Nurses' First Notes

1 0 0
                                        

Wednesday 3rd December 2008

Problem
Sue has been diagnosed with Stage 4 metastasis, primary unknown.
Requires support with condition

Patient/Nursing Goals
To ensure Sue is well supported at all times

Negotiated Plan of Care
Nurse to visit Sue on a fortnightly basis at present, increasing as necessary.
Give Sue Time to ask any questions and offer support at all times.
Order any equipment as and when needed.

Evaluation
Assessment requested by Leicester Royal Infirmary (LRI) Oncology department.
Sue had been diagnosed with Cancer (unknown) primary and has developed Stage 4 metastasis. Nurse to visit on a fortnightly basis and to increase when appropriate. Full assessment completed today.

Friday 30th January 2009

Susan was discharged from LRI on 29-1-09. Susan has been on a syringe driver whilst in hospital for nausea and vomiting, Nozinan was used. Authorisation has been sent home with Susan in case Driver needs to be set up whilst Susan is at home. No nausea felt at present. Pressure areas: assessed and intact. Pressure cushion: now insitu. Social Services have been contacted whilst Susan was in hospital; will chase this up as Susan is struggling with personal care. I will also contact ***** ******* to advise that Susan is home. Discussed having a key safe, which I will chase.

RetroexposureWhere stories live. Discover now