OET writing task 30: Sandra Peterson

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/

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