Nicole Smith (Case Note)
Nicole Smith (Case Note)
41 Vulture St
West End
Brisbane 4101
13 September 2009
Dear Director,
I am writing to refer Ms. Smith, an 18-year-old single mother who recently delivered a baby boy via
Caesarian Section. She requires care and support.
During hospitalisation, she had difficulty with vaginal delivery which took 16 hours labour. Therefore,
emergency Caesarian operation was performed due to foetal distress and progress failure. She had post
partum haemorrhage of 800mls as a result her haemoglobin was 90g/L for this reason she commenced
on Fefol and Vitamin C. Furthermore, she started breastfeeding but hesitant and opting to change to
bottle feeding, and she is also apprehensive in bathing and caring for the baby. Moreover, the baby is
progressing and feeding well, and weighs 4.1kg.
Socially, she lives in a shared flat and currently on a single parent pension. She has no relatives in
Brisbane and is estranged with the father of the baby as well as with her parents. Moreover, she is
reluctant towards her ability to be a good mother and has thought of offering the baby for adoption.
It would greatly appreciated if you could arrange a home visit for Ms. Smith to provide appropriate
advice and support in caring for her baby.
Yours sincerely,
Leah H. Valencia RN