The community nurse
spirit community health center
Cnr bell and burn street
Applethorpe NSW 2171
22 march 2021
Dear community nurse
Re: sandra peterson, aged 25
I am refering mrs, peterson, who has had diagnosed with upper respiratory tract infection requires on going nursing care and monitoring of medication complication, being discharged toady.
on 23 march 2021, mrs petrson presented to the hospital by ambulance , had fall in the bathroom at home due to dizziness followed by increased in confusional status, and had shortness of breath , high blond pressure 190/90 mmHg. During hospitalization commenced with intervenous saline for 24 hours , and augmentin 500mg twice daily along with her on going antihy pertensive medications . Blood investigation and radiology reports reveld normal . mrs peterson had remarkable progress, able to mobalize with seat walker at short distance, however wheel chair requires for long distance , along with one assistance. she is co- operative but mild confusion is present , therefore requires assistance for personal hyginic , bathing grooming and dressing.
Mrs peterson, lives in 2 bedroom flate with her daughter and son-in law , she is very supportive and has had serious concern about her mothers health, therefore she had arrange and house care worker to assist her in toileting , bathing and dressing twice in a week , she has had history of hypertension , moderate dementia and sowe time incontince of urine.
Based on above mentioned circumstance; regular monitoring of medication compliance , especially antibiotics should be taken at the start of the meal and followed by antihy pertensive drugs as mentioned in the notes. supenision and education to her daughter , regarding poly- pharmacy , extermely beneficial for her crunt health condition. continue assistance for ongoing activites of daily living , required if you require any additional information , please do not hesitate to contact me.
Spirit Hospital Medical Assessment unit