Вы находитесь на странице: 1из 21

Nurses Writing Task 1

Read the case notes below and complete the writing task which follows
Time allowed: 40 minutes
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
Address: 32 Sexton St, Ekibin
Phone: (07) 38485555
Date of Birth: 23 May 2008
Admitted: 15th July 2012
Gender: Male
Discharged: 25th July 2012
Country of birth: Sudan
Diagnosis: acute meningoencephalitis
Social History
Parents: Miri & Abdullah Obeki, refugees, arrived in Australia in 2011.
Employment: Abdullah: Golden Circle pineapple factory, shift worker
Miri: housewife
Accommodation: Recently moved to rental accommodation
GP: No family doctor
Sibling: 2 year old brother, Saeed
Language: Dinka, Arabic
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 unaware of vaccine for Mumps.
Discharge Plan
Appears to have fully recovered from mumps and acute meningoencephalitis.
Will need advice on recommended vaccines for both children.
Will need neurological check-up.
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:

Expand the relevant case notes into complete sentences

Do not use note form

The body of the letter should not be more than 200 words

Use correct letter format

Writing Task 2 Nurses


Read the case notes below and complete the writing task which follows.
Time allowed: 40 minutes
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
Address: Flat 4, Matthews Street, West End 4101
Phone: (07) 3441 3257
Date of Birth: 4 September 1994
Admitted: 9th September 2012
Discharged: 13th September 2012
Marital Status: Single
Country of birth: Australia
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
General health good
Had appendicectomy at 15 years
Non-smoker

No alcohol or illicit drug use.


No drug or other allergies
Obstetric History
First pregnancy
Attended for first antenatal visit at 16 weeks gestation.
8 antenatal visits in total.
No antenatal complications.
Birth details
Presented to hospital at 1900hrs on 9th September
Contracting 1:10mins
1st stage of labour: 16 hrs
Mode of delivery: Emergency Caesarean Section
Reason: Fetal distress and failure to progress.
Baby Details
DOB: 10th September 2012
Time: 1120hrs
Sex: Male
Weight: 4.4 kg
Apgar Score: 6 at 1 min, 9 at 5 mins
Resusitation: O2 only for few minutes
Postnatal Progress
Maternal post partum haemorrhage of 800mls
Blood loss now minimal
Wound: Clean and dry
Haemoglobin on 12/09/12: 90 g/L
Started on Fefol (Iron supplement) and Vitamin C
Started breast feeding but not confident. Prefers to change to bottle feeding.
Not confident in bathing and caring for baby
Baby weight at discharge: 4.1 kg
Feeding well
No jaundice
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:

Expand the relevant case notes into complete sentences

Do not use note form

The body of the letter should not be more than 200 words

Use correct letter format


Writing Task 3 Nurses

Read the case notes below and complete the writing task which follows.
Time allowed: 40 minutes
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
Address: Golden Pond Retirement Village
83 Waterford Rd, Annerley, 4101
Phone: (07) 3441 3257
Date of Birth: 29/01/1929
Marital Status: Widowed
Country of birth: Australia
Social History
Moved to a retirement village following the death of husband in December 2010.
Next of kin: Son, Nicholas Olsen,
53 Palmer Street, Warwick 4370
Ph (07) 4693 6552.
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.
Normally alert and orientated. Enjoys bridge, bingo and reading.
Medical History
Hypothyroidism since 2000
Hypertension since 2006
Glaucoma since 2007
Allergic to penicillin

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
Non prescription Medication
Golden Glow Glucosamine Tablet - 1 with breakfast for arthritis
Vitamin C Complex Sustained Release 1 with breakfast
Mobility / Aids
Independent with walking stick. Arthritis in hands. Wears glasses
Continence: Requires continence pad
Recent Nursing Notes
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
Didnt 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 patients past
medical history and condition.
In your answer:

Expand the relevant case notes into complete sentences

Do not use note form

The body of the letter should not be more than 200 words

Use correct letter format


Writing Task 4 Nurses: Nina Sharman

Time allowed: 40 minutes


Read the case notes below and complete the writing task which follows:
Todays Date: 21/03/12
Patient Details

Name: Ms. Nina Sharman

DOB: 09/02/1951

New resident of Dementia Specific Unit, Westside Aged Care Facility

Single

Under the Australian Guardianship and Administration Council protection

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

Recent Nursing Notes


15/02/12

Chest infection. Keflex 500mg QID x 7 days

26/02/12

Occasional cough & episodes of SOB with RR

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

Nursing assessment after treatment


o

Pulse 110 BPM

BP 120/70 mmHg

RR 22/min

T 37.1 C

BSL 6.0 mmol/L

1800 hrs

No complaints

Pulse 88 BPM

BP 115/70 mmHg

RR 16/min

T- 37.0 C

Skin: normal colour.

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.
Sharmans swallowing function and nutritional status urgently due to a high risk
of aspiration.

