Sample answer by Lifestyle Training Centre

General Health Care manager
Glenelg Aged Care Home,
Anzac Highway ,Glenelg.

10/1/2022

Dear Sir/Madam,
Re: Mrs Cilia Clement, 24 January 1946

Mrs Clement requires continuity of care and management, following her discharge today. She underwent a laparoscopic cholecystectomy on 06 January 2022.

Mrs Clement’s ultrasonography had confirmed acute cholecystitis. The surgery was a success, and her gallbladder infection was cleared; she is now comfortable. Her wound site was dressed, which needs to be removed after 48 hours. Her post-operative medications include oral paracetamol, 1gm, in case of pain.

Mrs Clement is commenced on a one-month low fat and low caloric diet to reduce her weight. Her modified diet will help her adapt with gall bladder removal and to avoid indigestion as well as flatulence. She is advised to consume smaller and frequent meals, and to avoid caffeine, snacks, spicy food, and sweets in between meals.

Based on the above, kindly provide care for Mrs Clement. Her wound site has to be inspected for signs of infections daily. Please manage her pain with Analgesic. Should you have further queries, please do not hesitate to contact me.

Yours faithfully,
Registered nurse.

(word count: 165)

Writing task:


WRITING 40 MINUTES
Notes:
Assume that today’s date is 10 January 2022
You are a registered nurse in Roseville Aged Care Hospital, responsible for the care of an
elderly patient Mrs Cilia clement
Name: Cilia clement (Mrs)
DOB:24 January 1946(76 yrs)
SOCIAL BACKGROUND
Address: Glenga Aged Care Home , Anzac
Retired, widow
2 Son(45yrs) works overseas
Visit occasionally
Social drinker consumes 2 units per day, ceased smoking
Diet: Unhealthy, prefers sweets between meals, mostly takes spicy snacks,
MEDICAL HISTORY.
DM ,HTN ramipril 5mg
Asthma on inhaler
BM I – 29
30 October 2021
Presenting complaints:
C/o right upper quadrant pain
Nausea, sweating, low mood
USG: acute cholecystitis
Plan: Arranged hospital ward admission for gallbladder infection
Treatment: IV antibiotic therapy for 4 days, analgesic
6 November 2021
Discharged with oral metronidazole 400mg q8h for 7 days and oral paracetamol to control pain when required
Scheduled laparoscopic cholecystectomy once infection get settled
06 January 2022
Re Admission for the surgery
Successfully completed without complications
Infection cleared
Dressing for 48 hrs
Medications oral paracetamol 1gm as an analgesic if required
Discharged with modified diet plan on 10 January 2022
Patient comfortable
Discharge Plan:
Monitor medication compliance (Analgesic)
Manage pain
Wound monitoring (daily inspection, signs of infection
Wound site monitoring daily once
Diet plan for one month
Dressing to be removed after 48 hours
Modified diet plan (adapt gall bladder removal, prevents flatulence and indigestion
Low fat low caloric diet (weight reduction)
Avoid food: Spicy, sweets in between meals, caffeine, snacks
Smaller and frequent meals
WRITING TASK
Using the information given in the case note, write a letter to patient’s General Health Care manager Glenelg Aged Care Home, Anzac Highway ,Glenelg. In your letter briefly outline care required, medical history and health needs.