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Day 12 Case Notes Analysis

This case notes will be used for writing today’s letters for correction. Before you proceed to writing this letter on the writing page, please read this case notes and answer the questions that below:

OCCUPATIONAL ENGLISH TEST

WRITING SUB-TEST: Nursing
TIME ALLOWED: READING TIME: 5 MINUTES
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.

NOTES

You are a Registered Nurse at All Angels’ Medical Centre. Ms. Andee Valley is a patient in your care who is being transferred to Duke’s Hospital today for a colostomy scheduled on 05/02/2018

Today’s date: 02/02/2018

Patient name: Ms. Andee Valley
Age: 70
Marital status: Married; lives with husband (very supportive)
1 daughter – interstate; 2 sisters – nearby
Retired school teacher (History & Science)
Hobbies: badminton, movies, socializing, playing cards, magic
Sedentary lifestyle – Overweight (since 30’s)

Medical background:

Appendectomy – 2003
Pneumonia – 2015
Arthritis in hands – 2016 (on Naproxen)

Diet

Red meat, processed meat, fast food; alcohol (Vodka, wine) – 4-5 days/wk; ex-smoker – quit 15 years ago

Nursing notes

28/12/2017: Visit to GP,
2 – 3 bleeding from rectum; rectal exam – definitely palpable mass; fast track referral for suspected colorectal cancer

11/01/2018:
8 cm mass on left lateral wall of rectum likely to be carcinoma – referred for colonoscopy

14/01/2018:
Colonoscopy – biopsies large bowel mucosa taken

18/01/2018:
CT & Local staging of primary tumour with MRI

23/01/2018:
Review of histology – colonoscopy report; Diagnosis – Colon cancer R/v by colorectal and general surgery consultant; CT – no evidence of metastatic cancer; Recommended colostomy; Pt. advised of diagnosis and surgery

02/02/2018: Identified needs/problems: prepare for colostomy;
Eating and drinking: Potential problems of dehydration due to above;
Anxious about probs of stoma on home and social life.
Involve family members in care.

Objectives

Minimise risk of post-op., wound infection from bowel contents
Allow surgeons clear access to operation site i.e. free from faeces
Complete pre-op. Care schedule
Encourage patient to voice concerns

Plan

Rectal wash-out before bedtime for three days (daily)
Purgatives as desired
Low-residue light diet; fluids only including soup and ice cream; clear fluid

Charge Nurse to see the pt. to discuss practical problems at home
Nil by mouth from 00.00 hours
Standard pre-op procedure
Ensure variety of acceptable drinks

Writing Task

Using the information given in the case notes, write a letter to Ms. Alerina Wikings, Charge Nurse, Duke’s Hospital, 119 Red Sparrow Road, Docklands, Melbourne outlining relevant findings and patient care plan to prepare Ms. Valley for the surgery.

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.

Now take this Case Notes Analysis and proceed to Letter Writing (Group 12 members)

  • Question of

    Single patient of multiple patients?

    • Single
    • Multiple
  • Question of

    Who is the patient?

    • An old woman who is going to undergo colonoscopy
    • An old woman who is going to undergo colostomy
    • An old woman who is in postoperative phase
  • Question of

    Who is receiving this letter?

    • Alerina Wikings, the surgeon
    • Alerina Wikings, the patient’s relative
    • Alerina Wikings, homecare
    • Alerina Wikings the charge nurse
  • Question of

    What is the purpose this letter?

    • Homecare
    • Postoperative care at home
    • Surgery
  • Question of

    What is the main discharge plan?

    • Purgatives
    • Diet control
    • Rectal washout
  • Question of

    What is the admission / discharge status?

    • Admitted
    • Admitted and discharged
    • Being discharged shortly

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2 Comments

  1. Ms Alerina Wikings
    The Charge Nurse
    Duke’s Hospital
    119 Red Sparrow Road
    Dockland, Melbourne

    02 February, 2018

    Dear Ms Wikings,

    Re: Ms Andee Valley, 70-years-old

    Ms Valley, who is scheduled to have colostomy on 05 February 2018 is being transferred to your facility today. She will benefit from specific preoperative care.

    Socially, Ms Valley, a retired school teacher is married to a supportive husband. She has a daughter that lives outside the state but her two sisters stay nearby. She is overweight with history of alcohol intake, consumes red and processed meat and takes solace in fast food.

    Regarding her medical history, Ms Valley presented on 28 December 2017 with the complaints of bleeding per rectum. She underwent colonoscopy and biopsy which revealed colon cancer, she was thereafter referred to the colorectal and general surgery consultant. She was counselled on the diagnosis and the necessity of surgery.

    In view of the above and the need to ensure postoperative wound free of infection, it would be beneficial if you could provide Ms Valley with preoperative care. Kindly do rectal washout for three nights, administer purgative as required, put on low residue diet which should be clear fluid but can contain soup plus ice cream and ensure nil per oral as from 00.00hours preceding operation date.

    Please do not hesitate to contact me for further enquiries.

    Your Sincerely,

    Charge Nurse

  2. 02 February 2018

    Ms Alerina Wikings
    Charge Nurse
    Duke’s Hospital
    119 Red Sparrow Road
    Docklands
    Melbourne

    Re: Ms Andee Valley, Age: 70 years

    Dear Ms Wikings

    I am writing regarding Ms Valley, who is scheduled for colostomy surgery on 05th February. She is being transferred today, and now requires pre-operative assessment at your facility.

    Ms Valley presented with rectal bleeding,for which she underwent colonoscopy and biopsy. She was diagnosed with colon cancer and recommended above mentioned surgery. She was explained regarding possible complications along with her alter eating and drinking following a surgery, which resulted in her being anxious of self-care and coping with social life.

    Ms Valley lives with her husband. As a result of leading a sedentary lifestyle and eating unhealthy foods, she is being overweight. She has been drinking 4-5 days per week since quitting her smoking habit 15 years ago. In terms of medical background, she has had pneumonia and arthritis since 2015 and 2016 respectively. she underwent appendectomy in 2003

    In view of the above, it would be greatly appreciated if you could accept Ms Valley into your care in order to provide pre-operative assessment. Please provide her rectal wash for three days and kindly advise her to take a low-residue diet,including clear fluids. Please keep her Nil by mouth from midnight before surgery.

    If you have any queries, please do not hesitate to contact me.

    Yours sincerely
    Nurse

Written by Biju John

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