Professional Documents
Culture Documents
Time Allowed: 40 Minutes: Today's Date
Time Allowed: 40 Minutes: Today's Date
Read the case notes below and complete the writing task which follows
Today's Date
25/07/12
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
Medical History
Parents state that both children had some kind of vaccination at birth but the vaccination record has
been lost. Parents unaware of vaccine for Mumps.
Discharge Plan
Writing Task
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:
Read the case notes below and complete the writing task which follows.
Today's Date
13/09/12
Notes
Ms Nicole Smith is an 18 year old woman who has just given birth to her first child at the Spirit
Mothers’ Hospital in Brisbane. You are the nurse looking after her.
Patient Details
Social Background
Nicole is single and has had no contact with father of child for six months. She does not know his
current address.
No family members in Brisbane. Parents and sister live in Rockhampton. Does not currently have
contact with them.
Lives in a rental share flat with one other woman.
Currently receives sole parent benefits.
Feels very isolated and insecure. Doubts her ability to be a good mother and has talked about
offering the baby for adoption.
Medical History
First pregnancy
Attended for first antenatal visit at 16 weeks gestation.
8 antenatal visits in total.
No antenatal complications.
Birth details
Baby Details
Postnatal Progress
Writing Task
Using the information in the case notes, write a letter to The Director, Community Child Health
Service, 41 Vulture Street, West End, Brisbane 4101 requesting a home visit to provide advice and
assistance for Nicole and her baby.
In your answer:
Read the case notes below and complete the writing task which follows.
Today's date
10/07/12
Notes
Betty Olsen is a resident at the Golden Pond Retirement Village. She needs urgent admission to
hospital. You are the night nurse looking after her.
Patient Details
Social History
Retired triple certificate nurse - was the matron of a small country hospital for 15 years. Very aware
of and interest in health issues. Likes to discuss and be kept fully informed of any changes to her
medication or treatment.
Medical History
Prescription Medications
Karvea 150mg 1 daily
Oroxine 0.1mg 1 daily am
Timoptol Eye Drops 0.5% 1drop each eye am & pm
Normison 10 mg as required
Mobility / Aids
16/05/12
Flu vaccination
29/06/12
Complaining of indigestion following evening meal. Settled with Mylanta
07/07/12
Unable to sleep – aches in shoulder. Settled following 2 Panadol and 1 Normison
09/07/12
Requested Mylanta for indigestion,Panadol for shoulder pain – slept poorly
10/07/12 am
Tired and feeling generally weak. BP 180/95. Confined to bed. GP called and will visit 11/7/12 after
surgery.
10/07/12 pm
Didn’t eat evening meal. Says felt slightly nauseous. Trouble sleeping, complaining of shoulder and
neck pain. BP 175/95 Given 1 Normison 2 Panadol at 10pm
Rechecked 10.45pm – Distressed, pale and sweaty, complaining of persistent chest pain,
BP 190/100. Ambulance called and patient transferred.
Writing Task
Write a letter for the admitting doctor of the Spirit Hospital Emergency Department. Give the recent
history of events and also the patient’s past medical history and condition.
In your answer:
Read the case notes below and complete the writing task which follows:
Patient Details
Medical History
Ischemic heart disease (IHD) since 2005, takes Nitroglycerine patch, daily
Stroke May 2011, after stroke - unsteady gait
In 2011 - diagnosed with severe dementia - able to understand simple instructions only,
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 30)
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 daily and, also, goes
into other residents’ rooms and eats their food as bananas, biscuits or lollies
Social History
No friends
Lack of interests, but likes colouring and watching TV
↑emotional dependence on nursing staff
Non-smoker, no use of alcohol or illegal drugs
26/02/12
27/02/12
Sporadic throat clearing after eating yoghurt
20/03/12
1700 hrs
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
1800 hrs
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.
Read the case notes below and complete the writing task which follows.
Today's Date
09/09/12
Notes
You are Lee Wong a registered nurse in the Coronary Care Unit, St Andrews Hospital Brisbane. Bill
O’Riley is a patient in your care.
Patient Details
Social History
• Never married
• Lives alone in own home just outside Goondiwindi
• Fencing contractor
Medical History
• Smokes 20 cigarettes/day
• Alcohol: 2 x 300ml bottles beer / day
• Ht 170cm Wt 99kg
• Usual diet: sausages, deep fried chips, eggs, MacDonalds
• Allergic reaction to nuts
Discharge Plan
• Returning Home to Goondiwindi
• Appointment made for follow up visit to local GP Dr. Avril Jensen 2pm 15/9/12
• Local physiotherapist to continue rehabilitation exercise program
Writing Task
Mr. O’Riley has requested advice on low fat dietary guidelines and healthy simple recipes. Write a
letter to the Community Information Section of the Heart Foundation, Gregory Terrace, Brisbane on
the patient's behalf. Use the relevant case notes to explain Mr. O’Riley’s situation and the
information he needs. Include Medical History, Body Mass Index and lifestyle. Information should be
sent to his home address.
