TASK 62        MARCH-2018            You are a district nurse (nurse caring patient at homes) taking care of Mrs. Anna Paro, who needs daily dressing for the leg ulcer.

Patient Details:         

Name  : Anna Paro                

Age      : 75 years

Medical History : COPD, Osteoarthritis, Appendoctomy-2009, Suffering with leg ulcer, Taking salbutamol pm, ipratropium 25/250 2 puffs daily

Social History            Lives alone, Husband died      Two children-one native, other overseas

10/03/2018.   Subjective        : SOB increase (especially day activities, not at night), Salbutamol ineffective, Need rest or sit down to hold breath back

Objective        : Comfortable at rest, no sob RR: 18/Mt, BP: 130/80.    Auscultation. Good air entry both sides, little wheeze on left Observed patient’s inhaler use inappropriate

Diagnosis        : SOB worse due to? COPD, inhaler use

Treatment, Ventolin 2 puffs under supervision

Educated about inhaler use with spacer – patient claims “this is not the way my pharmacist told”. Plan. Refer/advise pharmacist re inhaler.

WRITING TASK: Write a referral to Paro’s pharmacist to teach her about inhale

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