Admission Notes

Molly Jones aged 82 years old arrived by ambulance and was admitted to Belleview Aged Care Facility on 08.08.12, 12 in the morning. Vital signs has been taken blood pressure is 90/60 mmhg, temperature is 36.8, respiration is 16 and heart rate is 80; her weight on transfer is 35 kg. Molly is with her husband tom 88 years old been married for 66 years and never been separated for more than one night in that time prior to accident. They have no children and their close relative is a niece who lives 4 hours away.

Prior to admission molly attempted to cross the princess highway and was hit by a semi-trailer resulting to head injuries, fractured right clavicle, dislocated left wrist, fractured right hip and abdominal injuries. Molly had initial surgery on August 8th to have burr holes drilled in her skull to relieve the pressure of inter-cranial bleed, following the repair of her perforated bowel and has been left with permanent colostomy. August 9th she had the repair for her dislocated right hip, right clavicle and left wrist. August 14th while in hospital she had fall where she fractured her right wrist resulting to both arms in plaster. Molly fell as the night staff had left her without a buzzer and she wanted to drink of water and leaned out of bed to far and fell between locker and the bed. Molly is in denial with her colostomy and requires total assistance for all her ADLs. Shes refusing to eat because she thinks if she did not eat she might send back home-, as per dietician advice she needs high CHON (protein) supplements and small servings of nutritious meals. Physiotherapist ordered that she has passive exercised performed at least bd but preferably tds. Molly has pressure ulcers on both hips, her sacrum, both heals, left ear and right shoulder all of which require multiple complex dressing. Her colostomy acts irregularly due to poor dietary intake. She has poor fluid intake that requires close monitoring and incontinent in urine.