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2 for nursing
*Hospital acquired pneumonia 2/24 chest physio
Read the case notes and complete the writing task
which follows for 2/52, still requiring O2 2 litres via nasal prongs
but non
Notes
infective for 3/52.
Name: Mrs Jane LaPaglia
Age: 71 *↑confusion post ICU but now back to usual mild
level and
Cultural & religion data: Italian & Catholic, speaks
functional English Is quite settled.
Admission Date: 4th March 2011 – Prince Albert *Needs prompting to eat, drink, dress, walk, toilet
Hospital
& tend to personal hygiene but can independently
th
Discharge Date: 28 April 2011 do these
Diagnosis: Renal failure 2⁰ to dehydration, mild *Family conference 25/3/11. Consensus decision:
dementia, pneumonia pt will
*Given dialysis 3/52 which ↓ urea & creatinine, *Repeat electrolyte, urea & creatinine blood test
stable now weekly
Writing task
You are the Charge Nurse on the medical ward where Ms LaPaglia has spent most of her hospital
stay as a patient.
Using the information in the case notes, write a referral letter to the Charge Nurse at Boronia
Nursing Home, Coogee where Mrs Jane LaPaglia will be discharged to from your ward.
In your answer:
Expand the relevant notes into complete sentences
Do not use note form
Use letter formal ; The body of the letter should be approximately 180-200 words.
2. Nurse Writing Task 1
Read the case notes below and complete the writing task which follows
Notes:
Vamuya Obeki was admitted through the children’s Emergency department for acute meningoencephalitis as a result of
a complication following mumps.
Patient History
Social History
Interpreter needs: Abdullah understands spoken English but has limited written skills. Miri has limited understanding of
English. Abdullah attends English classes.
Medical History
Parents state that both children had some kind of vaccination at birth but the vaccination record has been lost. Parents
are unaware of vaccine for mumps.
Discharge Plan
Using the information in the case notes, write a letter to the Director, Community Child Health Service, 41 Jones Street,
Ekibin, requesting follow up of this family.
In your answer:
You are the Nurse at a Women’s and Children Health Clinic in Adelaide. Julia Roberts is your recent patient with 2 visits:
Patient Details
Name: Julia Roberts Date of Birth: 18/05/1999
Address: 287 Goodwood Road, Goodwood Next of kin: Ann Roberts (Mother)
Phone: 08 4898742
General Health
No known allergies No reported drug use
No current medications Commenced smoking 11 months ago, smokes 15/day
No significant medical or surgical history Alcohol on weekends. Drinks 2 wine glasses at night
Weight: 75kg, Height: 166cm
18 September 2018
Julia presented to clinic requesting a Pap test. Pap test suggested by Mother.
Julia concerned about weight gain of 10kg over last 12 months and wants to know about other methods of
contraception.
Sexual and reproductive health history taken
Partner risk discussed – no IV drug use, no recent overseas travel
No reports of pain, discharge or irregular bleeding
Urine PCR test for chlamydia collected
Pelvic exam undertake – NAD
Pap smear taken
Patient to return in 3-4 days for chlamydia results.
Safer sexual practices discussed, including barrier protection
Cervical screening information sheet provided
Risks of smoking and benefits of quitting discussed with patient.
Referred to Quitline
Referred to Women’s health nutritionist
21 September 2018
Returned for results: PCR test positive for chlamydia tracomatis
Patient informed of results
Arranged notification of partners
Prescribed azithromycin 1gram as a single dose
Advised not to have sexual contact for 7 days after treatment
For referral to GP for further testing and contraceptive advice
Write a referral letter to the Dr Silver Bullet, Medical Practitioner at the Prospect Medical Centre 22 Prospect Road,
Prospect 5086 requesting review of your patient to discuss contraceptive options and further testing for sexually
transmitted infections and blood borne viruses.
In your answer
Expand the relevant case notes into complete sentences
Do not use note form
Use correct OET letter format
The body of your OET letter should be approximately 180 – 200 words
4. Case Notes:
Hospital Royal Perth Hospital
Patient Details Alfred Billy
52 Years old
Marital status: married
Wife (Maria Jennifer) to be contacted if there is any sort of emergency
Address: Arillon City Arcade 207 Murray Street, Perth
Discharge Plan Daily obs; Medicine to be taken for one more week
Writing Task
You are the charge nurse on the hospital ward where Mr. Alfred Billy has recently
had undergone operation. Using the information provided in the case notes,
write a referral letter to the Community Nurse Head at “Care Well Hospital,”
Birmingham, who will be attending to Mr. Alfred Billy, following his discharge.
