General Information
E.S. is a 94 year old female, born July 30, 1909. She is widowed. She is of Catholic religion. She stated that her mother was from Germany and her father was from Ireland. She is an only child, and never finished school because she married at a young age. Her date of admission was July 8, 2002 with the diagnosis of left hip fracture and dementia. She was hospitalized for the left hip fracture on July 2, 2002, and then transferred to the nursing facility due to the inability of client to care for herself, as evidenced by inability to remember if she took her medication and needing assistance when toileting. Her code status is a DNR, comfort measures only. Antibiotics for infections are ok, but no feeding tubes or IV fluids. She has full upper and partial lower dentures. She receives a bed bath and has her nails and hair done once a week. She uses a wheelchair for ambulation, she needs assistance to help rise from her wheelchair to stand, and is unable to walk. Activity level is limited to those of which can be done in a wheelchair. She needs stand-by assistance with toileting and helping with transfers to and from her wheelchair.
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