Case Notes: Nina Sharman. Today’s Date: 21/03/12

Patient Details:

• Name: Ms. Nina Sharman

• DOB: 09/02/1951

• New resident of Dementia Specific Unit, Westside Aged Care Facility

• Single; Under the Australian Guardianship and Administration Council protection

• Medical History

• Ischemic heart disease (IHD) since 2005, takes Nitroglycerine patch, daily

• Stroke May 2011, after stroke – unsteady gait

• In 2011 – diagnosed with severe dementia – able to understand simple instructions only,

confused and disorientated

• Diabetes mellitus (type 2) since 2000 – on a diabetic diet

• Osteoarthritis of both knees 20 yrs. Voltaren Gel to both knees BD

• Weight gain 10 kg over the last 5 months, current weight 106kg (BMI of 30)

• Chronic constipation, takes Laxatives PRN

• No allergies to medication or food

• No teeth – has entire upper or lower dentures, sometimes refuses to wear dentures due to

confusion and disorientation

• Increased appetite– usually eats full portion of offered meals x 3 times daily and, also, goes

into other residents’ rooms and eats their food as bananas, biscuits or lollies

Social History

• No friends

• Lack of interests, but likes colouring and watching TV

• ↑emotional dependence on nursing staff

• Non-smoker, no use of alcohol or illegal drugs

Recent Nursing Notes: 15/02/12

• Chest infection. Keflex 500mg QID x 7 days 26/02/12

• Occasional cough & episodes of SOB with ↑RR

27/02/12: Sporadic throat clearing after eating yoghurt

20/03/12, 1700 hrs: Episode of choking on a piece of food (? food not chewed properly). She suddenly turned

blue, grabbed the throat with both hands and coughed. The piece of solid food was removed.

1710 hrs: Nursing assessment after treatment

 Pulse 110 BPM

 BP 120/70 mmHg

 RR – 22/min

1800 hrs: :No complaints

 Pulse – 88 BPM

 BP – 115/70 mmHg

 RR – 16/min

 T- 37.0 °C

 Skin: normal colour.

 Hospital visit not required

WRITING TASK: You are a Registered Nurse at the Dementia Specific Unit. Using the information in the case notes, write a letter to Dietician, at Department of Nutrition and Dietetics, Spirit Hospital, Prayertown, NSW 2175. In your letter explain relevant social and medical histories and request the dietician to visit and assess Ms. Sharman’s swallowing function and nutritional status urgently due to a high risk of aspiration.

Sample letter by Lifestyle Training Centre

Dietician
Department of Nutrition and Dietetics
Spirit Hospital
Prayertown, NSW 2175.

21/03/12        

Dear Dietician,
Re: Ms Nina Sharman

Ms Sharman urgently needs a visit to assess her swallowing function and nutritional status. She has high risk of aspiration.

Yesterday, Ms Sharman choked on a piece of solid food, probably due to improper chewing, and turned blue. The food was successfully removed, and she recovered afterwards.

Ms. Sharman, weighing 106 kg with a BMI of 30, has gained 10 kg in the last 5 months. She suffers from chronic constipation and uses laxatives. She has no allergies to food or medication and consumes three meals daily with additional snacks. Despite having no teeth, she chooses not to wear dentures, and sporadic throat clearing was noted from her after consuming yogurt.

Ms Sharman does not smoke, drink, or use illegal drugs. She recently had a chest infection and has been experiencing occasional coughing and shortness of breath. She has had Ischemic heart disease since 2005 and her gait is unsteady after an episode of stroke in May 2011; she suffers from Osteoarthritis on both knees. She is on diabetic diet since 2000 since the onset of type 2 Diabetes mellitus.

Based on the above, kindly visit Ms Sharman at her new residence in Dementia Specific Unit, Westside Aged Care Facility and assess her condition. Please note that she can only comprehend simple instructions as she is confused and disorientated. If you have any further queries, please do not hesitate to contact me.

Yours faithfully,

Registered Nurse.

                                                                                                                        (words 232)

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