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Case Notes Mr Stapleton Moore

Mr Stapleton Moore is a 63-year-old patient in Care Well Hospital where you are Charge Nurse.

Patient Details

  • Marital Status: Widower (8 years)
  • Admission Date: 5 September 2021 (Care Well Hospital)
  • Discharge Date: 9 September 2021

Diagnosis

  • THR – Total Hip Replacement
  • Higher BP

Social Background

  • Lives in Abrina Nursing Home, 1921 Victoria Street, Ashfield, NSW 2131
  • Had been there for 2 years before coming to Care Well
  • Has two children, both working overseas
  • Worked in a bank as an accountant before quitting at 60.
  • No pensioner
  • Hobbies: Reading, photography, fishing
  • Brother, Peterson, pays visits weekly
  • No severe signs of dementia observed yet

Medical Background

  • 2017 – Osteoarthritis requiring total hip replacement surgery
  • 2015 – Blood Pressure (management ongoing)

Medications

  • Aspirin (100mg)
  • Ramipril 5mg

Nursing Management and Progress

  • Dressing Daily
  • Recommend stretching exercises
  • Follow up FBE and UEC tests

Assessment

  • Good Condition – post operation
  • Walks with aid in the beginning
  • Now walks perfectly with wheelie-walker
  • Appeared disoriented during post operative recovery.
  • Possibly anaesthetic Hb dropped (71) post operatively,
  • Transfused three units of packed RBCs
  • Hb normal on discharge (112)

Discharge plan

  • Pain reliever given – Panadeine Forte (6 tablets / day)
  • Exercise recommended
  • Equipment required: Wheelie-walker, wedge pillow, toilet
  • Hospital is providing Wheelie-walker and wedge pillow.
  • With help from local medical supplier, raiser hired for 2 weeks.

Writing Task

Using the information in the case notes, write a letter to Ms Gladys Makuba. Senior Nurse at Abrina Nursing Home 19-21 Victoria Street Ashfield NSW 2131, who will be responsible for Moore’s continued care at the Nursing Home.

In your answer:

  • Expand the relevant notes into complete sentences
  • Do not use note form

Use letter format

Written by Biju John

Love for English begins with understanding its unknown rules. Biju John lives on the internet, teaching OET, IELTS and PTE. More than a million students have thanked him from their heart.

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