By D. Ateras. University of Maryland at Baltimore.

The following section offers some guidance on the four stages in composing such a letter purchase 17.5mg lisinopril with mastercard prehypertension risks. Preparation (a) Decide on your terms of reference What is your reason for writing the letter? An additional question to consider is whether you are the most appro­ priate person to write the letter purchase lisinopril 17.5mg blood pressure too low. In these cases you may need to refer to a senior colleague or manager before proceeding. Mistakes in a letter between clinicians may lead to misunderstandings or delays in the assessment and treatment of a client. Remember that your letter, like any other part of a health record, may be used as evidence in a court of law. Any mistakes are likely to reduce your credibility as a competent witness or defendant. Planning You can start to plan your letter once you have established your terms of reference and gathered the necessary information. You will need to select information that is relevant for both the purpose of the letter and the needs of the reader. Is it: ° to request information (for example information about previous treatment) ° to give information (for example test results) ° to request action (for example making a referral) ° to confirm an action has taken place (for example a discharge summary) ° to organise (for example making an appointment) ° to respond (for example replying to a complaint) ° to explain requirements (for example explaining procedures for making referrals)? Always consider your reader during the planning stage: What does he or she know already? For example, you may judge your explanation of events a successful response to a client’s complaint. However, it may disappoint the client if his or her expectation was that the letter would also include an outline of intended actions to prevent future occurrences. Drafting your letter Write your letter for your reader: ° Choose your words with care. Avoid unnecessary technical terms or abbreviations, especially when writing to clients. LETTERS AND REPORTS 79 ° Keep your sentences and vocabulary simple and straightforward. For example, rather than using ‘as soon as possible’, give an exact date. As they only have one answer, it may look as if you are trying to lead the reader to a specific conclusion. Editing your draft Once you have written your draft, you can check the content, spelling, grammar and presentation. Use the following checklist to help you make your edits: q Is it accurate? If it is still too long, you may need to write a report or call a meeting instead. Appointment letter – key content ° Name, address and identification details (date of birth, hospital number and so on) of the client. Common mistakes in appointment letters Inaccurate or out of date client address means delayed or misdirected post and appointments may be missed. Letters where the clinic address differs from that given on the headed paper are often confusing for the client. LETTERS AND REPORTS 81 Referral letter – key content ° Name, address and identification details (date of birth, hospital number and so on) of the subject of the referral. Common mistakes in referral letters Letter fails to provide sufficient details to enable the receiver to prioritise the referral. Client contact details are incomplete or out of date so it is difficult to notify the client about appointments. Important information relating to the client is omitted, for example the client requires an interpreter or hospital transport. Letter in reply to a complaint – key content ° Name, address and identification details of complainant.

It is recommended that shoes should generally be one size larger than previously worn because of a tendency of the feet to swell during the day generic 17.5 mg lisinopril visa prehypertension parameters. The patient should be assessed individually to ascertain the appropriate mattress for their long-term needs lisinopril 17.5 mg otc blood pressure medication equivalents. Patients are encouraged to contact the pressure clinic for information and advice regarding any aspect of their care. In addition, the community liaison staff while visiting the patient in the community are able to reinforce educational aspects. Bladder care Patients are taught the most effective method of bladder emptying (see chapter 7). Although men with high tetraplegia can often tap over the bladder to induce a detrusor contraction, they may require help to apply a sheath and to fit Figure 12. In women with high tetraplegia the bladder is often assess pressure distribution, which helps to prevent skin breakdown. Patients whose bladder emptying method • Intermittent self-catheterisation is preferred method for those involves an indwelling catheter are taught to regularly use a with acontractile bladders catheter valve (which can be opened and closed), to maintain • Condom sheath drainage in contractile bladders bladder volume and compliance. Intermittent clean self- • If indwelling catheter, suprapubic catheter is preferable to urethral catheter, to avoid urethral damage. Use catheter valve to catheterisation is the preferred method for most women and maintain bladder compliance and capacity men with paraplegia and some with low tetraplegia. Long-term bladder management Urinary tract infections are common but may be reduced by adequate hydration and often by urinary acidification. In general antibiotics are given only when an infection causes systemic symptoms. If recurrent urinary tract infections occur the patient should be investigated for underlying causes such as stones in the Box 12. Various surgical • Treat with antibiotics only if systemic symptoms present interventions are available in selected patients (see chapter 7). Patients with high tetraplegia generally have poor balance and have to be hoisted on to a padded shower chair which can be wheeled over a toilet. In some circumstances bowel evacuation may need to take place on the • Upper motor neurone cord lesion bed with the patient in the left lateral position. Patients who carry out manual evacuation are advised to keep their stools slightly constipated to ease removal. They should be able to transfer themselves onto a toilet, and the seat should be padded to prevent pressure sores from developing due to prolonged sitting. In practice most patients evacuate their bowels daily or on alternate days. When possible, the timing and frequency of bowel evacuation should be made to fit in with the Box 12. Patients are advised to maintain their bowel regime and to avoid • Daily or on alternate days strong oral and rectal stimulant laxatives and enemas. Further • Maintain consistent bowel regime educational principles are described in chapter 8 on nursing. Long-term options which can address chronic bowel management problems include colonic irrigation via the rectum, or through an abdominal stoma (an antegrade colonic enema), or a stoma, such as a colostomy. Autonomic dysreflexia Autonomic dysreflexia is commonly associated with bladder or Box 12. By the time of High lesion patients must: discharge from hospital, patients should be fully aware of the • be aware of the signs and symptoms signs and symptoms of autonomic dysreflexia and be able to • be able to direct care. In the long term, most patients tend to be • Diet of good nutritional standard, to include 5 servings of fruit constipated and will benefit from dietary re-education. A diet of and vegetables per day good nutritional standard but with a controlled calorific • Change of diet affects bowel management content is important. Care needs to be taken in changing the diet if constipation, or more seriously diarrhoea with a risk of bowel accidents, is to be avoided. Teaching the family and community staff When patients are discharged from hospital they should be thoroughly responsible for their own care. If the patient wishes, family members are given individual instruction on how to help in their care and have the opportunity to attend a study day about all aspects of spinal cord injury.

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