University Nursing Referral Letter: Mrs. Spring's Case

This assignment is a nursing referral letter written by a student, addressing the case of Mrs. Spring, a 72-year-old woman with a diabetic wound ulcer on her leg. The letter is addressed to a dietician and includes a detailed patient history, assessment findings (including vital signs, wound assessment, and investigation reports), current and past treatments, a preliminary diagnosis of venous insufficiency with a venous leg ulcer, and the rationale for the referral to the dietician. The referral aims to enhance immune function, control blood glucose, improve weight management, and provide nutritional interventions. The student nurse outlines their involvement in Mrs. Spring's care, including vital sign assessments, education, and collaboration with other healthcare professionals such as endocrinologists, general physicians, and physiotherapists, while also recognizing the need for counseling and psychiatric support for Mrs. Spring's social isolation and stress. The letter emphasizes the need for a comprehensive approach to manage Mrs. Spring's condition, considering her diabetes, venous insufficiency, and the impact of the wound on her quality of life.

Running head: NURSING
Nursing
Name of the Student
Name of the University
Author Note

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Dr. Shane Anderson
Dietician, 123 New Town street,
Melbourne
Dear Dr. Anderson,
RE- Referral for Mrs. Spring for a healthy diet based interventions.
Thank you for seeing Mrs Spring, 72-year-old lady, regarding severe diabetic wound ulcer on leg
possibly requiring proper diet planning. She had been suffering from ulcer from last five months.
Her reports showed her feet had become quite puffy and she is unable to wear her shoes. She is
having a dull ache in her legs. Her condition is deteriorating because of uncontrolled Diabetes.
Current medication
Her current medications are:
 Diabex 500mg twice
 Digoxin 125 mg daily
 Aspirin 100 mg daily
She needs a diet plan that has the potential to control as Diabetes. I request you to go through her
past medical records and assist her with a proper diet plan.

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Patient History
Mrs Spring was suffering from type II diabetes for a long time and was in a controlled
state. However, recently her blood glucose level was noted to be high, and she was finding it
difficult to control it. She also had a health history of congenital heart failure and had a varicose
vein surgery 30 years ago. Other than these issues, she remains quite well for a long time now.
Since five months she had been suffering from leg ulcer, and her foot has become quite
puffy these days. She also finds it quite challenging to wear shoes for a longer time. She also
experienced some dull aches in the leg quite often. Also, she reported having thick prudent
exudate that comes out from the wound regularly. Sometimes, the flow of exudate becomes high,
and it makes the wound appears red, heated and painful. She developed foul smell in her feet and
due to which children had stopped visiting her.
Social history/medical history
 Mrs Springs is an independent resident of a two-bedroom house.
 She likes socializing at the local citizen center, gardening, cooking.
 She has two children who live nearby and regularly visits her
 Her feet become quite puffy, and she finds it difficult to wear her shoe for very long, they
become more swollen as the day progress.
 Diagnosed with wound infection, by a wound swab growth of Staphylococcus aureus,
which was prescribed Clarithromycin 500mg twice daily for 14 days.
 Following the course of antibiotics, Mrs Springs wound her left outer gaiter show
improvement and reduction in pain.
 She was administered with a mild compression therapy until she undergoes formal
vascular assessment due to her pain and discomfort with the application

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 Her Diabetes is poorly controlled and she is overweight
 Mrs. Spring is a 72 years old lady who is an independent resident of a two-bedroom
house. She likes socializing, gardening, cooking, etc. near the local senior citizen center
in her community. She has two children who live nearby and regularly visits her.
Assessment Completed
On presentation of Mrs. Spring to the healthcare, her vital signs were assessed. The blood
pressure was minutely elevated with value 155/110 mm Hg. Her blood glucose level was high.
She is having pain on her left leg and scored seven on a scale of 10. On examination of the right
foot, it was warm when touched, and pulses were palpable. The sensation in that foot appeared to
be healthy. In comparison, such characteristics were also evident on the left foot as well.
Wound Assessment completed
On initial presentation to the healthcare setting Mrs. Spring had a high level of thick
purulent exudate, the wound seems to be red and painful. The exudate is clear in color since the
treatment with an antibiotic. There was some malodor from the wound. The wound superficial in
depth with 20% cover with granulation and 80% covering with slough.
The major contributing factor for the wound is previous vein surgery which is one of the
critical factors for venous disease. While here the history of Diabetes is linked with a risk factor
of arterial disease. Feature such as the moderate to heavy exudate is characteristic of venous
ulcers. While the dull ache is a feature of venous disease. The position on the leg is not stated
making it challenging to differentiate between venous or arterial. The patient had a history of
vein surgery, this led to the venous leg ulcer.

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Investigation report
On administration of Clarithromycin 500 mg twice a day, she reported having reduced
pain. Conduction of ABPI showed the result of a score of 0.95. She was administered with a
mild compression therapy until she undergoes formal vascular assessment due to her pain and
discomfort with the application. Her right foot is warm to touch, and palpation of the pulse is
observed. The sensation on that foot appeared to be healthy. The ulcer was superficial in depth
with 20% cover with granulation and 80% covering with slough.
Mrs Spring’s Diabetes is poorly controlled, and appear to be morbidity obese. HBA1c is
9%, on the upper limit suggestive of poorly controlled Diabetes.
Current and past treatment
Mrs Spring wants to live a normal life. However, she is quite anxious about the leg ulcer.
She has to depend on her children to visit her GP. She had a fear of high wound exudate and the
occurrence of wound odor due to which she is not able to visit the senior center where she
usually enjoyed in the past. Earlier she has to dress her wound on her own.
Currently, she is undergoing antibiotic therapy and regular wound dressing in local
healthcare in the community. Mrs Spring visits GP three time a week, due to the substantial level
of exudate and pain. She is taking her current medications for pain relief.
Preliminary diagnosis with justification
The preliminary diagnosis is venous insufficiency with a venous leg ulcer. History of
vascular surgery and absence of pedal pulse reflects arterial disease which cannot be ignored.
She was presented with comorbidities which adversely affected the wound and quality of her

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life. There is a need to control her Diabetes with proper medication and modification in her
lifestyle. It is essential to manage the high level of exudate and shunting.
Reason for a referral
Mrs Spring visit to the GP on a regular basis for management of wound, concerning it
there is the need for dietician for future advice. She might get benefitted from it. I refer her to
you to enhance the immune function; controls blood glucose and to improve weight management
and weight loss. I would also request to include nutrition assessment and provide intervention as
it is an essential component for overall diabetic treatment. Appropriate diet plan with low carbs
and cholesterol can be beneficial for controlling the blood glucose level and prevent any further
damage to the blood vessel.
My involvement
I will help Mrs. Spring with her vital sign assessment and daily follow-ups in association
with an endocrinologist, dieticians, physiotherapist and general physician for a regular checkup. I
will also educate Mrs. Spring and her daughter regarding the disease and the importance of
intervention that are being provided to her.
Other parties involved
Along with Mrs. Spring and I, endocrinologist, general physician, and physiotherapist
will be involved. Mrs. Spring is undergoing a lot of stress and is socially isolated. Therefore, a
counselor and psychiatrist can help her with coping skills and get back to a normal life.
Regards