In your answer:
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 History
Diagnosis
Treatment
Today's Date
19/3/12
Read the case notes below and complete the writing task which follows:
You are a nurse with the Blue Skies Home Nursing Centre. You visited this patient at home today for
the first time following a referral from the Spirit Public Hospital. He was discharged from hospital on
17/03/12.
Medical History
Family History
Married aged pensioner. Lives in housing commission home with wife Dorothy also an aged
pensioner. No children
18/3/12
1st Home visit
19/3/12
Henry showered and wound dressed. Still a little unbalanced. Rests most of the day. Does not
remember being showered yesterday. House still disorganised, washing piled up in bathroom.
Dorothy says she would be lost without help from neighbours who also appear to be cooking meals
for the couple.
Concerns: Provided there are not complications with the wound healing, your role in providing
nursing care ends when sutures are removed on 24 March. You consider that Jim and Dorothy need
to be assessed for further on-going assistance in managing the house and garden and with shopping
and the preparation of cooking.
Plan: Request a home visit by the Aged Care Assessment Team as soon as possible to fully assess
their needs and to arrange for appropriate further assistance to be provided.
WRITING TASK
Using the information in the case notes, write a letter to The Director, Aged Care Assessment Team,
Brisbane South Region, 78 Masterson St. Acacia Ridge, Brisbane 4110. Explain why you are writing
and what types of assistance may be required.
Read the case notes below and complete the writing task which follows.
You are the school nurse at a Toohey Point Primary State School
Today’s Date
07/03/2012
Patient Details
Alison Cooper
Year 5 student
DOB: 14/6/2002
Height:138cm
Weight:40 kg Overweight for her age
Eczema outbreaks on hands and mild asthma – has ventolin inhaler
No other significant illnesses
Youngest in her class
Social History
February 8: Complained of headache. Gave paracetemol, rested and returned to class. Noted
eczema on hands red and weepy - has ointment at home.
February 16: Complained of stomach ache. Called grandmother for pick up.
February 22: Complained of aching legs. Called grandmother for pick up.
March 4: Complained of headache. Gave parcetemol, rested 1 hour, still had headache. Called
grandmother for pickup.
March 6: Feeling nauseous - eczema on hands red and weepy. Called grandmother for pick up.
2011
Social History
Alison started school well but since Grade 3 has had trouble concentrating - rarely participates in
class activities unless encouraged. Avoids sporting activities – standard of her school work is
declining. Has few friends and is often teased by her classmates about eczema & weight.
Embarrassed about hands which don’t seem to be responding well to ointment suggested by
chemist.
Mother was contacted by class teacher regarding these issues. Says Alison is also becoming
withdrawn at home. Alison was very close to her father – often talks to her about him and cries
because she misses him. Seeks comfort in food like chips and cakes after school.
Plan
Refer her to the school psychologist to find out whether Alison has underlying grief related or other
psychological problems.
WRITING TASK
Using the information in the case notes, write a letter to refer this girl to the school psychologist,
Barnaby Webster, to assess her. Outline the purpose of the referral. Provide details of significant
factors which will assist the psychologist to make this assessment.
In your answer:
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.
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
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 31-05-12
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 into complete sentences
The body of the letter should be approximately 200 words long
Use correct letter format
Task 10 Case Notes: Jim Middleton
Patient Details
Jim Middleton aged 84 was admitted to your ward following surgery for a left inguinal hernia. His
doctor has advised he can be discharged within 48hrs if there are no complications following the
surgery. Jim reports some pain on movement but has recovered well from the surgery and is keen to
return home.
Medical History
Family History
Married 50 years to wife Olga DOB 8/2/36 – one son living in USA
Jim is Second World War veteran – served two years in Borneo –Prison of War 16 months.
Own their own home with large garden which they maintain without assistance.
Very independent and proud that they have never applied for a pension or home assistance. Have
always managed quite well on their income from a number of investments.
Olga told you she is worried as income from these investments has recently been significantly
reduced due to severe stock market falls. She is concerned Jim will not be able to continue to
maintain their garden and they will not be able to afford a gardener or any other help at this time.
Transport is also a problem as Olga does not drive. Not close to any reliable public transport so will
have to rely on taxis. Olga thinks they may now be eligible to receive a pension and other assistance
from the Department of Veteran Affairs but doesn’t know how to find out - doesn’t want to worry
Jim.
Olga is in good general health but becoming increasingly deaf - finds phone conversations difficult.
She would appreciate a home visit. You agree to enquire on her behalf. Their address is 22 Alexander
Street, Belmont, Brisbane 4153 Phone (O7) 6946 5173
Discharge Plan
• Must avoid any heavy lifting
• Should not drive for at least six weeks
• Light exercise only
• May take 2 Panadol six hourly for pain
• Appointment made to see surgeon for post operation check at 10am on 11 August
• Contact Department of Veterans Affairs re eligibility for pension and home help
WRITING TASK
Using the information in the case notes, write a letter to The Director, Department of Veterans
Affairs, GPO Box 777 Brisbane 4001. In your letter, explain why you are writing and the assistance
they are seeking.