1349: Initial home visit performed. The client was hospitalized last week for four days following a ground-level fall, delirium, and cystitis. The client is alert and fully oriented. Clear lung sounds bilaterally. Peripheral pulses 2+. Her muscle movements were uncoordinated as she missed grabbing the television remote and a can of cola. Speech was intelligible with some pauses. When ambulating to the bathroom, she used scattered furniture as assistive devices. Skin is warm, dry, and normal for ethnicity. She reports significant fatigue throughout the day. She states that during the day, the heat bothers her, so she is reluctant to go to the mailbox. She is also tired while cooking and cleaning in the evening hours. Since discharge, the client reports that she sleeps 7-8 hours, but does not feel rested in the morning. She reports that her urine is clear and without odor, but she has an urgency when going to the bathroom. She reports numbness and tingling in the lower extremities that last all day. She does report her legs ‘stiffening up’ intermittently throughout the day. She reports that she is taking the prescribed antibiotic when she remembers. Denies any loss of appetite and has increased her fluids with cola and sweet tea since discharge.

• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm 
• multivitamin 1 tablet daily 
• ergocalciferol 10,000 international units p.o. daily

1349: Initial home visit performed. The client was hospitalized last week for four days following a ground-level fall, delirium, and cystitis. The client is alert and fully oriented. Clear lung sounds bilaterally. Peripheral pulses 2+. Her muscle movements were uncoordinated as she missed grabbing the television remote and a can of cola. Speech was intelligible with some pauses. When ambulating to the bathroom, she used scattered furniture as assistive devices. Skin is warm, dry, and normal for ethnicity. She reports significant fatigue throughout the day. She states that during the day, the heat bothers her, so she is reluctant to go to the mailbox. She is also tired while cooking and cleaning in the evening hours. Since discharge, the client reports that she sleeps 7-8 hours, but does not feel rested in the morning. She reports that her urine is clear and without odor, but she has an urgency when going to the bathroom. She reports numbness and tingling in the lower extremities that last all day. She does report her legs ‘stiffening up’ intermittently throughout the day. She reports that she is taking the prescribed antibiotic when she remembers. Denies any loss of appetite and has increased her fluids with cola and sweet tea since discharge.

1539: Environmental assessment completed. The client resides in a two-story home, with the bathroom located on the second floor. Loosely fitted grab bars were observed in the bathroom. She reports using the shower curtain for support when getting in and out of the tub. No scatter rugs were identified. Lighting is adequate in all hallways and in the bathroom. Medications were stored, though some were mixed together. She lives with her daughter, who occasionally leaves her alone for approximately 7–8 hours while at work.

1349: Initial home visit performed. The client was hospitalized last week for four days following a ground-level fall, delirium, and cystitis. The client is alert and fully oriented. Clear lung sounds bilaterally. Peripheral pulses 2+. Her muscle movements were uncoordinated as she missed grabbing the television remote and a can of cola. Speech was intelligible with some pauses. When ambulating to the bathroom, she used scattered furniture as assistive devices. Skin is warm, dry, and normal for ethnicity. She reports significant fatigue throughout the day. She states that during the day, the heat bothers her, so she is reluctant to go to the mailbox. She is also tired while cooking and cleaning in the evening hours. Since discharge, the client reports that she sleeps 7-8 hours, but does not feel rested in the morning. She reports that her urine is clear and without odor, but she has an urgency when going to the bathroom. She reports numbness and tingling in the lower extremities that last all day. She does report her legs ‘stiffening up’ intermittently throughout the day. She reports that she is taking the prescribed antibiotic when she remembers. Denies any loss of appetite and has increased her fluids with cola and sweet tea since discharge.

1539: Environmental assessment completed. The client resides in a two-story home, with the bathroom located on the second floor. Loosely fitted grab bars were observed in the bathroom. She reports using the shower curtain for support when getting in and out of the tub. No scatter rugs were identified. Lighting is adequate in all hallways and in the bathroom. Medications were stored, though some were mixed together. She lives with her daughter, who occasionally leaves her alone for approximately 7–8 hours while at work.

Two-Week Follow-Up Visit

1234: Client reports feeling slightly more rested in the morning but continues to experience daily fatigue and numbness in the lower extremities. States, “I’m still tired when I clean or cook, and the heat makes it hard to go out.” Urinary urgency persists, though urine remains clear and without odor. Reports of tingling and intermittent leg stiffness. The home remains on a two-story layout, with the bathroom still located on the second floor. A bedside commode was noted on the ground floor. Client reports that a home health assistant visits twice a week. Medications were organized in a pill organizer with a digital alarm. The bathroom on the second floor had flickering lights and lacked a shower curtain. She denies any recent falls.