TASK 23: Miss Alison Watson, a 6 year old, is patient in the medical ward of which you are Charge Nurse. Admitted after near drowning Hospital: Westmond Public Hospital 22 High Street, Westmond
Patient details
Name : Allison Watson Age : 6 years Next of kin : Marge Watson (mother)
Admission date : 21 February 2016 Discharge date : 3 March 2016
Diagnosis : Near drowning, potential hypoxic brain injury
Family : Lives with mother and father (Tim)
Medical history Chicken pox (3yo),Fractured collar bone (4yo),Mild asthma
Social background Primary school student (grade 1) Enjoys sport (soccer, athletics)
BackgroundFell into fresh water lake while on fishing holiday with father Found 15-20 minutes later face down.
Paramedics arrived 10 minutes later, basic life support started. On admission to ED: cyanotic, pulseless, apnoeic, fixed & dilated pupils, tympanic temp 27.7°C
Nursing Management and Progress: 21/2/16 CPR performed
Ventilator & endotracheal tubing inserted;
Heated humidifier, radiant warmer, preheated blankets applied Paediatric ventilator used
Initial ABG (Arterial Blood Gas) =7.04 / 84 / 36 / 19 / 78% Spontaneous circulation achieved
23/2/16 ABG = 7.44 / 34 / 94 / 23 / 97% BP 98/64
Tympanic temp 34.8 ˚C Patient stable – transferred from ICU to general ward
25/2/16 Temperature normal Unresponsive to command Moving around the bed
No longer hyperventilated for protection Weaning off mechanical ventilation begun
29/2/16 Responsive to commands
Basic communication possible – slurred speech Speech therapy commenced
Difficulty concentrating Paracetamol 3x daily for headaches Coughing up pink sputum Mechanical ventilation stopped
3/3/16 Communication improving, still some slurring of speech Concentration improving, cognitive function appears ok Neurological exams clear – need more tests to check for delayed problems as precaution.
Parents concerned about permanent speech and cognitive effects. Paracetamol given when needed Occasional cough. Ready for discharge
Discharge plan: Paracetamol for headaches
Monitor cough, return to hospital ASAP if worsens Speech therapy for speech
Neurologist for tests (neuropsychological, visual-spatial. IQ) in one week
GP to check cough, headaches
Parents to monitor cough, headaches, concentration. Call Dr if Minor issues, bring to ER if severe
Writing Task: Please choose 1 only (as instructed by your teacher)
A: Using the information provided in the case notes, write a referral letter to the GP, Dr Anne Simons, Southern Medical Centre, 15 Eltham Place, Curtain
B: Using the information provided in the case notes, write a letter detailing the post- discharge care required for the patient to the patient’s mother, Mrs Marge Watson, 34 View Rd, Tenningway.
C: Using the information provided in the case notes, write a referral letter to the neurologist, Dr Frank Rivers, Head Neurologist at Western Neurology Group, 95 Fitzroy St. Green Valley.
The body of the letter should be approximately 180-200 words.
Please note: It’s not common for a nurse to write a letter to a Neurologist in the OET exam. However, adapting your writing to suit the needs of different professions is a useful learning tool
Submit your OET letters for correction: (for a minimal fee)
https://goltc.in/oet-writing-correction/