TASK 30 Read the case notes below and complete the writing task which follows.
Today’s Date: 22/03/2014
Hospital: Spirit Hospital Medical Assessment Unit (MAU) Admission Date : 20/03/2014-
Discharge Date : 22/03/2014
Patient Details Name : Sandra Peterson Date of birth: 01/01/1923
Address : 258 Addison St. Applethorpe Marital Status: Widowed 25 Years
Next of kin : Daughter- Ann Macarthur, Ph: 0438856277
Diagnosis: URTI (Upper Respiratory Tract Infection) – dehydration, bi-basal crackles heard on chest, SOB
Polypharmacy– on 24 medication encouraged by her daughter.
History of Presenting Illness
13/03/2014 : Coughing (yellow sputum)
18/03/2014 : led mobility, found in a sitting position on the floor in her room, no injuries.
19/03/2014 : led confusion had another fall in the toilet, no injuries. 20/03/2014 : BP 190/90, SOB, dizziness, the 3rd fall, an ambulance was called
Past Medical History
Moderate dementia, HTN, Incontinent of urine- Occasionally
Social History: Lives in 2 bed room flat with her daughter and son-in-law
Daughter is overly supportive, overreacting and anxiety about her mother’s health.
Religion: Orthodox Christianity, attends church weekly with daughter.
Hobbies: Listening to classical music, watching movies.
Requires some assistance with bathing, dressing and toileting.
Homecare worker visit 2 x wkly (bathing).
Medical Progress: X-Ray-normal; FBC-WCC 9.0, Hb 115g/l
CT-brain- no acute changes; Commenced on Augmentin 500 mmg x BD. per os.
Now intermittent dry cough; IV normal Saline for 24 hrs
Medications rationalized by doctor as detailed in discharge plan.
BP 150/70 – after adjustment of anti- hypertensive.
Nursing management
Vital signs : afebrile, haemodynamically stable, saturating 96% room air.
Mobility : Short distance-independently ambulant with a seat walker, long distance wheelchair x 1 assistant.
Hygiene : full assistance require with bathing, some assistance with dressing and grooming.
Psycho/ Social : Mild confusion, but co-operative.
Discharge Plan
Community nurse referral; Continue 500 mg tablet of Augmentin BD 5/7, should be taken at the start of a meal.
Metoprolol 25 mg BD.; Candesartan 16 mg mane
Medications- monitoring and assistance.; Daughter requires education/monitoring due to Hx of polypharmacy.
Ongoing care with personal hygiene required.
WRITING TASK
You are the charge nurse on the MAU where Mrs. Sandra Peterson has resided during her hospital stay. Using the information in the case notes, write a letter to the Community Nurse at Spirit Community Health Centre. Cnr Bell & burn Streets Applethorpe, NSW, 2171. In your letter explain relevant background and medical history and provide information about discharge requirements.
Submit your OET letters for correction: (for a minimal fee)
https://goltc.in/oet-writing-correction/