: 15 January 2012

Patient History          Baby boy: Dylan Charles       

DOB: 04/12/11

Born: Romaville Maternity Hospital.  First baby of Raymond and Sylvia Charles

Address: 19 Mayfield St, Romaville.

Discharged: 08/12/11

Family History

Mother: Aged 24 First Child, Father: Aged 25 Soldier Currently away from home on duty

Birth History: Normal vaginal birth at term, Birth weight: 3400gm, Apgar score at 5 min: 9

No antenatal or postnatal complications

15/01/12 Subjective

Silvia and baby attended for routine 6 week check-up. Silvia says she is concerned about constipation: once every three days, hard stool. Mother is asking about stool Softener or prune juice for baby

Breast fed for first three weeks after birth

Baby become unsettled during summer heatwave in December.

Silvia got sick and had a fever for a few days. Mother-in-law (Mary Charles) came to visit and advised changing baby to formula feeds. Mary advised extra powder in formula feeds to improve weight gain.

Silvia worried she does not have enough breast milk and now gives extra formula feeds as well as breast feeding. Dylan difficult to bottle feed.

Silvia wishes to breast feed properly as she believes it would be the best thing for her son

Mary Charles plans to stay with the family for at least a further month to help with baby. Tensions developing between mother and mother-in-law over what is best feeding method for Dylan.

Objective

Reflexes normal, Slightly lethargic,  No abdominal tenderness, Heart Rate: 174, Respirations: 56, Temperature: 37.1, Weight: 4200gms, 3 wet nappies in last 24 hours, Urine dark: 

Assessment: Mild constipation and dehydration

Plan: Increase breast feeds

Refer to breast feeding support service, Check formula is correctly prepared, If continuing formula feeds, advise to supplement with water (boiled and cooled). Advise on keeping baby cool in hot weather

Return for review in 48 hours.

Writing Task: Please write a referral letter to the Lactation Consultant at the Breast Feeding Support Centre, 68 Main Street Romaville

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TASK 17

Patent Details: Mr. Gerald Baker is a 79 year old patient on the ward of a hospital in which you are Charge Nurse

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

Medical Background  :          

2008 – Osteoarthritis requiring total hip replacement surgery

1989 – Hypertension (ongoing management)

1985 – Colles fracture, ORIF

Medications    :           Aspirin 100mg mane (recommenced post-operatively) Ramipril 5mg mane

Panadeine Forte (co codamol) 2 qid prn

Nursing Management and Progress    :daily dressings surgery incision site

Range of motion, stretching and strengthening exercises Occupational therapy

Staples to be removed in two weeks (21/9). Also, follow-up FBE and UEC tests at City Hospital Clinic

Assessment    :  Good mobility post-operation

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 riser, 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.

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TASK 16: Nurse: You are Sonya Matthews, a qualified nursing sister working with the Blue Nursing Home Care Agency Bob Dawson is a patient in your care. Read the case notes below and complete the writing task which follows

Name   :           Bob Dawson

Address :          141 Montague, West End 4101

Phone            :           (07) 3442 1958.    

DOB:25 September 1924

Social Background: Married wife Elizabeth aged 83. Lives in own home – Both receive age pensions Bob is World War 11 Veteran with Gold Health Card entitlement

Medical History: Cerebrovascular accident (CVA) 4 years ago

Rehabilitation generally successful – Mentally alert, slight speech impairment, – residual weakness left side – walks with limp – balance slightly impaired

18/5/08: Had fall descending stairs. Badly grazed left knee. GP has requested daily visits by Blue Nursing Home Care to dress wound and assist with showering.

19.5.08: Grazed knee redressed – no sign of infection

Bob managing to get around the house slowly with aid of his wife. Reports that apart from “usual aches and pains” he is doing well.

23.5.08: Knee healing well. Suggested use of a walker or walking stick to assist with mobility.

Bob said he had a walking stick but it was useless. Wife says he had never learned to use it properly. She asked if I would contact their local physiotherapist to see if Bob could receive a home visit to assess further assistance to improve his mobility

WRITING TASK: Using the information in the case notes, write a letter to Ms. Marcia Devonport, West End Physiotherapy Centre, 62 Vulture Street, West End, Brisbane 4101 on behalf of Mrs. Elizabeth Dawson requesting a home visit to provide advice and assistance with improving her husband’s mobility.

View sample answer by Lifestyle Training Centre

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TASK 15: Case Notes: Betty Olsen. Today’s date: 10/07/12.

Notes: Betty Olsen is a resident at the Golden Pond Retirement Village. She needs urgent admission to hospital. You are the night nurse looking after her.

Patient Details:

Address: Golden Pond Retirement Village 83 Waterford Rd, Annerley, 4101.      

Phone: (07) 3441 3257

Date of Birth: 29/01/1929 Marital Status: Widowed Country of birth: Australia 

Social History: Moved to a retirement village following the death of husband in December 2010.

Next of kin: Son, Nicholas Olsen, 53 Palmer Street, Warwick 4370. Ph (07) 4693 6552.

Retired triple certificate nurse – was the matron of a small country hospital for 15 years. Very aware of and interest in health issues. Likes to discuss and be kept fully informed of any changes to her medication or treatment.

Normally alert and orientated. Enjoys bridge, bingo and reading.

Medical History:       Hypothyroidism since 2000. Hypertension since 2007.

