COMPREHENSIVE GERIATRIC ASSESSMENT TOOL

Biographical Data
Name: Hijara Dianalan
Address: Marantao
Age: 63
Sex: Female
Civil Status: Married
Religion: Islam
Educational Attainment: College
Employment Status: None

History of Present Illness

A case of a 63 years old woman from Barangay Maul, Marantao City has signs and
symptoms of rheumatoid arthritis. Pain reported on rheumatoid nodules present on
fingers, joints and feet. Experiences morning stiffness of joints, and exercises after to
alleviate pain. Patient has been taking 1 tablet of 200 mg Celcoxib per day as her
maintenance medication.

Past Medical History

Patient was born at home with a midwife and received no immunization, patient has no history
of infectious disease, she was hospitalized before at Amai Pakpak Medical Center due to Dengue and
discharged after five days in 2016, she has rheumatoid arthritis diagnosed in 2015, no known allergies,
and she is taking multivitamins.

Family History with Genogram

Acquired Diseases: Genogram

_x__ Hypercholesterolemia
_x__ Kidney Disease
_x__ Tuberculosis
_x__ Alcoholism
_x__ Drug Addiction

_x__ Hepatitis

Heredo-familial Diseases:
_x__ Diabetes
_x__ Heart Disease
_+__ Hypertension
_x__ Cancer
_x__ Asthma
_x__ Epilepsy
_x__ Rheumatism /Arthritis
___ Others: _________

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Personal Situation (Living condition, Economic situation)

Medication Review
(List of prescribed or over the counter medications the client is taking)

Name of drug and dosage:

___Celebrex (400 mg) as treatment for: inflammation, mild pain, fever
___Methotrexate (15 mg) as treatment for: reduce inflammation of joints
___Prednisone (10 mg) as treatment for: reduce inflammation of joints
___________________________ as treatment for: ______________________
___________________________ as treatment for: ______________________

General Observation:

The patient is a 63 years old female. Upon receiving, patient is conscious, fatigued and sitting
on a chair. She is wearing a simple blue dress covering her body and extremities. Patient is
coherent and responsive during interview. She responds appropriately to the questions being
asked of her and cooperated throughout the physical examination.

Vital Signs: T: __37.5 C_________

P: __94 bpm_________
R: __18 cpm_________
BP: __110/90 mm/Hg_________

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 REVIEW OF SYSTEMS

Integumentary Patients’s skin is cold, thin and pale. Less elasticity evident due to saggy and
crinkled appearance of patient’s skin. No lumps and swelling of the face,
absence of masses and there is no pain felt during palpation of face. No lesion
or scar on skin, except for black-coloured moles on buccal. The patient has a
well-trimmed nails, normal curvature and tissues surrounding nails are intact.
Capillary refill is 3 seconds. Rheumatoid nodules present on fingers, wrists and
toe, with inflamed left and right patellar. No skin irritation, no presence of
previous allergies, and no petechiae.

Respiratory Patient’s chest wall is inline with each other, with no masses and signs of
trauma or surgery. Chest wall bones are apparent with loss of subcutaneous
fat on chest area. Patient’s chest is warm to touch and dry. No adventitious
breath sounds upon auscultation. Respiratory rate during assessment is
18cycles per minute.

Cardiovascular Strong palpations on apical, carotid, and brachial pulse sites. No bruit sounds
heard upon palpation of carotid artery. Heart rate during assessment is 94
beats per minute. Oxygen saturation is 97%. Heart sounds are clear and strong.

Digestive Patient has denture, patient’s teeth are white in color. Abdomen is soft,
symmetric, and non-tender without distention. No abdominal mass palpated.
There are no visible lesions, or scars. The aorta is midline without bruit or
visible pulsation. Normal bowel sounds. . Patient’s stool is brown in color, and
is semi-formed to watery in texture. Circumference of abdomen to back is 53
cm.

Excretory Patience is not diaphoretic. Patient defecate semi formed stool to watery,
color is brown. Urine is amber in color and transparent

Musculoskeletal Patient is generally weak. Muscle strength of 4/5 on the upper and lower
extremities.

Nervous The patient has a good and straight posture with steady gait., and walks
without assistance and maintains balance while standing. Patient was able to
differentiate hot and cold sensation and sharp sensation as well. Patient
exhibited well-behaviour, and alertness, Coherent thought is clear, easy to
follow, and logical, and also oriented to time, date and year when asked.

