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hi i need help with completing the admission form and discharge…

 

hi i need help with completing the admission form and discharge process template based on the case study. i have attached both documents. and case study is below. thanks:)

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Case Scenario:
Name Eileen Rowbottom Gender: Female D.O.B 15/5/1940
Allergies Penicillin- rash Admitting diagnosis: Functional Decline secondary to UTI
Admitted via Emergency, bought in by neighbour who noticed patient not leaving the house as usual (normally seen
gardening twice a week and catches bus to church on Sundays). Normally can walk 25 metres. Found in home looking
unkempt and thinner, house messier than normal, Webster packs unopened. Patient was more confused than normal
and malodourous as she has been incontinent of urine. Was complaining of abdominal pain (acute) and chronic lower
back pain. Current weight on admission 45kg.
Past medical history O.A. HTN, GORD, Hyperlipidaemia,
Social history
Eileen was born in England and migrated to Australia at aged 12. Her faith is of the Church of England. She lives home
alone and cancelled community services cleaner as “was not doing a good enough job” but still has MOWS bought every
second day. Eileen has 2 sons, one lives interstate and the other lives approximately one hour away, comes to visit
approximately every fortnight. Eileen has been widowed for 6 years.
She walks with a 4-wheel frame when she leaves the house but around the house holds onto furniture. Denies falls, but
old bruising noted on body. Has no medical power of attorney. Nil recent hospital admissions, has mild hearing
impairment, nil visual impairments and is usually continent. Eileen states she forgets to eat sometimes and often forgets
to wear her dentures. There is no active Advanced Care plan.
Vitals:
BP: 160/90 mmHg, HR- 99 bpm, Temp- 35.8°C, RR- 20 bpm, Oxygen Saturations- 94%, pain 6/10
Skin inspection:
Old bruising found on r) lateral thigh and r) forearm. Non blanching redness noted on intact skin on sacrum. Lower legs
appear slightly oedematous and dry. Skin on hands dry and thin with small skin tear on L) dorsum.

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