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    Case Note 10: Patient Details

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    BINCY
    The document describes a case note for 60-year-old Mrs. Rachel Andrewson who was admitted to the renal unit for renal failure and was undergoing hemodialysis; she has a history of hypertension, diabetes, smoking, and alcohol use and was discharged with a plan for weekly dialysis, fluid and dietary restrictions, and follow up care.

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    Case Note 10: Patient Details

    Uploaded by

    BINCY
    252 views2 pages
    The document describes a case note for 60-year-old Mrs. Rachel Andrewson who was admitted to the renal unit for renal failure and was undergoing hemodialysis; she has a history of hypertension, diabetes, smoking, and alcohol use and was discharged with a plan for weekly dialysis, fluid and dietary restrictions, and follow up care.

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    The document describes a case note for 60-year-old Mrs. Rachel Andrewson who was admitted to the renal unit for renal failure and was undergoing hemodialysis; she has a history of hypertension, diabetes, smoking, and alcohol use and was discharged with a plan for weekly dialysis, fluid and dietary restrictions, and follow up care.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    252 views2 pages

    Case Note 10: Patient Details

    Uploaded by

    BINCY
    The document describes a case note for 60-year-old Mrs. Rachel Andrewson who was admitted to the renal unit for renal failure and was undergoing hemodialysis; she has a history of hypertension, diabetes, smoking, and alcohol use and was discharged with a plan for weekly dialysis, fluid and dietary restrictions, and follow up care.

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    CASE NOTE 10

    Mrs. Rachel Andrewson is 60 years old patient admitted to the ward of Maxwell Renal Special care Unit,
    where you are a charge nurse.

    Patient Details:

    Name: Mrs Rachel Andrewson


    Marital status: Married, Divorced 10 years ago

    Admission date: 03/09/2010


    Discharge Date: 10/09/2010
    Diagnosis: Renal failure for 5 years on hemodialysis.
    Adress: 68 Warren avenue ,Canton beach ,New South Wales 2263

    Medical Back ground

     Hypertension -12 years on tab analapril .


     Diabetic mellitus 5 years on medical management.
     Appendectomy – 2000

    Social Back ground

     Lives at Mark Royal Nursing home [since 2002]


     Two children, Mr. Peter visits occasionally and Mr. Paul lives in US with wife and children.
     Alcoholic and smoker.

    03/9/2010

     Admitted with serve breathlessness, fatigue, giddiness, edema all over the body, disorientation.
     BP:110/70mmHg, Temp 36.7 degree f, PR-88, PR-22
     Taken for an emergency hemodialysis
     Allergic to nuts, penicillin, seafood.
     Asked for dietary advice after discharge, to be sent to nursing home.
    04/09/2010
     Disoriented
     Refused medicine and food.
     Weight loss – Improper dietary habits
     Nephrologists advised for fluid restriction 1lit/day & sodium restricted diet.
     Patient prefers deep fried chips, sausages and egg.
     Exercise initiated and explained its need.
     Protein urea, electrolyte imbalance.
     Advised to avoid alcohol and smoking.
     Edema reduced
    06/09/2010

     Vital signs stable


     Medication continued
     Recovering well, follow in take output chart.
     Oriented.

    Discharge Plan

     Assistance needs in daily activities.


     Monitor side effects.
     Encourage protein rich diet, requires simple recipies.
     Advised potassium restriction
     Weekly dialysis recommended fluid restriction 1lit /day.
     Follow up in OPD – 1 week later.

    Writing Task

    1 .Using the information in the case note, write a letter to dietician, Mr. Maxwell, Renal special care unit,
    Brisbane. Ask for advice on renal diet and healthy simple recipes guidelines.

    2. Using the information given write a letter to head nurse of Mark Royal Nursing home, New South
    Wales for continued assistance and care. Explain relevant information in the letter for further care.

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