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

Writing Task 5 Nurses


Read the case notes below and complete the writing task which follows.
Time allowed: 40 minutes
Today's Date
09/09/12
Notes

You are Lee Wong a registered nurse in the Coronary Care Unit, St Andrews
Hospital Brisbane. Bill ORiley is a patient in your care.
Patient Details
Name: Bill ORiley
DOB 12 January 1959
Address 9476 Old Dam Road, Goondiwindi QLD 4390
Next of Kin Brother, Ernie ORiley 72 Burke St, Cunnamulla QLD 4490
Admitted 2 September 2012
Diagnosis Obstructive coronary artery disease
Operation Coronary artery bipass grafts (x 4) on 4th September 2011
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
Nursing Management and Progress
Routine post operative recovery
Advised to cease smoking, reduce alcohol
Low fat diet
Walking well
Wounds healing well
Routine visit from Social Worker
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. ORiley 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. ORileys 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:

Expand the relevant case notes into complete sentences

Do not use note form

The body of the letter should not be more than 200 words

Use correct letter format

Task 6 Case Notes: Robyn Harwood


Time allowed: 40 minutes
Todays date: 12/07/11
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
Name: Robyn Harwood
Address: 8 Peach St, New Farm

Phone: (07) 3397 2695


Date of Birth: 4 February 1950
Social Background
Marital status: Widow. No children. Lives alone
Next of kin: Megan Mack (Niece)
Niece lives with husband in Sydney who works as software engineer for Google
Australia. Sister died recently. No other relatives.
Medical History
Diabetes Mellitus Type 2
Metformin 500mg mane
Diagnosis
Right partial rotator cuff tear
Presented to Spirit hospital with pain and weakness in the right shoulder,
especially when lifting arm overhead.
Descending stairs at home and slipped, falling onto outstretched arm.
Xray and MRI showed a partial rotator cuff tear.
Orthopaedic surgeon discussed surgery. Patient prefers to try non-surgical
treatment.
Date of admission: 30-06-2011
Date of discharge: 12-07-2011
Treatment
Ibuprofen orally QID
Cortisone injections
Daily physiotherapy
Nursing Care Needs
Needs blood glucose level monitoring 4 hourly
May be elevated because of cortisone
Needs assistance with shower and housework
Orthopaedic review on 01/08/11
WRITING TASK
Using the information in the case notes, write a letter to the Nursing Director Ms.
Jenny Attard of the Community Home Care Agency, requesting visits from the
home care nurse.
In your letter:

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 7 Case Notes: Henry O'Keefe


Time allowed: 40 minutes
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.
Name: Henry OKeefe

Address: 12 Donaldson Street, Greenslopes 4121


Phone: (07) 3941 2267
Date of Birth: 2 February 1929
Admitted: 14/3/12
Diagnosis: Malignant Melanoma Left Shoulder
Medical History
Large lesion successfully removed 14/3/12
Discharged 17/3/12
Needs assistance with showering and to dress wound prior to removal of sutures
at Mater Public Hospital on 24/3/12
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
Showered patient. Wound dressed healing satisfactory no sign of infection
Balance a little shaky - complaining of increased arthritic pains in hands and legs.
Currently taking Glucosamine & Chondroitin Supplement recommended by GP.
Pain relieved with 2 Panadol 3 times daily. Confused about why he had operation.
Dorothy concerned about future. Tells you she will be 83 in August. Says Henry
has not been himself since the surgery. Keeps forgetting things. She finds it
difficult to manage the house and garden. Neighbours are helping with shopping.
Kitchen and bathroom disordered - trouble finding clean towels dishes piled in
sink, bed unmade.
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.

Do not use note form in the letter

Expand the relevant case notes into full sentences

Write between 180-200 words

Task 8 Case Notes: Alison Cooper


Read the case notes below and complete the writing task which follows.
Time allowed: 40 minutes
You are the school nurse at a Toohey Point Primary State School

Todays 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
Father died in motor accident 18 months ago.
Lives with mother, a bank manager, working full time
Middle child- brother, Simon, aged 7 and sister, Lisa, aged 12
Paternal grandmother lives near school - provides after school and holiday care looks after children if unwell
School Medical Record
Regular absences from school dating back to time of fathers death
Year 2: 3 days
Year 3: 4 days
Year 4: 10 days
Year 5: 8 days in first term
School Health Centre Records
2012
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
February 15: Complained of toothache. Called grandmother for pick up.
April 4: Complained of headache. Gave paracetemol - rested 1 hour.
May 14: Headache, eczema on hands red and weepy, rested 1 hour not better
called
grandmother for pick up.
July 25: Feeling nauseous. Called grandmother for pick up.
August 16: Slight fever. Called grandmother for pick-up.
September 22: Feeling unwell. Eczema irritating. Called grandmother for pick up.
October 23: Complained of stomach ache. Rested 1 hour, returned to class.

November 27: Complained of headache. Gave paracetemol, rested 30 minutes.


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 dont
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:

Do not use note form.

Expand the relevant case notes into full sentences.

The body of the letter should not be more than 200 words.

Use correct letter format.

Task 9 Case Notes: Annette MacNamara


Time allowed: 40 minutes
Todays date: 21/05/12

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.
Name: Annette MacNamara
Address: Unit 15, 86 Smart St, West End
Phone: (07) 3379 5926
Date of Birth: 14 June 1939
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
Date of admission: 20-05-2012
Date of Discharge 22-05-2012 provided no complications and home assistance
arranged.
Admitted to hospital following fall. Slipped and fell while descending stairs to put
out garbage.
X-ray revealed fractured right wrist Laceration to left hand caused by broken
glass. Stitches required- Severe bruising of right shoulder and lower back.
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


Time allowed: 40 minutes

Read the case notes below and complete the writing task which follows:
Todays date: 9/7/12
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.
Name: Jim Middleton
Date of Birth: 3 July 1928
Admitted: 7 July 2012
Planned Discharge Date: 9 July 2012
Diagnosis: Left inguinal hernia
Medical History
Hypertension diagnosed 2002
Medication Atacand 4mg daily
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 doesnt know how to find out - doesnt 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.

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