Glaucoma since 2007 Allergic to penicillin

Prescription Medications:    Karvea 150mg 1 daily Oroxine 0.1mg 1 daily am

Timoptol Eye Drops 0.5% 1drop each eye am & pm Normison 10 mg as required

Non prescription Medication: Golden Glow Glucosamine Tablet – 1 with breakfast for arthritis Vitamin C Complex Sustained Release – 1 with breakfast

Mobility / Aids: Independent with walking stick. Arthritis in hands. Wears glasses Continence: Requires continence pad

Recent Nursing Notes:

16/05/12: Flu vaccination

29/06/12: Complaining of indigestion following evening meal. Settled with Mylanta

07/07/12: Unable to sleep – aches in shoulder. Settled following 2 Panadol and 1 Normison

09/07/12: Requested Mylanta for indigestion,Panadol for shoulder pain – slept poorly

10/07/12 am: Tired and feeling generally weak. BP 180/95. Confined to bed. GP called and will visit 11/7/12 after surgery.

10/07/12 pm: Didn’t eat evening meal. Says felt slightly nauseous. Trouble sleeping, complaining of shoulder and neck pain. BP 175/95 Given 1 Normison 2 Panadol at 10pm

Rechecked 10.45pm – Distressed, pale and sweaty, complaining of persistent chest pain,

BP 190/100. Ambulance called and patient transferred

Writing Task: Write a letter for the admitting doctor of the Spirit Hospital Emergency Department. Give the recent history of events and also the patient’s past medical history and condition.

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TASK 14 Patient       :           Amir Akbari              Age      :           41

Marital status :           Married.                      Religion ethnicity      :           Moslem & Iranian

Admission Date :6^th March 2011, Prince Charles Hospital Randwick       Discharge Date    :22^nd April 2011

Diagnosis        :           Guillain-Barre Syndrome

Family/Psychosocial :           ‘Lives in rented house with Iranian wife & 2 kids (3 & 4) PhD students; pt & wife speak good English support network in Australia.

Children in university childcare 2/7; nil extra days available at center at present

Pt works at service station 3/7. Pt has PTSD issues trauma in mid-80’s – prone to depression and anxiety related to this. Medical History and Medications. Otherwise physically healthy prior to onset of GBS Medication information to be forwarded by doctor

Management and Progress during Hospitalization: *Rapid deterioration and recovery

‘Required ventilation in ICU 3/7 March 20-22’.  At peak of GBS couldn’t move limbs independently

Now muscle tone/strength and needs light assistance with ADLS but can walk slowly with walking frame

Went for regular plasmapharesis and had a total of 5/7worth of IV gamma globulin. Daily physio program including self exercises. Now becoming depressed about his prospects. Wife not coping with financial, study and childcare pressures

Discharge Plan: Continue physio program and encourage pt. to do his, own limb exercises too. Discuss with your team re? Need for psych assessment re? depression. Ensure your s/w is aware of the family and wife’s pressures and provides follow up Halal diet. Pt oxygenation very stable on R/A now but observe for any, in respiratory status or in neurological signs

Writing task: You are the Charge Nurse on the neurological ward where Amir Akbari has stayed for most of his hospital admission. Using information provided in the case notes, write a letter of referral to the Charge

Nurse at Prince Henry Rehabilitation Centre, Malabar Bay where he will be transferred to for rehabilitation after discharge from your ward.

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TASK 13:

Patient      :           Mrs. Joy Rafferty       

Age: 65.

Occupation :           Retired clothing machinist

Patient has attended the Community Health Center since her retirement ten years ago. Recently a new Center has opened much closer to her home.

SOCIAL HISTORY:  Widowed since 1984 and has supported the family since her husband’s death

Lives alone in a Housing Commission flat. Has 6 adult children with 3 living nearby in the same suburb

A close family. Social activities are restricted to family occasions. Outside outings are also restricted (Family does her shopping and collects her for outings, etc.). Previously active with the Church and its social circle however this has stopped because the patient can no longer drive.

MEDICAL HISTORY: Benign hypertension over 10 years, now progressing to essential hypertension 180/100 Coversyl 4 mg daily. Rapid weight gain in past year 75 kg to 90 kg

Undifferentiated osteoarthritis type aches and pains, Analgesics required for pain,  Mild depression

FAMILY INVOLVEMENT:  Several meetings with the family to encourage the patient to make social contacts and therefore become less dependent on the family.

Family concerned and overprotective but in agreement with suggestions

DISCHARGE PLAN: Improve her general health status by Increasing exercise regime and stimulatininer

Continue family meetings. Introduce client to suitable interest and activity groups in the area e.g. Aqua aerobics, local women’s chair, Meals on Wheels, parish visiting groups. Encourage and monitor attendance

WRITING TASK : You are the Community Health Nurse who has been looking after Mrs. Rafferty for the past ten years. You are concerned about her increasing isolation and general health. Write a letter referring her to the new Center. The contact persons is: Ms. Rhonda Johns, RN., Community Health Care, 25 River Street, Clayton, Vic: 31804

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We hope this information has been valuable to you. If so, please consider a monetary donation to Lifestyle Training Centre via UPI. Your support is greatly appreciated.

Would you like to undergo training for OET, PTE, IELTS, Duolingo, Phonetics, or Spoken English with us? Kindly contact us now!

📱 Call/WhatsApp/Text: +91 9886926773

📧 Email: [email protected]

🗺️ Find Us on Google Map

Visit us in person by following the directions on Google Maps. We look forward to welcoming you to the Lifestyle Training Centre.

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Thank you very much!