Case Note 19: You Are A Charge Nurse at Holy Spirit Hospital
Case Note 19: You Are A Charge Nurse at Holy Spirit Hospital
Case Note 19: You Are A Charge Nurse at Holy Spirit Hospital
Mr. Johnson is a Patient in your care; He is going home from hospital. Read the following discharge
summary and complete the writing task.
Chief complaints
Breathing Difficulty
Fever
cough – with sputum
Diagnosis
03/07/16
OPD
06/07/16
07/07/16
Condition worsened
Intubated with 7.5 ET tube.
Suspected for H1N1 -swab sent
Repeat CT-scan shows complete collapse of lungs
Discussed patient condition with family
08/07/2016
ABG, APTT 6th hourly monitoring
NG feed started with Nepro- HP
Chest physiotherapy started
Change position every 6th hourly
Family counseling given
09/07/2016
VAP developed
Antibiotic changed to Inj . Meropenem 1gm 1-1-1
23/07/2016
26/07/16
28/07/16
30/07/2016
HTN since2000
Tablet amlong 5mg
Current Medication
Tab.Meropenem 1-0-1
Tab. Pan 1-0-0
Tab.pct (sos)
Discharge plans
Writing task
1. Write a letter to the pulmonologist, Dr. Trump,3 rd Main ,Brisbane, Australia to assess his progress
and for necessary management. Include all relevant medical history in the letter
2. Write a letter to community health Nurse regarding follow up care .Include relevant medical history
and discharge plan. You can send letter to the Community Health Nurse, Community Health Center ,
Oakland Community
3. Write letter to dietician, Brisbane town No.462, Australia and request for nasogastric feed
guidelines and diet plan