Task 9 Case Notes

Time allowed: 40 minutes

Today’s date: 21/05/09

You are Grace Jones, a qualified nursing sister working in Ward C25, Princess
Alexandra Hospital. Contact Ph. 07 3897 7642. Annette MacNamara is a patient
in your care. Read the case notes below and complete the writing task which
follows.

Name: Annette MacNamara Address: Unit 15, 86 Smart St, West End Phone:
(07) 3379 5926 Date of Birth: 14 June 1936

Social Background Single Age Pensioner - Recently moved to a small flat in

new suburb. House she rented for 10 years was sold. Feels increasingly lonely
and isolated - rarely sees neighbours – transport problems make it impossible to
continue to attend bowls and bridge clubs. Next to kin, Niece – Stella Attois Ph
075 5984 7216 lives and works in Southport - generally visits once a fortnight.

Medical History Date of admission: 20-05-2009 Date of Discharge 22-05-2009

– provided no complications and home assistance arranged. Admitted to
hospital following fall. Slipped and fell while descending stairs to put out
garbage. X-ray revealed fractured right wrist – Laceration to left hand caused by
broken glass. Stitches required- Severe bruising of right shoulder and lower
back.

Medications Karvea 150mg daily am – history of high blood pressure now

controlled Normison 10mg-1 nightly for insomnia when required. Pain relief – 2
Panadol 4 hourly while pain persists.

Discharge plan Organise daily visits from Blue Nursing Service to assist with
showering and to dress hand wound. Social Worker to organise Meals on
Wheels and physiotherapy. (niece will visit at weekend to help with housework
and shopping) Stitches to be removed and situation to be reviewed at Out
Patient Department appointment - 10.30 am 31-05-09

WRITING TASK Using the information in the case notes, write a letter to the
Director, Blue Nursing Service, 207 Sydney Street, West End. Do not use note
form in the letter. Expand on the relevant case notes to explain patient’s
background and medical history and the assistance requested. The letter should
be 15-20 lines long. No more than the first 25 lines will be assessed.

Task 9 Model Letter

21/05/09

The Director Blue Nursing Service 207 Sydney Street New Farm, 4106

Re: Ms Annette McNamara DOB 14.06.1936

I am writing to request daily visits by the Blue Nurses to provide support for
this patient, an aged pensioner who lives on her own.

Ms McNamara was admitted to the Princess Alexandra Hospital on 20th May

following a fall down a flight of stairs at her flat. She sustained a fractured right
wrist, lacerations to her left hand which required stitches and severe bruising to
her right shoulder and lower back. Providing there are no complications,
hospital discharge is scheduled for 22 May. She has a 10.30am appointment on
31/05/09 at our Out Patient Department to remove the stitches and review her
situation.

Meals on Wheels and a home physiotherapist visit are being organised by a

social worker. Ms McNamara will also require assistance with showering and to
have her left hand wound dressed.

Ms McNamara’s current medications are Karvea 150mg daily to control high

blood pressure, Normison 10mg as required for insomnia and 2 Panadol 4
hourly while pain persists. She moved to a new flat recently and has lost her
usual social contacts. Her next of kin is a niece, Stella who can be contacted on
075 5984 7216.

Please contact me if you require any further information.

Yours sincerely,

Grace Jones Ward C 25 Princess Alexandra Hospital

Word Length: 201 Words