Writing Nurses12.pdf

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  Time allowed: 40 minutes Read the case notes below and complete the writing task which follows: Today’s Date: 21/03/12 Patient Details   ã   Name: Ms. Nina Sharman ã   DOB: 09/02/1951 ã   New resident of Dementia Specific Unit, Westside Aged Care Facility ã   Single ã   Under the Australian Guardianship and Administration Council protection Medical History   ã   Ischemic heart disease (IHD) since 2005, takes Nitroglycerine patch, daily ã   Stroke May 2011, after stroke - unsteady gait ã   In 2011 - diagnosed with severe dementia - able to understand simple instructions only, confused and disorientated ã   Diabetes mellitus (type 2) since 2000 – on a diabetic diet ã   Osteoarthritis of both knees 20 yrs. Voltaren Gel to both knees BD ã   Weight gain 10 kg over the last 5 months, current weight 106kg (BMI of 30) ã   Chronic constipation, takes Laxatives PRN ã   No allergies to medication or food ã   No teeth – has entire upper or lower dentures, sometimes refuses to wear dentures due to confusion and disorientation ã   Increased appetite– usually eats full portion of offered meals x 3 times daily and, also, goes into other residents’ rooms and eats their food as bananas, biscuits or lollies Social History   ã   No friends ã   Lack of interests, but likes colouring and watching TV ã   ↑ emotional dependence on nursing staff ã   Non-smoker, no use of alcohol or illegal drugs Recent Nursing Notes  15/02/12 ã   Chest infection. Keflex 500mg QID x 7 days 26/02/12 ã   Occasional cough & episodes of SOB with ↑ RR 27/02/12 ã   Sporadic throat clearing after eating yoghurt  20/03/12 1700 hrs ã   Episode of choking on a piece of food (? food not chewed properly). She suddenly turned blue, grabbed the throat with both hands and coughed. The piece of solid food was removed. 1710 hrs ã   Nursing assessment after treatment o   Pulse 110 BPM o   BP 120/70 mmHg o   RR – 22/min o   T– 37.1° C o   BSL – 6.0 mmol/L 1800 hrs ã   No complaints o   Pulse – 88 BPM o   BP – 115/70 mmHg o   RR – 16/min o   T- 37.0 °C o   Skin: normal colour. o   Hospital visit not required WRITING TASK  You are a Registered Nurse at the Dementia Specific Unit. Using the information in the case 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 nutritional status urgently due to a high risk of aspiration. ã   Do not use note form in the letter ã   Expand on the relevant case notes into complete sentences ã   The body of the letter should be approximately 200 words long ã   Use correct letter format  21/03/2012 Dietician Department of Nutrition and Dietetics Spirit Hospital Prayertown NSW 2176 Dear Dietician, RE: Ms. Nina Sharman DOB: 09/02/1951 Thank you for seeing this patient, a 61-year-old single female resident of our Dementia Specific Unit, who had an episode of choking with a piece of food on 20/03/12 and now requires an urgent swallowing and nutritional assessment due to a high risk of aspiration and chest infection. Ms. Sharman’s condition has been deteriorating since May, 2011, when she suffered a stroke. Over the last year she has developed advanced dementia and is now confused and disorientated. Apart from this, she is edentulous for both upper and lower teeth and sometimes refuses to wear dentures due to her confusion. Moreover, it has been noted that she has had an insatiable appetite and has progressively gained weight of 10 kg over the last 5 months. Her current weight is 106kg (BMI of 30)and she complains of chronic constipation. She has no allergies to medication or food. Her vital signs and blood sugar level were all within normal limits. In regards to her medical history, Ms Sharman has been living with type 2 diabetes since 2000, which has been managed by a diabetic diet only. She was also diagnosed with ischaemic heart disease in 2005 and has had osteoarthritis for the past 20 years. Socially, Ms. Sharman is under the Australian Guardianship and Administration Council’ protection. If you require any more information, please do not hesitate to contact me. Yours sincerely, Registered Nurse Dementia Specific Unit Westside Aged Care Facility
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