Task 4 Case Notes: Sandra Peterson Read the case notes below and complete the writing task which follows. Time Allowed Reading Time: 5 minutes Writing Time: 40 minutes Today’s Date 22/03/14
Hospital Spirit Hospital - Medical Assessment Unit (MAU) Admission Date: 20/03/2014 Discharge Date: 22/03/2014 Patient Details
Name: Sandra Peterson DOB: 01/01/1923 Address: 258 Addison St, Applethorpe Marital status: widowed – 25 yrs Next of kin: daughter – Ann Macarthur ph 0438856277
Diagnosis
URTI (Upper Respiratory Tract Infection) – dehydration, bi- basal crackles heard on chest, SOB Polypharmacy - on 24 medications at admission including a variety of OTC medication encouraged by her daughter
History of Presenting Illness
13/03/2014 –coughing (yellow sputum) 18/03/2014 - ↓ed mobility, found in a sitting position on the floor in her room, no injuries 19/03/2014 - ↑ed confusion had another fall in the toilet, no injuries 20/03/2014 - BP 190/90, SOB, dizziness, the 3rd fall, an ambulance was called
Past Medical History
Moderate dementia HTN Incontinent of urine – occasionally
Social History
Lives in 2-bedroom flat with her daughter and son-in-law Daughter is overly supportive, overreacting and anxious about her mother’s health Religion: Orthodox Christianity, attends church weekly with daughter Hobbies: listening to classical music, watching movies Requires some assistance with bathing, dressing and toileting Home Care worker visits 2 x wkly (bathing)
Medical Progress
X- Ray – normal FBC – WCC 9.0, Hb 115g/L CT-brain – no acute changes Commenced on Augmentin 500 mg x BD, per os Now intermittent dry cough IV normal saline for 24 hrs Medications rationalised by doctor as detailed in discharge plan BP 150/70 - after adjustment of anti-hypertensives
Nursing management
Vital signs: afebrile, haemodynamically stable, saturating 96% room air Mobility: short distance – independently ambulant with a seat walker, long distance – wheelchair x 1 assistant Hygiene: full assistance require with bathing, some assistance with dressing and grooming Psycho/Social: Mild confusion, but co-operative
Discharge Plan
Community nurse referral Continue 500-mg tablet of Augmentin BD 5/7, should be taken at the start of a meal Metoprolol 25 mg BD Candesartan 16 mg mane Medications – monitoring and assistance Daughter requires education/monitoring due to Hx of polypharmacy Ongoing care with personal hygiene required
Writing Task You are the charge nurse on the MAU where Mrs Sandra Peterson has resided during her hospital stay. Using the information in the case notes, write a letter to the Community Nurse at Spirit Community Health Centre, Cnr Bell & Burn Streets Applethorpe, NSW, 2171. In your letter explain relevant background and medical history and provide information about discharge requirements. In your answer:
Expand the relevant case notes into complete sentences Do not use note form The body of the letter should be approximately 180~200 words Use correct letter format
Task 2 Case Notes: Robyn Harwood Read the case notes below and complete the writing task which follows. Time Allowed: Reading Time: 5 minutes Writing Time: 40 minutes Today’s Date 12/07/12
You are Sonya Matthews, a registered nurse at the Spirit Hospital. Robyn Harwood is a patient in your care. Read the case notes below and complete the writing task which follows. Patient Details Name: Robyn Harwood Address: 8 Peach St, New Farm Phone: (07) 3397 2695 Date of Birth: 4 February 1951 Social Background Marital status: Widow. No children. Lives alone Next of kin: Megan Mack (Niece) Niece lives with husband in Sydney who works as software engineer for Google Australia. Sister died recently. No other relatives. Medical History Diabetes Mellitus Type 2 Metformin 500mg mane Diagnosis Right partial rotator cuff tear Presented to Spirit hospital with pain and weakness in the right shoulder, especially when lifting arm overhead. Descending stairs at home and slipped, falling onto outstretched arm. Xray and MRI showed a partial rotator cuff tear. Orthopaedic surgeon discussed surgery. Patient prefers to try non-surgical treatment. Date of admission: 30-06-2012
Date of discharge: 12-07-2012 Treatment Ibuprofen orally QID Cortisone injections Daily physiotherapy Nursing Care Needs Needs blood glucose level monitoring 4 hourly May be elevated because of cortisone Needs assistance with shower and housework Orthopaedic review on 01/08/12
