TASK –72: Mr Lionel Ramamurthy, a 63-year-old, is a patient in the medical ward of which you are Charge Nurse.                        

Hospital: Newtown Public Hospital, 41 Main Street, Newtown

Patient details:         

Name: Lionel Ramamurthy (Mr)

Marital status: Widowed – spouse dec. 6 mths 

Residence: Community Retirement Home, Newtown 

Next of kin: Jake, engineer (37, married, 3 children <10)

Sean, teacher (30, married, working overseas, 1 infant)

Admission date: 04 February 2014              

Discharge date: 11 February 2014

Diagnosis: Pneumonia                                  

Past medical history: Osteoarthritis (mainly fingers) – Voltaren

Eyesight ↓ due to cataracts removed 16 mths ago – needs check-up

Social background: Retired school teacher (history, maths). Financially independent. Lonely since wife died. Weight loss – associated with poor diet.

Medical background: Admitted with pneumonia – acute shortness of breath (SOB), inspiratory and expiratory wheezing, persistent cough →chest & abdominal pain), fever, rigors, sleeplessness, generalised ache.

On admission – mobilising with pick-up frame, assist with ADLs

(e.g., showering, dressing, etc.), very weak, ambulating only short distances with increasing shortness of breath on exertion (SOBOE).

Medical progress: Afebrile. Inflammatory markers back to normal. Slow but independent walk & shower/toilet. Dry cough, some chest & abdom. pain. Weight gain post r/v by dietitian.

Nursing management: Encourage oral fluids, proper nutrition.

Ambulant as per physio r/v. Encourage chest physio (deep breathing & coughing exercises). Sitting preferred to lying down to ensure postural drainage.                                                

Assessment: Good progress overall

Discharge plan: Paracetamol if necessary for chest/abdom. pain. Keep warm.

Good nutrition – ↑fluids, eggs, fruit, veg (needs help monitoring diet).

Writing Task: Using the information given in the case notes, write a discharge letter to Ms Georgine Ponsford, Resident Community Nurse at the Community Retirement Home, 103 Light Street, Newtown. This letter will accompany Mr Ramamurthy back to the retirement home upon his discharge tomorrow.

View sample answer by Lifestyle Training Centre

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