Task 1 Case Notes:

Bronwyn Green
Reading Time: 5 minutes
Writing Time: 40 minutes

Today's Date 10/02/2018

Patient Details
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: Takes Tiotropium inhaler 1 puff Mane, Fluticasone & Salmeterol
250/25mcg inhaler 2 puff 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 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 using oxygen 2L NP daily.
Very anxious and c/o SOB during mobility. Requires reassurance.
Able to walk 10m with 4w/walker Assist x 1
Takes regular analgesic: Paracetamol 1g QID and PRN Endone 2.5mg (Max dose 20mg) PRN for
surgical pain.
Takes regular laxative: Coloxyl and Senna 2 tabs BD. Bowels open regularly.
Urgent incontinence of urine: Wears pull up pad.
Lost 5kg after operation. Poor appetite.
Regular dietician review; HP Diet and monitor oral intake.
Observation stable. Sats 98% with NP2L. Aim Sats 88-91%. The goal is weaning oxygen to NP1L.
Abdo 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.
Abdo wound redressed.
Minimal exudate.
Complained minimal pain.
Poor appetite. Notified Dietician.

04/02/2018
Patient only required minimal assistance with shower and ADL's.
Sat 91% NP1L.
Mobilizing with 4w/walker, required supervision.
SOB with long distance, and temporary 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 pad.
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 abdo wound.
Monitor anxiety & O2 usage

Writing Task
You are a Registered Nurse at the Thoracic Ward Spirit Hospital. Using the information, write a
referral letter to Nursing Director, North West Transition Care Program Community Service 12
West St 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