Writing Task
Using the information in the case notes, write a letter to the Nursing Director Ms. Jenny Attard of the Blue Care Agency, requesting visits from the home care nurse. In your answer:
Expand the relevant case notes into complete sentences Do not use note form The body of the letter should be approximately 180~200 words Use correct letter format
Task 3 Case Notes: Kate Murray Read the case notes below and complete the writing task which follows. Time Allowed Reading Time: 5 minutes Writing Time: 40 minutes Today’s Date 27/08/12
You are an orthopaedic nurse at the Brisbane Childrens' Hospital Fracture Clinic. Your patient is Kate Murray who broke her leg while doing gymnastics after school. She was taken to the clinic by a school staff member as her parents could not be contacted at the time of the accident. Patient History Name: Kate Murray DOB: 10/7/2005 Parents: Scott and Susan Murray Address: 4 Pemberton St, Tarra Hill General Health Good – not on any medication – no known allergies Recent Medical History 27/08/12 Childrens’ Emergency Patient presented distressed with pain and swelling in right lower leg. Unable to stand. X-ray: spiral fracture to right tibia, no displacement. Backslab and bandage applied. Panadol 250mg 4/24 prn for pain Crutches fitted and supplied on loan Plan Appointment scheduled for fiberglass cast 1.30 pm, 03/09/10 at Brisbane Childrens' Hospital Fracture Clinic. Care of the affected leg • During the first 48 hour, keep limb elevated above the level of heart to reduce swelling • Encourage toe movement
• Elevate your child's leg on pillows when resting • Assist your child in gaining confidence with the use of crutches Check for the following: • Excessive swelling of the toes • Pins and needles, tingling or burning. • Numbness or loss of feeling. • Inability to move toes. • An upset child that cannot be settled If any of the above occur, elevate the limb for 20 minutes and encourage toe movement. If the symptoms are not relieved call Brisbane’s Children’s Hospital on 07-33567853 immediately. Skin Care Ensure your child does not scratch under the cast with sharp objects e.g. knitting needles, chopsticks or pens. Children may push objects under the plaster and this can cause a pressure ulcer on the skin. Cast Care • Do not wet, cut, heat the cast at home. • Do not allow your child to walk on a leg cast or take part in any active play or sport. Rehabilitation • Usual recovery time 6~10 weeks • There may be some stiffness and weakness in the limb. • After cast removal, bone still healing so care required for at least another month. • Sometimes physiotherapy is needed to help improve muscle strength, joint mobility and balance • Can do non-impact sports i.e swimming • Must not do gymnastics for 4 weeks or other impact activities such as skateboarding, horse riding or running • Full recovery expected with no long term effects Writing Task Write to the child's parents with a summary of Kate Murray's injury and any relevant information they need for her immediate care and future rehabilitation. In your answer:
Expand the relevant case notes into complete sentences Do not use note form The body of your letter should be approximately 180~200 words Use correct letter format
Case Notes: Betty Olsen Read the case notes below and complete the writing task which follows. Time Allowed Reading Time: 5 minutes Writing Time: 40 minutes Today's Date 10/07/14 Notes Betty Olsen is a resident at the Golden Pond Retirement Village. She needs urgent admission to hospital. You are the night nurse looking after her. Patient Details Address: Golden Pond Retirement Village 83 Waterford Rd, Annerley, 4101 Phone: (07) 3441 3257 Date of Birth: 29/01/1931 Marital Status: Widowed Country of birth: Australia Social History Moved to a retirement village following the death of husband in December 2012. Next of kin: Son, Nicholas Olsen 53 Palmer Street, Warwick 4370 Ph (07) 4693 6552 Retired triple certificate nurse - was the matron of a small country hospital for 15 years. Very aware of and interest in health issues. Likes to discuss and be kept fully informed of any changes to her medication or treatment. Normally alert and orientated. Enjoys bridge, bingo and reading.
