Nursing

Notes:

Assume that today's date is 15 May 2022. Mrs. Margaret Johnson, a 75-year-old woman, is a patient in the surgical ward of your hospital. You are the Charge Nurse.

Hospital: Hillside General Hospital, 123 Oak Avenue, Hillside

 

PATIENT DETAILS:

Name: Mrs. Margaret Johnson Marital status: Married Residence: Hillside Retirement Home, Hillside Next of kin: John Johnson, son (45, married, 2 children) Admission date: 10 May 2022 Discharge date: 20 May 2022 Diagnosis: Post-operative wound infection following appendectomy Past medical history: Hypertension, managed with medication Social background: Retired teacher, enjoys reading and gardening, active in the retirement home's social activities, widowed for 5 years

Medical history:

• Appendectomy on 8 May 2022

• Developed a wound infection post-surgery

Medical background: Admitted with wound infection at the surgical site - redness, swelling, and purulent discharge. Pain at the incision site. Afebrile. Mobilizing independently. Mild weakness. Scheduled for wound dressing changes every 2 days.

Medical progress: Mild improvement in wound appearance. Pain at the incision site has decreased. No fever. Ambulating independently.

Nursing management: Wound care, administering antibiotics, monitoring vital signs, and pain management.

Assessment: Satisfactory progress in wound healing.

Discharge plan: Prescribed oral antibiotics for 5 more days. Continue wound dressing changes every 2 days. Provide instructions for monitoring and reporting any signs of infection or complications.

 

Writing Task:

Using the information given in the case notes, write a discharge letter to Mr. Richard Anderson, Administrator of Hillside Retirement Home, 789 Elm Street, Hillside. This letter will accompany Mrs. Johnson back to the retirement home upon her discharge. In your answer:

• 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.