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 Endocrine Weight and height are not taken. No history of goiter.. No enlargement of
thyroid. Skin is slightly warm to touch; no eyeball protrusion skin color is no
yellowish but is brown in complexion.

Reproductive A case of a 63 years old woman. Menarche at 14 years old and seized at forty-
eight years old, with an obstetric history of five pregnancies, five births on full
term, and five alive children.
FUNCTIONAL ASSESSMENT
KATZ INDEX OF INDEPENDENCE IN ACTIVITIES OF DAILY LIVING

ACTIVITIES INDEPENDENCE: DEPENDENCE:

POINTS (1 OR 0) (1 POINT) (0 POINTS)
NO supervision, direction or personal assistance WITH supervision, direction,
personal assistance or total
care

BATHING (1 POINT) Bathes self completely or needs help in (0 POINTS) Needs help with
bathing only a single part of the body such as the bathing more than one part of
back, genital area or disabled extremity. the body, getting in or out of
the tub or shower.
POINTS:_____1______ Requires total bathing.

DRESSING (1 POINT) Gets clothes from closets and drawers and (0 POINTS) Needs help with
puts on clothes and outer garments complete with dressing self or needs to be
fasteners. May have help tying shoes. completely dressed.
POINTS:_____1______

TOILETING (1 POINT) Goes to toilet, gets on and off, arranges (0 POINTS) Needs help
clothes, cleans genital area without help. transferring to the toilet,
cleaning self or uses bedpan
POINTS:_____1______ or commode.

TRANSFERRING (1 POINT) Moves in and out of bed or chair (0 POINTS) Needs help in
unassisted. Mechanical transferring aides are moving from bed to chair or
acceptable. requires a complete transfer.
POINTS:_____1______

CONTINENCE (1 POINT) Exercises complete self-control over (0 POINTS) Is partially or

urination and defecation. totally incontinent of bowel or
POINTS:_____1______ bladder.

FEEDING (1 POINT) Gets food from plate into mouth without (0 POINTS) Needs partial or
help. Preparation of food may be done by another total help with feeding or
person. requires parenteral feeding.
POINTS:_____1______

TOTAL SCORE: ______6______ A score of 6 indicates full function, 4 indicates moderate impairment, and 2 or
less indicates severe functional impairment.

LAWTON - BRODY
INSTRUMENTAL ACTIVITIES OF DAILY LIVING SCALE (I.A.D.L.)
Scoring: For each category, circle the item description that most closely resembles the client’s highest
functional level (either 0 or 1).
A. Ability to Use Telephone E. Laundry

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 1. Operates telephone on own 1 1. Does personal laundry completely 1
initiativelooks up and dials numbers, etc. 2. Launders small items-rinses stockings, 1
2. Dials a few well-known numbers 1 etc. 0
3. Answers telephone but does not dial 1 3. All laundry must be done by others
4. Does not use telephone at all 0
B. Shopping F. Mode of Transportation
1. Takes care of all shopping needs 1 1. Travels independently on public 1
independently transportation or drives own car
2. Shops independently for small 0 2. Arranges own travel via taxi, but does not 1
purchases 0 otherwise use public transportation
3. Needs to be accompanied on any 3. Travels on public transportation when 1
shopping trip 0 accompanied by another
4. Completely unable to shop 4. Travel limited to taxi or automobile with 0
assistance of another 5. Does not travel
at all 0
C. Food Preparation G. Responsibility for Own Medications
1. Plans, prepares and serves adequate 1 1. Is responsible for taking medication in 1
meals independently correct dosages at correct time
2. Prepares adequate meals if supplied with 0 2. Takes responsibility if medication is 0
ingredients prepared in advance in separate dosage
3. Heats, serves and prepares meals, or 0 3. Is not capable of dispensing own 0
prepares meals, or prepares meals but medication
0
does not maintain adequate diet
4. Needs to have meals prepared and served
D. Housekeeping H. Ability to Handle Finances
1. Maintains house alone or with 1 1. Manages financial matters 1
occasional assistance (e.g. "heavy work independently(budgets, writes checks, pays
domestic help") 1 rent, bills, goes to bank), collects and keeps
2. Performs light daily tasks such as track of income 1
dishwashing, bed making 1 2. Manages day-to-day purchases, but
3. Performs light daily tasks but cannot 1 needs help with banking, major purchases, etc. 0
maintain acceptable level of cleanliness 3. Incapable of handling money
4. Needs help with all home 0
maintenance tasks
5. Does not participate in any
housekeeping tasks
Score 3 Score 4

Total score______7____________

A summary score ranges from 0 (low function, dependent) to 8 (high function, independent) for
women and 0 through 5 for men to avoid potential gender bias.

