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Nursing Discharge Letter Guide

Mrs. Beryl Casey, a 72-year-old widow, underwent a left hip replacement surgery after fracturing her left hip from a fall. She received a blood transfusion and IV antibiotics during her hospital stay. By day 6, she was mobilizing with assistance and preparing for discharge. Her discharge plan involved transferring to a rehabilitation center on day 7 to receive further therapy, with her son notified and transportation arranged.
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0% found this document useful (0 votes)
110 views1 page

Nursing Discharge Letter Guide

Mrs. Beryl Casey, a 72-year-old widow, underwent a left hip replacement surgery after fracturing her left hip from a fall. She received a blood transfusion and IV antibiotics during her hospital stay. By day 6, she was mobilizing with assistance and preparing for discharge. Her discharge plan involved transferring to a rehabilitation center on day 7 to receive further therapy, with her son notified and transportation arranged.
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We take content rights seriously. If you suspect this is your content, claim it here.
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OCCUPATIONAL ENGLISH TEST

Mobility & activities of daily living (ADLs):


Day 2 Sitting out of bed (SOOB) short periods, full assistance
WRITING SUB-TEST: NURSING
Day 3 Mobilising with pick-up frame (PUF) & 2-person assist
Day 4 Uneventful
TIME ALLOWED: READING TIME: 5 MINUTES Day 5 Mobilising short distances with PUF & 1-person assist
WRITING TIME: 40 MINUTES Abduction pillow when resting in bed (RIB)
Anti-embolic stockings in situ for 14 days
Read the case notes below and complete the writing task which follows. ADLs – full assistance
Day 6 Uneventful day
Preparing for discharge
Notes:
Discharge plan:
Patient: Mrs Beryl Casey (DOB: 21/11/1941) is a 72-year-old woman who is being
Day 7 (1100hrs) Discharge to the Rehabilitation Centre
discharged from hospital to a rehabilitation centre.
Discharge medications – Ramipril 5mg daily, paracetamol 1g qid prn
Marital status: Widowed (recently) Family to be notified of transfer
Hospital transport arranged for 1100hrs
Family: 2 children – son lives locally & daughter interstate.
Day 8 Repeat check of hemoglobin (Hb) levels
Social: Lives alone in 2-bedroom house with stairs to entrance. Son (married, 2 children – Monitor BP b.d., for 3/7, due to adjustment in anti-hypertensive meds
6 & 8) lives 20 minutes away – visits twice a week. Assess for rehab therapy (inpatient & on return home)
Enjoys gardening.
Day 10 Removal of remaining staples, wound can remain exposed afterwards
Medications: Anti-hypertensive (Ramipril) 10mg

Admission date: 4/02/14 at 1200hrs


Fainted getting out of bed & fell to the floor. Found by son 2 hours later.

Diagnosis: X-ray – fractured left neck of femur (# L NOF) post fall


Writing Task:
Treatment: Left hemiarthroplasty (Austin Moore hip replacement); general anaesthesia
Incision closed with staples & 2x Exudrain Using the information given in the case notes, write a discharge letter to the Nursing Unit Manager, The
Rehabilitation Centre, Waterford.
Post operation: Intravenous (IV) therapy: 3 units packed cells – with IV Lasix (furosemide) 40mg
therapy after each unit (intraoperative & post op) In your answer:
Maintained IV therapy for 36hrs, then ceased and oral fluids encouraged • Expand the relevant notes into complete sentences
Intravenous antibiotics (IVABs) – Cephazolin 1g t.d.s. for 3/7 – course completed • Do not use note form
• Use letter format
Vital signs: BP hypotensive – 95/60, other obs. within normal limits
Anti-hypertensive medication reviewd by Dr – Dose  now Ramipril 5mg daily
The body of the letter should be approximately 180–200 words.
www.occupationalenglishtest.org

Pain management: Patient-controlled analgesia (PCA) with Fentanyl for 36hrs –


pain relief – satisfactory. Commenced oral analgesia 36hrs post op  Panadeine or
Panadol 4/24 prn, Max 4 doses/24hrs
Wound management: Dressing √
Total of 600ml haemoserous fluid discharge from Exudrains over 24hrs
Drain tubes removed 48hrs post op (Day 2)
Alternate staples removed Day 5 and dressing changed

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