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.
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
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)
Appendectomy – 2003
Pneumonia – 2015
Arthritis in hands – 2016 (on Naproxen)
Red meat, processed meat, fast food; alcohol (Vodka, wine) – 4-5 days/wk; ex-smoker – quit 15 years ago
28/12/2017: Visit to GP,
2 – 3 bleeding from rectum; rectal exam – definitely palpable mass; fast track referral for suspected colorectal cancer
8 cm mass on left lateral wall of rectum likely to be carcinoma – referred for colonoscopy
Colonoscopy – biopsies large bowel mucosa taken
CT & Local staging of primary tumour with MRI
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.
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
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
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)
Single patient of multiple patients?
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
Who is receiving this letter?
Alerina Wikings, the surgeon
Alerina Wikings, the patient’s relative
Alerina Wikings, homecare
Alerina Wikings the charge nurse
What is the purpose this letter?
Postoperative care at home
What is the main discharge plan?
What is the admission / discharge status?
Admitted and discharged
Being discharged shortly