Case Notes 17 Jessica Morris

Occupational English Test – Writing (Nursing)

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

Notes:

Jessica Morris was admitted to the hospital with symptoms of severe abdominal pain and nausea. After a thorough examination, she underwent an emergency appendectomy. She is currently recovering well and you are her charge nurse.

Today’s Date: 29 July 2024

Patient Details:

• Name: Mrs. Jessica Morris.
• Age: 42 years.
• Husband: David (45), works as an accountant, very supportive, present during admission.
• Children: Two children (ages 8 and 10), well-cared for by husband during hospitalization.
• Hobbies: Gardening, cooking.
• Lifestyle: No smoking or drinking habits; active lifestyle, enjoys family activities.
• Address: 112 Maple Street, Sydney.
• Admitted: City Hospital, Sydney, 27 July 2024.
• Discharge: 30 July 2024.

Diagnosis

• Acute Appendicitis.
• Severe Abdominal Pain and Nausea.

Medical Background:

• Past Medical History: No significant past medical issues; no known allergies.
• Current Medications: Ceftriaxone 1 g IV once daily for 5 days; Paracetamol 500 mg orally every 6 hours as needed for pain; Antiemetics: Ondansetron 4 mg orally every 8 hours as needed for nausea

Nursing Management and Progress:

• Surgical Procedure: Appendectomy performed on 27 July 2024.
• Wound Care: Dressing on surgical site to be changed daily; site should be kept clean and dry.
• Pain Management: Regular analgesics administered; pain level consistently managed with current medication.
• Observation: Monitoring for signs of infection or complications; no signs of fever or abnormal discharge noted

Assessment:

• Recovery progressing well. No signs of infection / complications.
• Pain Manageable (current analgesics); Patient reports minimal discomfort.
• Mobility: Ambulating (with minimal support); vitals stable, within normal ranges.

Discharge Plan:

• Continue to keep the surgical site clean and dry; monitor for signs of infection such as increased redness or swelling.
• Continue Ceftriaxone and Paracetamol as prescribed; ensure completion of antibiotic course.
• Avoid heavy lifting, strenuous activities, intense physical exertion (at least 2 weeks).
• Follow-Up Appointment in one week to assess recovery and remove stitches if necessary.
• Provide husband with detailed instructions on wound care and medication management.
• Ensure adequate support at home for patient’s recovery and assist with childcare if needed.

Writing Task:

Using the information in the case notes, write a letter to Zelda Denizen, Community Health Nurse, 15 Walter’s Street, Sydney, who will be responsible for Mrs. Morris’ continued care at her home.

In your letter:

• 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.