TASK – 63: You are the charge nurse in the Emergency Department at Newtown Hospital. Read the case notes below and complete the writing tasks which follows.
Patient’s Details:
Name: Kenneth Mason
Address: 8 Stuart Street, Perth, WA 6000
DOB: February 27, 2000
Social Background: A secondary student studying in Perth University, a varsity football player.
Medical History: January 2018- Had right femur fracture sustained during one practice.
March 2015- Suffered Concussion after being hit accidentally with a ball
Allergies to Food: nil Previous medications: nil
Date of Admission: 16 June 2018 Presenting Situation:
Chest pain is increasing especially when coughing
Suffered Chest contusion 20 minutes earlier after playing football. Difficulty of breathing
Diagnosis is chest pneumothorax as confirmed by Chest X-ray. Shortness of breath.
Assessment: 92% Oxygen Saturation
Has nasal Flaring upon inspection (has difficulty in breathing) Restless
Cannot complete sentences when speaking Oriented, knows his name, age and present location
Has peripheral bluish cast/discoloration in the skin and mucous membrane
Chest Palpation: No mass heaving upon palpation
Chest Auscultation: Normal but still has pain Lung Inspection: Left lung: Normal
Right lung: present air upon entry
Treatment: Immediate insertion of ICC and connected to water sealed drainage
IV Fluid of 2li/24 hours Morphine 10 mg given IV stat
Monitoring of any bleeding in the ICC May have free fluids and light meals
Care Plan: Monitor Blood present in the ICC Monitor Vital signs until stable
The nurse will accompany patient in ward to report medical history, current situation, treatment plan, etc.
Writing Task:: Using the information in the case notes write a letter to Ms. Angela Coyne the charge nurse in Surgical Ward A, Newtown Public Hospital, 900 Carrington Street to report medical history, current situation, treatment plan, etc.
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