Nursing Admission Form for Ms. Rebecca Moskowitz

QUESTION

Identification: – Ms. Rebecca Moskowitz is a 79-year-old, Jewish lady who lives alone.

Situation: – Ms. Moskowitz presented to the emergency department at 8:00 am this morning after a fall on the stairs in her two-story home at 6:30 am this morning. X-Ray of the right-sided elbow has revealed an Olecranon fracture. She has also sustained a small wound on her left elbow. She vomited once after having a sandwich around 11:00 am. Since then, she has refused to eat or drink anything. She has been transferred to the medical ward for a 48-hour observation. Ms. Moskowitz’s right arm has been placed in a back slab cast for 2 weeks.

Background – Ms. Moskowitz’s past medical history includes:

• Unstable diabetes mellitus which was diagnosed at the age of 35 (Metformin 500mg / BDS)
• Diagnosed with osteoporosis last year (Fosamax 35 mg orally once a week)
• Hypertension (Ramipril 5mg / ODS)
• Operated for Uterine fibroid at the age of 30 post-pregnancy

Personal, Social & family background:

• Lives alone in her own two-story house, independent with all ADLs. Has a cleaner come in once/ week. Her 52-year-old son and his family live nearby and are very supportive of their mother.
• Is retired. No Financial stress.
• Reports many social friends. Alcohol intake is the occasional Sherry at night.
• History of smoking (10 -12 cigarettes per day), however, quit smoking since she diagnoses with Osteoporosis.
• Poor diet quality, as she does not like to cook for ‘just herself’. Prefers ready-to-cook meals.

Assessment: On examination, you note that the patient has a temperature 380C, BP – 155/ 88, RR- 18/min, and Pulse reported as 86/min, she is having 6 /10 pain in her right elbow. O2 saturation 100% on room air. Ms. Moskowitz is 156cm and her weight is 82 kg.

Recommendation: 1 hourly observation for the next 12 hours including neurological observation. Regular pain assessment. Encourage food and fluid intake. Monitor for any dizziness, headache or nausea, or vomiting.

QUESTION: Referring to the information provided in Rebecca Moskowitz’s case study, dowload and complete the nursing admission form, on the template provided, using appropriate medical terminology. Ensure the documentation meets legal requirements.

ANSWER

Nursing Admission Form for Ms. Rebecca Moskowitz

Patient Information
Name: Ms. Rebecca Moskowitz
Age: 79 years
Gender: Female
Date of Admission: [Date]
Medical Record Number: [Unique ID]
Address: [Home Address]
Contact Number: [Phone Number]
Emergency Contact: [Emergency Contact Information]
Religion: Jewish

Medical History
Unstable Diabetes Mellitus diagnosed at 35 years:
Medication: Metformin 500mg BDS
Osteoporosis diagnosed last year:
Medication: Fosamax 35mg orally once a week
Hypertension:
Medication: Ramipril 5mg ODS
Uterine fibroid surgery at the age of 30 post-pregnancy

Allergies
No known allergies

Social History
Lives alone in a two-story house, independent with ADLs
Supportive 52-year-old son and family living nearby
Retired with no financial stress
Occasional social drinking (sherry)
Quit smoking (10-12 cigarettes/day) after osteoporosis diagnosis
Poor diet quality, prefers ready-to-cook meals

Physical Assessment
Temperature: 38.0°C
Blood Pressure: 155/88 mmHg
Respiratory Rate: 18/min
Pulse Rate: 86/min
O2 Saturation: 100% on room air
Height: 156cm
Weight: 82 kg
Pain Assessment: 6/10 pain in right elbow

Admission Diagnosis
Olecranon fracture
Small wound on left elbow

Plan of Care
1-hourly observation for the next 12 hours
Neurological observation
Regular pain assessment
Encourage food and fluid intake
Monitor for dizziness, headache, nausea, or vomiting

Signature
[Your Name]
[Title]
[Date]