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Highlights: Wk 10
135
Highlights
Week 10 Session 1 & 2
Copyright by Gladys Luk 2021
- English Learning Portfolio
- Patient Case Report
- Citation and referencing
- Nursing Interventions
English Learning Portfolio
English Learning Portfolio
English Learning Portfolio
English Learning Portfolio
That is the patient case report.
English Learning Portfolio
Unit 1
English Learning Portfolio
Unit 2
English Learning Portfolio
Unit 3
English Learning Portfolio
Unit 4
English Learning Portfolio
Unit 5
English Learning Portfolio
How is the English Learning Portfolio marked?
Overall Language Proficiency (20 marks)
Completeness and Effort (20 marks)
English Learning Portfolio
English Learning Portfolio: Self-improvement
Reminder on the self-improvement part:
- Evidence
- Evidence of your effort of improvement
- Evidence of your improvement
English Learning Portfolio: Self-improvement
What can the evidence be?
- Exercises you have done
- scanned pages of your voc book/ sentence-making book/ articles you have read with comments and remarks/ videos you have watched with descriptions/ audio sound files recorded by you
English Learning Portfolio: Self-improvement
Remember to upload all documents including evidence to your English Learning Portfolio in your google drive.
Most importantly, provide me with the link to access the documents without asking me to log in or obtain authorization.
Patient Case Report
Basic structure
Sections in each patient case report
3 Sections
Patient's summary
Diagnosis description
Nursing intervention
Background and symptoms
Recommendations for patients in various aspects
Diagnosis e.g What is it?
Causes, etc
Points to remember
The flow
Rules governing how information is presented
Patient's summary
Sorting the information
Sorting information collected
Patient's summary
Information collected from:
- A case history
- Conversation between the nurse and Mr Scott
summarise in the table
Sorting information collected
Patient's background:
- Personal particulars
- Reason for admission
- Marital status
- Lifestyle/undesirable habit(S)
- Initial diagnosis and medical history (the patient's)
- Other problems such as allergy, etc
- Family history
Sorting information collected
The following are to be placed in the patient's background.
Sorting information collected
Sorting information collected
The rest should be related to symptoms.
They include:
Sorting information collected
Sorting information collected
Sorting information collected
Therefore, the flow should be:
- 3 weeks ago
- 2 days later
- 2 weeks ago
- 3 days ago
- the previous 24h
- In the morning of admission/ recently
Patient's background
Patient's background
Note:
1. Relevant information e.g. medical history and family history must be related to the reason of admission and initial diagnosis.
2. Don't mention illnesses that the patient suffered a long time ago.
Patient's background
Personal particulars (case History & conversation):
- Robert Scott, 62 years old, a retired bus driver
Reason for admission (case History):
- severe chest pain when breathing and high fever (Case History)
Marital status (conversation):
- married and with no children
Patient's background
Lifestyle/ undesirable habit(s) (conversation):
- drinks 8 units of alcohol per week
- stopped smoking 2 years ago
Initial diagnosis and medical history (case history & conversation):
- Respiratory tract infection 3 weeks ago with 5 days antibiotics prescribed
Don't mention illnesses such appendicetomy, cervical spondylosis and hypertension - too long ago
Patient's background
Other problems such as allergy etc (conversation):
- not allergic to any medicine
- but allergic to nuts, causing inability of breathing smoothly
Patient's background
emphysema: the lungs become larger and do not work properly causing difficulty in breathing
myocardial disease: related to heart (people have heart disease may increase the risk of having pneumonia
Family history (case history):
- Father died of lung cancer, a family history of emphysema and myocardial disease on father's side
- wife had throat infection
Don't mention 'rheumatoid arthritis' - nothing to do with chest infection.
Rheumatoid arthritis: having swollen and painful joints
Symptoms
Symptom description: comments
Symptoms:
- which symptoms should go with which symptoms
- when certain symptoms happened
- arranging symptoms according to the sequence (the two rules)
Symptom description: comments
Symptoms:
cough with blood ... + barely rousable ...
confused ... the previous 24h
had increased thirst ... a few occasions
occasional severe ... + radiating ...
Symptom description: comments
Symptoms:
slight acute dull ache ... + relieved ... + worse after ...
breathe faster ... + coughing up ...
Symptom description: comments
3 weeks ago: coughed with blood
2 days later: rousable
2 weeks ago: thirst, incontinent of urine
3 days ago: slight acute dull ache, relieved ... worsened
the previous 24h: confused
Recently: chest stabbing pain ... breathes faster ... coughs up ...
disoriented ... depression
Symptom description
Sequence and the flow
1. From past to present / present perfect (chronological order)
2. From physical to psychological
Symptom description
According to the first rule,
- 3 weeks ago
- 2 days later
- 2 weeks ago
- 3 days ago
- previous 24 hours
- Recently
Symptom description
Information has to be selected from the Case History and the conversation between the nurse and Mr Scott
3 weeks ago (Case History + conversation):
- general malaise, coughed up some blood
2 days later (Case History):
- a little breathless, barely rousable and breathless at rest
Symptom description
2 weeks ago (Case History):
- increased thirst and nocturia and incontinent of urine on a few occasions
3 days ago (conversation):
- slight acute dull ache in chest, relieved by sitting down, worsened after taking a deep breath or a short walk
Symptom description
Previous 24 hours (Case History):
- confused and was unable to get up
Recently (conversation):
- has occasional severe left chest stabbing pain when breathing in, radiated to his left fingers, breathe faster than usual and coughs up with thick green and yellow phlegm with blood
Symptom description
According to the second rule, now mention psychological symptoms
disoriented (lose perception of time, place or one's personal identity):
- I don't know ... I ... Maybe I'm at home ... Where is Katie? My wife ...
