. !

lowed: 40 minutes
T,rne a
he case notes below and complete the writing task which follows :
Read t
Today's Date: 21/03/12

Patient Details

• Name: Ms. Nina Sharman

• DOB : 09/02/1951
• New resident of Dementia Specific Unit, Westside Aged Care Facility
• Single
• Under the Australian Guardianship and Administration Council protection

Medical History

• lschemic heart disease (lHD) since 2005, takes Nitroglycerine patch, daily
• Stroke May 2011 , after stroke - unste,,dy gait
.. In 20 11 - diagnosed with severe dementia - able to understand simple instructions
onl y, confused and disorientated
--- Diabetes mellitus (type 2) since 2000 - on a diabetic diet
• Osteoarthritis of both knees 20 yrs. Voltaren Gel to both knees BD
.,..,.... Weight gain 10 kg over the last 5 months, current weight 106kg (BMI of 3 0)
v-"• Chronic constipation, takes Laxatives PRN
•• No allergies to medication or food
• No teeth - has entire upper or lower dentures, sometimes refuses to wear dentures due
\./'
to confusion and disorientation
• Increased appetite- usually eats full portion of offered meals x 3 times dai/y and, also.
goes into other residents' rooms and eats their food as bananas, biscuits or lollies

Soda! History

• No friends .
• Lack of interests but likes colouring and watchmg TV
• jemotional depe~dence on nursin~ staff
• Non-smoker, no use of alcohol or illegal drugs

Recent Nursing Notes

l 5/02/12
. . SOOm QID :~ 7 days
• Chest infection. Keflex g

26/02/12
. d of SOB with l RR
h & ep1so es
• Occasional coug

27/02/12
. yoghurt
. after eaung
. throat cleanng
• S parad1c
 10103112
/700 hrs

, Episode of choking on a piece of food ')

turned blue, grabbed the throat with bo~i food not chewed properly)_. She suddenly
1 nd
was removed. ha s and coughed. The piece of solid food

17!0 hrs

• Nursing assessment after treatment

o Pulse 110 BPM
o BP 120/70 mmHg
0 RR- 22/min
o T-37.1°C
0 BSL - 6.0 mmol/L
1800 hrs

• No complaints
o Pulse - 88 BPM
o BP- 115170 mmHg
o RR - 16/min
o T- 37.0 °C
o Skin : normal colour.
o Hospital visit not required

WRITING TASK

You urc a Registered Nurse at the Dementia Specific Unit. Using the information in the c:,se
notes, write a letter to Dietician, at Department of Nutrition and Dietetics, Spirit Hospital.
Prayertown, NSW 2175 . In your letter explain relevant social and medical histories and
request the dietician to visit and assess Ms. Sharman 's swallowing function and nutri tionnl
status urgently due to a high risk of aspiratio~_. ·

• Do not use note form in the letter

• Expand 011 the relevant case notes into ~omplete sentences
• The body of the Jetter should be approximately 200 words long
• Use correct letter format