Nursing Writing task

Reading time: 5 minutes

Writing time: 40 minutes

Patient name: Susan Matthews

Age: 76

Social Background:

- Husband died 5 years ago (cancer of bowel)

- Lives alone in own home
- Involved in bowling club, church, community groups

Medical History:

- Cerebrovascular accident (CVA) 4 years ago

- Lonely and isolated since husband passed away
- Weight: 48kg, height 165cm
- Hip replacement 2014
- Hypertension diagnosed 14years ago
- Non-smoker

10/11/16

- Presented to Emergency Dept

- Accident – fell off ladder while cleaning the fan
- Neighbour brought her to hospital

Observation - Laceration to R thigh, bruising, grazed legs, disorientated

Treatment - 10 sutures to R thigh, graze-antiseptic and clean, tetanus injection

- X-rays – nothing broken.

- Admitted to hospital for observation

11/11/16

Progress - Pt sore and disorientated, not sure how accident happened

- Not interested in food.

Treatment - Wound dressing, monitor patient mental health

12/11/16

Progress - Wound site red, swollen, pain 8/10, graze oozing fluid, temp 38o, lack of appetite, unwilling to
shower and dress independently.

Treatment - Oral penicillin, paracetamol 1-2 500mg 4hrly.

- Arrange visit with dietitian and physio

- Wound cleaned and dressed with non-stick dressing
13/11/16

Progress - Dietitian review – new high protein diet aim to weight

- Physio – mobilising patient with transfers (shower, toilet, bed)

- Temp 37o

Treatment - Wound cleaned and dressed

- Paracetamol 4hrly

14/11/16

Progress - Pt’s condition improving. Following diet, enjoying food

- Swelling reduced, nil exudate, nil fever, pain controlled

- Mobilising independently, but slow

Discharge date - 15/11/16

- Medications – paracetamol as needed, oral penicillin – 7days (must complete)

- Refer to community nurse

Community Nurse Assessment

16/11/16

- Pt moody, lonely, not coping with new diet regime, mobilising well at home with frame
- Regular paracetamol
- Wound cleaned and dressed with antiseptic solution
- Refer pt to Meals on Wheels and Domiciliary Care
- Refer pt to social worker – local support groups

18/11/16

- Pain controlled
- Nil exudate, nil redness
- Pt started Meals on Wheels
- Pt mood improved
- Leave wound exposed

20/11/16

- Pt coping reasonably well, more positive,

- Mobilising independently
- Wound good, no signs of infection
- Eating well - needs to be monitored
- Sutures to be removed in a week

Writing Task

You are the community nurse and you are writing to Susan Matthews’ GP (Dr. Maria Jones, 128 Blacks Rd, Lonsdale,
SA 5123) requesting follow-up care. You are concerned about the patient’s mental health, weight and wound.

In your answer:

- Expand the relevant case notes into complete sentences

- Do not use note forms
- The body of the letter should not be more than 200 words
- Use correct letter form