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    Benjamin Latimer Case Notes

    Uploaded by

    Santosh Kamble
    Oet nursing writing

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd

    Benjamin Latimer Case Notes

    Uploaded by

    Santosh Kamble
    716 views2 pages
    Oet nursing writing

    Copyright

    © © All Rights Reserved

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    PDF or read online from Scribd

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    Oet nursing writing

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Download as pdf
    716 views2 pages

    Benjamin Latimer Case Notes

    Uploaded by

    Santosh Kamble
    Oet nursing writing

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Download as pdf
    of 2
    OET NURSE’S REFERRAL LETTER CASE NOTES You are a nurse at the Family Health Clinic in Subiaco. You are referring a Patient for day surgery at St John of God Hospital. Write to Ms Margaret Dunne, Surgery Day Nurse, Colorectal Surgery, St John of God Subiaco Hospital, 12 Salvado Rd, Subiaco 6008 Patient’s name: Mr Benjamin Latimer Date of birth: 03/07/1955 (60 years old) Marital status: Single (never married) Occupation: Plumber (retired) Social background: © Lives alone © Likes going to the football, sometimes with friends * sees siblings (one brother, one sister) at Christmas © eats out a lot * social drinker * heavy smoker (I packet cigarettes day) Medical history: * 1958: chickenpox * 1970: severe acne, treated with antibiotics * 1982: concussion after an accident at work * 1995: bronchitis (quit smoking temporarily) * 2011: constipation * 2012: flu, educated about the need for vaccination * 2013: fever, hospitalised © 2014: constipation Family history: Paternal grandfather died, possibly of colon cancer; father died of bowel cancer 7ugust #; patient presented to his local GP, Dr Susan Peters for a check-up after receiving a letter on the risk of bowel cancer. This was part of a general distribution of letters by the Health Department to people aged 60. Expressed anxiety about family history. Advised to stop smoking and drinking Educated about low-fat diet’ Temperature 37.6 C, pulse 82 bpm, respiratory rate 20/m, BP 190/145 Blood test ordered Colonoscopy advised Patient referred to St John of God Hospital for colonoscopy to take place on August 15" at l/ aon» tout amie of Sx or Patient to fast completely from 10 pm on august 14th Nursing management: (in hospital) . Blood test results will arrive before Procedure is carried out Colonoscopy consent form to be signed Vital signs to be observed Pre and post-operative procedures to be explained Risks and possible complications to be explained Patient to be given booklet re Post-operative procedures and possible bleeding/infection Assessment by anaesthetist Note: patient not allergic to anything, but sensitive to codeine Plan: Patient to return for review 1 week after colonoscopy — counselling, discussion of possible options after result of colonoscopy. TASK: Write a letter to the surgery day nurse regarding the patient’s medical history, assessment and the total colonoscopy procedure, = eo Ppa , TOPRYS Dy TE DETE OF THE Le TIER) y iegreat BOE 2S

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