Symptom description
Depression:
- from the conversation between the nurse and Dr Chapman
Tips for preparing the symptom description:
- Identify and underline the time expressions first
Tips for preparing the symptom description
When did he call on his general practitioner?
Two days later?
Tips for preparing the symptom description
Three weeks ago: general malaise (case history), coughed up some blood
Points to bear in mind
- Reason for admission should be given in the first sentence
- All problems should be presented e.g. severe chest infection + high fever
- All symptoms must be presented according to the two rules e.g. past to present ... physical symptoms before psychological symptoms
- When paraphrasing, make sure that the meanings remain the same.
Diagnosis Description
Diagnosis Description
Some points to remember:
Mr Robert Scott has been diagnosed as having ...
Pneumonia is an infection of the lung ...
- Introduction is not necessary.
- Start right away with the nature of the disease.
- Start with the general to the specific.
- COPD/ Alcoholism/ myocardial disease
Pneumonia is an ... Streptococcus pneumoniae is ...
People with COPD are at increased risk of developing heart disease, lung cancer and ...
Diagnosis Description
vomitting, diarrhoea and thirst
barely rousable; a stabbing pain
- Don't mix up symptoms in patient's summary with symptoms in diagnosis description.
- Recommendations should be included in nursing interventions not in diagnosis description.
- 'tomorrow' and 'our'
Drink less alcohol, vaccination, etc
arranged for an ECG tomorrow; transferred to our chest physiotherapist
Diagnosis Description
- What is it (What is pneumonia)?
- Causes
- Signs and symptoms
- Diagnosis
- Treatment
- Prognosis
- Presented in a paragraph
- Follow this order
- Don't include headings
What is pneumonia?
Pneumonia:
- an infection of the lungs that is caused by bacteria, viruses, fungi, or parasites
Causes
The primary causes of pneumonia:
- bacteria and viruses
Causes
- Pneumonia-causing germs lungs
- Immune system unable to prevent their entry in small air sacs called alveoli
- then multiply
- white blood cells attack the infection
- the sacs filled with fluid and pus - causing pneumonia
Causes
Streptococcus pneumomiae:
- the most common cause of bacterial pneumonia
High risk group:
- COPD
- alcoholism
Causes
- get pneumonia from Kebsiella pneumoniae and Hemophilus influenzae
Signs and symptoms
Signs:
- characterized primarily by inflammation of the alveoli in the lungs or by alveoli that are filled with fluid
Signs and symptoms
Symptoms:
- vomit
- diarrhea
- thirst
Diagnosis
Based on:
- Chest X-ray
- sputum test
- by Dr Chapman
- in St. Andrew Hospital
Treatment
- Oral antibiotics for 2 weeks
- oxygen therapy to make sure that he can breathe smoothly
- Electrocardiographic (ECG) examination
Treatment
- a normal saline drip to avoid dehydration
- referred to the Chest Physiotherapist to learn how to cough out phlegm
Nursing Intervention
Nursing Interventions
Main aim: to prevent the illness(es) from recurring.
Recommendations should be on:
1. pneumonia
2. depression
When presenting recommendations, apart from details, provide reasons as well
Nursing Interventions
- They meet the requirement of SMART
- It would be better that suggestions are from different scopes e.g. food, exercise, actions to avoid, etc
Nursing Interventions: comments
Mr Scott will be transferred to the Chest Physiotherapist ...
- Should not mention anything related to treatment
- Should Mr Scott be asked to stop smoking?
- name the vaccination
- Don't name the wrong vaccination
Nursing Interventions: comments
- check if your recommendations really apply to the patient e.g. not to spend excessively
- also check if the recommendation is suitable for the patient e.g. asking a 62-year-old man to skip for 15 minutes or go mountain running
i.e. all recommendations should be based on the patient's illness, age and suitability.
Nursing Interventions
Recommendations regarding pneumonia:
1. Pneumovax vaccination after recovery to decrease the risk of further infection
2. wash hands
3. refrain from drinking because people who misuse alcohol are five times more likely to die from pneumonia
Nursing Interventions
4. eat healthfully
5. stay away from sputum or cough particles from others with pneumonia or throat infection
You can mention all of them as they are preventive measures.
If not, you need to at least mention vaccination and refrain from drinking.
Nursing Interventions
To beat depression, as suggested :
1. develop interests
2. Laugh
3. Fix personal problems
4. Stop bad behaviour
5. Fix diet
Choose those related to Mr Scott's case.
Nursing Interventions
Need to explain and justify.
For example:
Developing interests is necessary to keep Mr Scott's mind off problems and negative thoughts and emotions
eat more vegetables and keep a balanced diet ... improve immunity.
Nursing Interventions
When recommending Mr Scott to develop interests, you need to provide concrete suggestions. That is what he should do or why he should do it.
The patient has been retired and does not have children. He might have too much free time but nothing to do. For example, he can do housework to kill his time.
Revision
Revision
- Patient Case Report is supposed to be the last piece of writing which has to be prepared by students themselves.
- Therefore, the part on grammar is not commented.
Revision
- Therefore, you need to read your report again to check for grammatical mistakes.
- Revise the report with all the mistakes corrected.
- Submit the revision of the whole report.
Revision
- How to submit?
- Put everything in your English Learning Portfolio.
- Don't send the revisions to me.