PATTERNS:
Health-perception-health-management pattern

Patient perceives pain on joints as embedded in her everyday life. She feels restless due to
the constant pain but continues to participate in activities to still enjoy life. Patient is religious with
her drug regimen and drinks them on a daily basis.

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 ______________________________________________________________________________________

Nutritional-metabolic pattern

Patient’s typical food intake is coffee and bread for breakfast. Fish, vegetable soup and rice
for lunch and dinner. Fruits and vegetables are part of the the daily diet. Fried sweets for between
meal snacks. Patient avoids inflammation inducing foods like pastries, chocolate bars, sodas, cheese,
and crackers. Daily fluid intake is three liters. Weight is 75 kg. Patient is taking multivitamins.

______________________________________________________________________________________

Elimination pattern

The patient usually urinate five to six times a day, the color of the urin e is amber in color and
is transparent. The patient usually defecates one to two times a day, and the waste or stool is usually
brown in color, sometimes the stool is quite watery but most of the time it is formed. Excessive
perspiration occurs during exercise in the morning.

______________________________________________________________________________________

Activity and Exercise pattern

The patient is a very active 63 years old woman, and is very active in the household activities,
although she has limited ROM. Patient walks slowly and carefully due to pain in patella. Patient is also
engaged in social events like seminars, weddings, and visiting the sick. At minimum, patient attends a
social event every other day. She is fond of visiting her relatives around their barangay. Every
morning, after breakfast, patient waters and cleans the garden as exercise. Then at late afternoon,
waters again and tends her plants.
______________________________________________________________________________________

Cognitive-perceptual pattern

Patient has no hearing difficulty and does not use any hearing aid. Patient does not wear
glasses throughout the day, except when reading. No reported change in memory. Important decision
are easy to make, according to patient. Patient experiences stiffness on joints of fingers, wrists and
toes every morning. Throughout the day, she reports that pain on patellar is present.

Patient is oriented to time, date, and year. She hears whisper, and can read newsprint. Upon
interview, she shows exemplary ability to grasp ideas and questions; alternates speaking languages of
English, Filipino and Maranao when responding to questions; and encompasses great vocabulary level
and long attention span.
______________________________________________________________________________________

Self-perception Self-concept pattern

Patient properly describes herself and feels good about self. She says she copes with her
limited range of motion due to disease. Things that frequently make her annoyed are family

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problems. She feels anxious for her youngest son. She says she does not lose hope because she
believes in the divine power of the Creator. Patient maintained eye contact during interview , body
posture is normal and very relaxed.

______________________________________________________________________________________

Role relationship pattern

Patient lives with her husband, along with his son, daughter in law and grandchildren
harmoniously. Family depends on patient for financial accounting. Patient expressed her frustration
on son. Also, patient belongs to the social group of the community and is leading and making all
decisions necessary for the group. Patient reports satisfaction with her relationship to husband, family
and social groups.
______________________________________________________________________________________

Sexuality reproductive pattern

A case of a 63 years old woman. Menarche at 14 years old and seized at fourty-eight years
old, with an obstetric history of five pregnancies, five births on full term, and five alive children.
______________________________________________________________________________________

Coping-Stress-Tolerance pattern

During interview, patient says big changes in life in the last year is the birth of her grand
daughter. She reports that she experiences stress only on family problems and immediately organizes
a proper response to problem to lessen her stress.
______________________________________________________________________________________

Value-Belief pattern

Patient reports that she generally gets what she wants in life, and at the same time constantly
plans important activities for monthly and yearly activities. Patient reiterates importance of religion in
her life, and claims that she has been making the right decision since her religious devotion in Islam.
She says she receives light and guidance in her faith when difficulties arise.
______________________________________________________________________________________

PHSYLOGICAL ASSESSMENT

GERIATRIC DEPRESSION SCALE

Instructions: Choose the best answer for how you felt over the past week.

