Narrative Charting

Mrs. Dinah George is a 93-year-old Irish native female who was received in from the ER where she was transported after taking really bad fall. Mrs. George was climbing out of a car and trying to find her footing on the slick and rainy sidewalk Sunday night when she was spotted groaning on the sidewalk. There was a gash on her forehead and her left arm was bruised and bleeding. She had injured her hip in the fall and was rushed into ER at 0500 where she was admitted with a concussion, abdominal pain, bruised rib and serious concerns about her musculoskeletal and neurological health. Due to her age and the nature of her fall, there is concern that she may never be able to move around the way she did before. Pt is on the critical care floor where she has been placed on O2 with nose cannula and will be monitored for signs of progress.

Mrs. George is taking a lot of medication and while she is awake, she remains groggy and is not alert enough to eat or communicate. She lays resting in bed, slowly nodding her head as family members flip the tv channels and suddenly stopping when they see that she has stopped nodding, it means there is a show she wants to see. Very weak hand and leg strength. Has carpel tunnel in hands, takes Motrin IB to reduce the pain 2 times a day. Pt maintains IV in her right arm because she is left-handed. IV site shows signs of infection. Mrs. George’s are glassy but free of puffiness and redness. Mrs. George’s allergies and sinuses have been flaring up, likely due to the dust in the room and flowers from her floormate’s open room across the hallway. Mrs. George’s son and daughter-in-law come daily for lunch and dinner, sometimes alternating so that they can brush her teeth and bathe her in the bed. They also brush her hair while singing lullabies to her and telling her all about the events of the day.

Patient is not mobile. Has had foley for 24 hours, placed in at ER. Urine is getting progressively darker. May indicate an infection. No signs of skin irritation down on thighs or vaginal area, Not able to go on independently, no dryness or burning sensation when she urinates, small amount of blood detected in urine. Physician has ordered a urinalysis. No signs of edema on feet or legs. Vitals are 140/70, pulse is 100, temp is 99.5.