4 December 2018
Ms Leyla Ward
The Community Nurse
Aston Health Centre
Somrville
Dear Ms Ward,
Re: Mrs Charlotte Prince, aged 86
Mrs Prince is being referred to you for ongoing care at home. She was admitted due to mild concussion and was treated right toe infection. She is being discharge today.
Mrs Prince was admitted fourth eight hours pre cautionary admission due to mild concussion by following fall. During her initial assessment, right toe infection identified which was affected since September this year due to untreated ingrow toe mail. Initially, she was commenced with dressing and Tab amoxicillin 500 mg three times daily upto two weeks. How ever, it’s require recompliance.
Medically, Ms Shaw has had hypertension and mild scoliosis and on rampril 10 mg , ibuprofen respectively. In her past, she underwent knee replacement, removal of cancerous skin moles three times. She had a whiplash injury in 1987. She was treated conjunctivitis, gastroenteritis several times repeatedly due to improper hand and food hygiene. This kindly provide advice to her regarding hand and food hygiene. She has been suffering with urine in continence.
Ms Prince is widow, lives alone in three bedroom house. She is a retired postal worker wanted to lives alone and reluctant to receive visitors. She has been noted to have risk fall due to her health condition and usage of walking stick. I would like to inform you that , she is reluctant to visit GP also.
In discharge plan, Ms Prince require home visit from you twice a week. Kindly provide assistance during showering and dressing. Please continue cleaning the wound and change dressing twice a week by following oversee treatment. Encourage her to take adequate rest . Monitor her amoxicillin and ramipril medication compliance.
Please don’t hesitate to contact me for further queries.
Your’s sincerely,
Registered Nurse.
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