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 pre-
prosthetic 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 re-
applied 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
