Read the case notes below and complete the writing task that follows.

Time allowed : 40 minutes

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 8/12/11

Family History

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

Birth Histor

• 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 became 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
• 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.

• In your letter expand the relevant case notes into complete sentences
  • Do not use note form
  • The body of your letter should be approximately 180~200 words
  • Use correct letter format.

Sample answer by Lifestyle Training Centre

15/01/2012

Dear Sir/Madam,

Re: Dylan Charles, 04/12/11

I am writing to refer baby Dylan, who suffers from mild constipation and dehydration; and also his mother, Sylvia, who requires education on breast feeding.

Dylan was breastfed the initial three weeks of birth and had no complications. Sylvia, then, switched to formula feed as per her mother-in-law’s advice as she got sick for a few days. She also mixes extra powder in formula feed, hoping to improve his weight, 4200gms.

Dylan is difficult to be bottle fed, and Sylvia prefers breast feeding over formula feed. However, she is concerned that she doesn’t have enough breast milk. Therefore, please teach Sylvia proper breast feeding technique and correct preparation of formula feed. If formula feed should be continued, boiled and cooled water needs to be added in the feed.

Dylan suffers from constipation, and his stool is hard every three days; the urine appears dark. He only had 3 wet nappies in the last 24 hours. Since he had become unsettled during summer wave, he needs to be kept hydrated and cool in hot weather. His reflexes and vitals are normal, but he is slightly lethargic.

In view of the above, we request you to assess the baby and help Sylvia to improve breast feeding. Please return them for review in 48 hours. Should you have further queries, please do not hesitate to contact me.

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