Reading Time: 5 minutes

Writing Time: 40 minutes

Today's Date 10/02/2018

Patient Details

• Mrs. Bronwyn Green

• DOB: 15/03/1949
• Widow, no children
• Husband died 2008
• Lives alone in low set house; no stairs
• Uses home oxygen NP 1L
• Ex- smoker: 20 cig/day (20 years).
• Recently stopped smoking.

Medical History

• COPD since 2004: Uses tiotropium inhaler 1 puff mane, fluticasone & salmeterol250/25mcg
inhaler 2 puffs BD
• HTN since 1993: Takes amlodipine 5mg mane, BP stable
• Anxiety and depression since 2013: Takes oxazepam 15mg nocte, citalopram 10mg mane.
Recently, patient dx w/ low-grade adenocarcinoma and admitted to surgical ward, North West
Hospital 18/01/2015.
• Patient had R/ hemicolectomy 20/01/2018.
• Post-op complication (metabolic and respiratory acidosis) after 5 hours anesthetic. Patient
transferred to ICU, then transferred to thoracic ward 24/01/2018.

Post-operative Condition
• Patient used oxygen 2L NP daily.
• Very anxious and c/o SOB during mobility. Required reassurance.
 • Able to walk 10m with 4w/walker Assist x 1
• Took regular analgesic: paracetamol 1g QID and PRN Endone 2.5mg (max dose 20mg) PRN for
surgical pain.
• Took regular laxative: Coloxyl and Senna 2 tabs BD. Bowels open regularly.Urgent incontinence of
urine: Wore pull-up pads.
• Lost 5kg after operation. Poor appetite.
• Regular dietitian review; HP diet and monitor oral intake.
• Observation stable. Sats 98% with NP2L. Aim Sats 88-91%. The goal was weaning oxygen to NP1L.
Abdominal wound: pain well-controlled with paracetamol, minimal exudate.

Social History
• Lives alone. Patient's sister lives close and comes to help sometimes.
• Patient uses community services (Meals on Wheels, cleaning and shopping).

Recent Nursing Notes

30/01/18
• Patient became very anxious during shower. Required prompting and moderate assistance.
• Sat 98% with NP2L. Suggested patient ê oxygen 1L, but patient refused to change.Patient required
encouragement with mobility.
• Abdominal wound redressed.Minimal exudate.
• Complained minimal pain.
• Poor appetite. Notified Dietician.

04/02/2018
• Patient only required minimal assistance with shower and ADLs.Sat 91% NP1L.
• Mobilized with 4w/walker, required supervision.
• SOB with long distance, and temporarily required NP2L after mobility.
 • Mood and appetite improved.
• ACAT (aged care assessment team) completed for TCP (transition care program) this morning.Plan
for OT HV (home visit) today.

05/02/18
• Patient requires modifying bathroom and toilet as a result of HV; applying rails.OT will organize
prior to discharge.
• Patient is keen to go home with community service.
• Existing home oxygen need to be checked prior to discharge.

10/02/2018
• Patient is able to walk with (single point stick) SPS. Supervision required.
• Mood is stable, appetite ↑
• Occasional incontinence of urine, still wears pull-up pads.OT reports home modifications
completed.
• Plan for discharge 11/02/2018.
• Patient's sister will escort to home by taxi. Patient is happy to take own medication at home.
Requires 3/7 dressing change for abdominal wound.
• Monitor anxiety & O2 usage

Writing Task

You are a Registered Nurse at the thoracic ward of Spirit Hospital. Using the information, write areferral
letter to Nursing Director, North West Transition Care Program Community Service; 12 West Street,
Northbridge, QLD, 4543

• Do not use note form in the letter

• Expand on the relevant case notes into complete sentences
• The body of the letter should be approximately 180~ 200 words long
• Use correct letter format