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Susan Mathews Case Notes

Susan Matthews, a 76-year-old widow, fell off a ladder and was brought to the emergency department by a neighbor. She received 10 sutures for a laceration on her right thigh and was admitted for observation. Over the next few days, her wound became infected and she lacked appetite. She was treated with antibiotics and physiotherapy and discharged after her condition improved. The community nurse made referrals for meals, home care, and social support as the patient struggled at home.

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Harshit Aggarwal
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3K views2 pages

Susan Mathews Case Notes

Susan Matthews, a 76-year-old widow, fell off a ladder and was brought to the emergency department by a neighbor. She received 10 sutures for a laceration on her right thigh and was admitted for observation. Over the next few days, her wound became infected and she lacked appetite. She was treated with antibiotics and physiotherapy and discharged after her condition improved. The community nurse made referrals for meals, home care, and social support as the patient struggled at home.

Uploaded by

Harshit Aggarwal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Observations and Actions (10/11/16)
  • Observations and Actions (12/11/16)
  • Patient Overview
  • Observations and Actions (11/11/16)
  • Writing Task Instructions
  • Discharge Plan (15/11/16)
  • Observations and Actions (14/11/16)
  • Observations and Actions (13/11/16)
  • Community Nurse Assessment

Nursing Writing task

Reading time: 5 minutes

Writing time: 40 minutes

Patient name: Susan Matthews

Age: 76

Social Background:

- Husband died 5 years ago (cancer of bowel)


- Lives alone in own home
- Involved in bowling club, church, community groups

Medical History:

- Cerebrovascular accident (CVA) 4 years ago


- Lonely and isolated since husband passed away
- Weight: 48kg, height 165cm
- Hip replacement 2014
- Hypertension diagnosed 14years ago
- Non-smoker

10/11/16

- Presented to Emergency Dept


- Accident – fell off ladder while cleaning the fan
- Neighbour brought her to hospital

Observation - Laceration to R thigh, bruising, grazed legs, disorientated

Treatment - 10 sutures to R thigh, graze-antiseptic and clean, tetanus injection

- X-rays – nothing broken.


- Admitted to hospital for observation

11/11/16

Progress - Pt sore and disorientated, not sure how accident happened

- Not interested in food.

Treatment - Wound dressing, monitor patient mental health

12/11/16

Progress - Wound site red, swollen, pain 8/10, graze oozing fluid, temp 38o, lack of appetite, unwilling to
shower and dress independently.

Treatment - Oral penicillin, paracetamol 1-2 500mg 4hrly.

- Arrange visit with dietitian and physio


- Wound cleaned and dressed with non-stick dressing
13/11/16

Progress - Dietitian review – new high protein diet aim to weight

- Physio – mobilising patient with transfers (shower, toilet, bed)


- Temp 37o

Treatment - Wound cleaned and dressed

- Paracetamol 4hrly

14/11/16

Progress - Pt’s condition improving. Following diet, enjoying food

- Swelling reduced, nil exudate, nil fever, pain controlled


- Mobilising independently, but slow

Discharge date - 15/11/16

- Medications – paracetamol as needed, oral penicillin – 7days (must complete)


- Refer to community nurse

Community Nurse Assessment

16/11/16

- Pt moody, lonely, not coping with new diet regime, mobilising well at home with frame
- Regular paracetamol
- Wound cleaned and dressed with antiseptic solution
- Refer pt to Meals on Wheels and Domiciliary Care
- Refer pt to social worker – local support groups

18/11/16

- Pain controlled
- Nil exudate, nil redness
- Pt started Meals on Wheels
- Pt mood improved
- Leave wound exposed

20/11/16

- Pt coping reasonably well, more positive,


- Mobilising independently
- Wound good, no signs of infection
- Eating well - needs to be monitored
- Sutures to be removed in a week

Writing Task

You are the community nurse and you are writing to Susan Matthews’ GP (Dr. Maria Jones, 128 Blacks Rd, Lonsdale,
SA 5123) requesting follow-up care. You are concerned about the patient’s mental health, weight and wound.

In your answer:

- Expand the relevant case notes into complete sentences


- Do not use note forms
- The body of the letter should not be more than 200 words
- Use correct letter form

Nursing Writing task Reading time: 5 minutes Writing time: 40 minutes Patient name: Susan Matthews Age: 76 Social Ba
13/11/16 Progress - Dietitian review – new high protein diet aim to weight - Physio – mobilising patient with tr

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