Read the case notes and complete the writing task which follows
Notes
Name: Phillip Satchell
Age: 73
Marital status: Wife deceased (2007)
Family: Two sons in their 40’s in Darwin.
First attended community centre: March 2007
Last visit to community centre: Feb 2011
Diagnosis: Multiple sclerosis, Type 2 diabetes, chronic L & R leg ulcers
Social/Medical Background: Current: lives alone in public housing in Orange
Future: will move to equivalent housing in Maroubra to Î
access for MS treatment.
Income: aged pension
Poor compliance with oral diabetic agents and diabetic diet
MS currently stable but frequent relapses
2-3/12 Staphylococcus Aureus infections
in leg ulcers; pus ++
Lonely and isolated, but nil mental illness; good relations
with sons but rarely see them. They run a pet shop business.
Nursing management and progress: Medications: IV antibiotics twice daily and metformin for
diabetes three times per day.
Twice daily dressings to L & R legs
Monitored blood sugar levels, medication compliance
and provided education re diabetes.
Constantly monitored for signs of MS relapse
Discharge plan
Switch to oral antibiotics but continue same diabetic medications and dressings.
Please refer to Prince of Wales Diabetic Clinic (medication review + Î education).
Via your doctors, facilitate referral to neurologist for MS follow up.
Support to link with community services to Î coping and social network.
Writing task
Using the information in the case notes, write a referral letter to the Community Nurse, Community
Health Centre, Maroubra, outlining relevant information and requesting continued community care.
In your answer:
Expand the relevant notes into complete sentences
Do not use note form
Use letter format
The body of the letter should be approximately 180-200 words.
Sample answer by Lifestyle Training Centre
Community Nurse,
Community Health Centre,
Maroubra
February 2011
Dear Nurse,
Re: Mr Phillip Satchell, aged 73 years.
I am writing to refer Mr Satchell, who requires on going care, particularly for multiple sclerosis, following his relocation to Maroubra. He has been undergoing treatment for MS, Type 2 diabetes, and chronic L & R leg ulcers with us since March 2007.
Though Mr Satchell’s MS is presently stable, it often worsens. He is regularly monitored for signs of MS relapse and now requires finer medical access in Maroubra to treat his condition. With the help of your doctors, kindly refer him to a neurologist for his MS follow up.
Mr Satchell has been suffering from leg ulcers along with Staphylococcus Aureus infections, which happens up two three times a year. Both his legs need to be dressed twice daily. As his medical compliance is poor, he was educated on diabetes and its diet.
Mr Satchell is a widower and his two sons, who live in Darwin, rarely visit him. As he is lonely and isolated, kindly connect him with community services, and help him to increase his social network. He has no mental illness.
Based on the above, please provide Mr Satchell care and assistance on his arrival to Maroubra. His IV antibiotics, twice daily, needs to be switched to oral. He also needs to continue taking metformin for diabetes, three times per day. Kindly refer him to Prince of Wales Diabetic Clinic for medication review and further education. If you have further queries, please do not hesitate to contact me.
Yours faithfully,
Community Nurse.
(words used: 230)
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