Medical History Hypothyroidism since 2002 Hypertension since 2009 Glaucoma since 2010 Allergic to penicillin Prescription Medications Karvea 150mg 1 daily Oroxine 0.1mg 1 daily am Timoptol Eye Drops 0.5% 1drop each eye am & pm Normison 10 mg as required Non prescription Medication Golden Glow Glucosamine Tablet - 1 with breakfast for arthritis Vitamin C Complex Sustained Release – 1 with breakfast Mobility / Aids Independent with walking stick. Arthritis in hands. Wears glasses Continence: Requires continence pad Recent Nursing Notes 16/05/14 Flu vaccination 29/06/14 Complaining of indigestion following evening meal. Settled with Mylanta 07/07/14 Unable to sleep – aches in shoulder. Settled following 2 Panadol and 1 Normison 09/07/14 Requested Mylanta for indigestion,Panadol for shoulder pain – slept poorly 10/07/14 am Tired and feeling generally weak. BP 180/95. Confined to bed. GP called and will visit 11/7/14 after surgery. 10/07/14 pm Didn’t eat evening meal. Says felt slightly nauseous. Trouble sleeping, complaining of shoulder and neck pain. BP 175/95 Given 1 Normison 2 Panadol at 10pm
Rechecked 10.45pm – Distressed, pale and sweaty, complaining of persistent chest pain, BP 190/100. Ambulance called and patient transferred Writing Task Write a letter for the admitting doctor of the Spirit Hospital Emergency Department. Give the recent history of events and also the patient’s past medical history and condition. In your answer:
Expand the relevant case notes into complete sentences Do not use note form The body of the letter should be approximately 180~200 words Use correct letter format
Assignment - Task 3 Case Notes: Ling Wu Read the case notes below and complete the writing task which follows. Time Allowed Reading Time: 5 minutes Writing Time: 40 minutes Today’s Date 22/02/14
Patient details:
Name: Ling Wu, female DOB: 01/03/1996 Status: Single
Social History
Ling is a student of the Bachelor of Accounting course in the University of Western Sydney Enjoys cycling She lives in a 3-bedroom one-story house with her parents and younger sister No tobacco, alcohol or drug use
Past Medical History: None Allergies: no known allergies Date of admission: 26/01/14 –Trauma Ward at St. Angus Public Hospital Date of discharge: 23/02/14 Diagnoses
Left tibial-fibular fracture secondary to cycle accident Left above-knee amputation Phantom limb pain
Description of accident : The patient was parked off the road, when a car skidded across and collided with her cycle. At Emergency Department
The initial assessment: an open tibial-fibular fracture of the left extremity with near amputation Her Glasgow Coma Scale was 15 & head CT was negative Obs: BP- 178/90 mmHg, P-110bpm, RR- 22/min, SpO2 – 90 in room air The patient was taken to the operation theatre and above-knee amputation was performed on the same day
Hospital progression 27/01/14
Post – operative pain controlled with intravenous opioids (morphine) via PCA infusion pump The limb has been elevated for one or two hours, two or three times each day to reduce local oedema & pain She had been totally assisted with mobility Bladder care (Indwelling catheter inserted on 26/01/14 and removed on 28/01/14) Deep venous thrombosis (DVT) prophylaxis: The patient had negative Dopplers and prophylaxed with Fragmin 5000 IU once daily, subcutaneously. Bowel management: The patient was started on Citrucel secondary to her pain being treated with narcotics. On a high fibre diet and fluid intake Prevention of infection: Cephalexin IV tds - 5/7, protective dressing and drainage.
01/02/14
She complained of a cramping and twisted posture of the missing limb (phantom limb pain), treated with opioids (Endone 5 mg BD), tricyclic antidepressant (amitriptyline 10 mg tds)and antiepileptic (Neurontin 100 mg tds) Commenced participating in physiotherapy program and involved with preprosthetic training.
15/02/14
Orthopaedics Amputation incision remained intact, Stitches out Wound almost healed Residual limb wrapped with an ace bandage to ↓swelling and pain and reapplied every 3-4 hours Mental state: insomnia, silent rumination, and social withdrawal She has a fear of being seen in public Consulted with a Social Worker
22/02/14
Fragmin was discontinued. No signs of DVT were observed Phantom limb pain: she remained stable on Paracetamol-Osteo 665 mg qid and Tramadol prn Min oedema of the stump w/peeling skin, no signs of infection Bowel management: Citrucel was discontinued. She started Coloxil with Senna one tablet bd and Dulcolax suppository prn Fluids, Electrolytes, Nutrition: The patient was on a regular diet Able to walk with rolling walker for short distances along the ward and use wheelchair for long distances, but needs ↑ assistance for stairs Trained to wrap the stump with ace bandage Parents were educated about assistance with ADL Vital signs with no abnormalities
Discharge plan:
Warm compresses, ice packs and massage are recommended for phantom limb pain To continue regular exercises as per physio program and dressings with ace bandage to shape the amputated limb for fitting with a prosthesis The patient is at increased risk of developing post-traumatic stress disorder (PTSD) or depression in the late period after the trauma. Peer counselling or support groups to support her can be helpful The patient will be seen at the trauma clinic at 3:30 p.m. on 13/04/14
Medication at discharge (self-administration):
Neurontin 100 mg q8 h Paracetamol Osteo 665 mg q8 h, prn trazodone 50 mg p.o. at bedtime prn Laxatives prn Writing Task
You are a Charge Nurse at the trauma ward of St Agnus Hospital, Sydney. Using the information in the case notes, write a letter to a Community Nurse at Spirit Family Medical Practice, 12 Gar Street, Holy Hill, NSW, 2167. In your letter explain relevant social and medical histories and request the Community Nurse to visit Ms Ling Wu after discharge to provide proper health management and assistance for this patient and her family. In your answer:
Expand the relevant case notes into complete sentences Do not use note form
The body of the letter should be approximately 180~200 words Use correct letter format
