Elder: Patricia Giles

Visit #3

11-7-18

My visit with Pat was focused on her mobility and possibility of falls. As I’ve written
before, Pat is able to walk around the house without serious problems. She does have some pain
when walking for prolonged periods because of the numbness in her feet from her diabetes. She
said the pain in her feet when walking is a 4/10. I first focused on her risk for falls when walking
around her house. I noticed that she has bars in her bathroom and by her bed. She had rugs
around the house and I talked to her about the possibility of falling with them, but it is her house
and she said she likes the rugs. She only needs some help when standing up, which she uses the
bars by her bed and toilet for. Her husband helps her up at other times. He is very mobile and
independent. When discussing her neuropathy pain, the methods of management I suggested
were monitoring her diabetes more closely and considering talking to her physician about
medication if the pain gets worse and impairs her mobility. I also talked to her about purchasing
shoes that are designed for diabetics to help make walking easier and more comfortable.

Physical Assessment:
Skin: Intact, good turgor, no wounds, warm
Respiratory: Normal breath sounds, no effort with breathing, symmetrical, no O2 assistance
Gastrointestinal: Colostomy last emptied 2 days ago, Low carb diet (diabetic diet)
Genitourinary: Nocturia, no painful urination, excessive urination throughout day
Cardiovascular: Normal heartbeat, radial pulse 2+, normal skin color, good capillary refill
Neurological: PERRLA, oriented x3, normal behavior, open, clear speech, glasses
Musculoskeletal: Normal ROM, able to walk independently, numbness in toes, assistance in
standing with bars
Pain: 2/10 with feet sitting, 4/10 when walking, very bothersome
Glucose Level: 240