In your answer:
· Expand the relevant notes into complete sentences
· Do not use note form
· Use letter format - The body of the letter should be approximately 180-200 words.
Case Notes:
Patient: Maria Joseph is a 39 years old woman who has been a patient at a hospital you are working in as a head nurse.
Apart from usual childhood illness such as chicken pox, she had been healthy.
10 / 5 2011
Subjective:
Frontal headache for 6 hrs. Mild assoc, suffering from nausea, no vomiting, patient with blurred vision but not aura. No
other symptoms noticed. She has no family history of migraine.
Objective:
P96, BP 130/ 70. Normal Cervical Spine Movement, examination normal.
14/5 /2011
Subjective Complained of continuous headaches (left sided and frontal), blurred vision, throbbing headache (left sided).
Vomited 5 times during last three hours. Complaining of slight paraesthesia.
15 / 5 / 2011
Home Visit
Subjective Fell down at home due to severe left sided headache, Injured her right arm, bruises on left leg. slurred
speech, half unconscious.
Objective P 100, BP 150/90, extension 4/5 power, left leg knee flexion 4/5
Writing Task
Using the information given above write a letter to the neurologist, who will attend the patient in the emergency
department.
In your answer:
· Expand the relevant notes into complete sentences
· Do not use note form
· Use letter format
Read the case notes below and complete the writing task which follows.
Time Allowed:
Today’s Date
12/07/12
You are Sonya Matthews, a registered nurse at the Spirit Hospital. Robyn Harwood is a patient in your care. Read the
case notes below and complete the writing task which follows.
Patient Details
Social Background
Medical Histor
Treatment
Needs blood glucose level monitoring 4 hourly Needs assistance with shower and housework
May be elevated because of cortisone Orthopaedic review on 01/08/12
Writing Task
Using the information in the case notes, write a letter to the Nursing Director Ms. Jenny Attard of the Blue Care Agency,
requesting visits from the home care nurse.
7 Task 4 Case Notes: Sandra Peterson
Read the case notes below and complete the writing task which follows.
Time Allowed
Reading Time: 5 minutes
Writing Time: 40 minutes
Patient Details
Diagnosis
URTI (Upper Respiratory Tract Infection) – dehydration, bi- basal crackles heard on chest, SOB
Polypharmacy - on 24 medications at admission including a variety of OTC medication encouraged by her
daughter
Moderate dementia
HTN
Incontinent of urine – occasionally
Social History
Medical Progress
X- Ray – normal
FBC – WCC 9.0, Hb 115g/L
CT-brain – no acute changes
Commenced on Augmentin 500 mg x BD, per os
Now intermittent dry cough
IV normal saline for 24 hrs
Medications rationalised by doctor as detailed in discharge plan
BP 150/70 - after adjustment of anti-hypertensives
Nursing management
Discharge Plan
Writing Task
You are the charge nurse on the MAU where Mrs Sandra Peterson has resided during her hospital stay. Using
the information in the case notes, write a letter to the Community Nurse at Spirit Community Health Centre,
Cnr Bell & Burn Streets Applethorpe, NSW, 2171. In your letter explain relevant background and medical
history and provide information about discharge requirements.
In your answer:
Dear Dr Bullet,
Re: Julia Roberts, D.O.B: 18/05/1999
I am writing to refer Ms Roberts, a 19-year-old single lady who was diagnosed with chlamydia
trachomatis. She requires further advice and management.
The patient’s medical history is unremarkable, but she has gained 10kg over the last 12 months.
Apart from that, she is a regular smoker (15 cigarettes/day) and drinks moderately on
weekends.
Ms Roberts recently ended a monogamous relationship of 10 months and now she has a new
partner of 2 months. Besides, she has been using oral contraceptive pills since last year and she
does not use condoms. Her last sexual contact was 14 days ago.
Risks of smoking, benefits of quitting, partner risk and safer sexual practice were discussed, and
she was referred to Quitline and a Women’s Health nutritionist. Also, a pelvic exam and PCR
were done and a cervical screening information sheet was provided. She was prescribed
Azithromycin 1 gram and advised to avoid sexual contacts for 7 days after the treatment.
It would be greatly appreciated if you could review her and provide contraceptive options and
further tests for sexually transmitted infection and blood borne viruses.
Yours sincerely,
Nurse