No. Question Answer Score

1. Are you basically satisfied with your life? YES / NO 0

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 2. Have you dropped many of your activities and interests? YES / NO 0

3. Do you feel that your life is empty? YES / NO 0

4. Do you often get bored? YES / NO 0
5. Are you hopeful about the future? YES / NO 0
6. Are you bothered by thoughts you can’t get out of your head? YES / NO 0
7. Are you in good spirits most of the time? YES / NO 0
8. Are you afraid that something bad is going to happen to you? YES / NO 1
9. Do you feel happy most of the time? YES / NO 0
10. Do you often feel helpless? YES / NO 1
11. Do you often get restless and fidgety? YES / NO 0
12. Do you prefer to stay at home, rather than going out and doing YES / NO 0
new things?
13. Do you frequently worry about the future? YES / NO 0
14. Do you feel you have more problems with memory than most? YES / NO 0
15. Do you think it is wonderful to be alive now? YES / NO 0
16. Do you often feel downhearted and blue? YES / NO 0
17. Do you feel pretty worthless the way you are now? YES / NO 0
18. Do you worry a lot about the past? YES / NO 0
19. Do you find life very exciting? YES / NO 0
20. Is it hard for you to get started on new projects? YES / NO 1
21. Do you feel full of energy? YES / NO 0
22. Do you feel that your situation is hopeless? YES / NO 0
23. Do you think that most people are better off than you are? YES / NO 1
24. Do you frequently get upset over little things? YES / NO 0
25. Do you frequently feel like crying? YES / NO 0
26. Do you have trouble concentrating? YES / NO 0
27. Do you enjoy getting up in the morning? YES / NO 0
28. Do you prefer to avoid social gatherings? YES / NO 0
29. Is it easy for you to make decisions? YES / NO 1
30. Is your mind as clear as it used to be? YES / NO 0
TOTAL 5
This is the original scoring for the scale: One point for each of these answers. Cutoff:
normal-0-9; mild depressives-10-19; severe depressives-20-30.
1. NO 6. YES 11. YES 16. YES 21. NO 26. YES

2. YES 7. NO 12. YES 17. YES 22. YES 27. NO

3. YES 8. YES 13. YES 18. YES 23. YES 28. YES
4. YES 9. NO 14. YES 19. NO 24. YES 29. NO
5. 5. NO 10. YES 15. NO 20. YES 25. YES 30. NO

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 Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric
depression screening scale: a preliminary report. J Psychiatr Res
1983; 17:37-49.

COGNITIVE ASSESSMENT
SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE (SPMSQ) version 1

Question Response Incorrect

Response
1. What are the date, month, and year? *
2. What is the day of the week? *
3. What is the name of this place? *
4. What is your phone number? *
5. How old are you? *
6. When were you born? *
7. Who is the current president? *
8. Who was the president before him? *
9. What was your mother's maiden name? *
10. Can you count backward from 20 by 3's? *
Total Errors
Scoring*
NOTE ON
SCORING
0-2 errors: normal mental functioning *One more error is
3-4 errors: mild cognitive impairment allowed in the
5-7 errors: moderate cognitive impairment scoring if a patient
has had a grade
8 or more errors: severe cognitive impairment school education or
less. One less error
is allowed if the
patient has had
education beyond
the high school
level.

Source: Folstein, F. (1975). A short portable mental status questionnaire for the assessment of
organic brain deficit in elderly patients. Journal of American Geriatrics Society. 23, 433-41.

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 NURSING CARE PLAN
Cues Subjective
“Hindi ako pwede tumayo o umupo ng matagal dahil sasakit and paa ko,” as
verbalized by patient.
Objective
Received patient, conscious, fatigued, and sitting on a chair, wearing a blue
dress covering her body and extremities. Patient has initial vital signs:
BP: 110/90 mmHg
PR: 94 cpm
RR: 18 bpm
Temperature: 37.5 C
O2 Sat: 97%
 Pale
 Active and responsive
 Unable to bend knee completely
 Swelling on left and right patella
 Limited ROM
 Rheumatoid nodules on small joints of fingers, wrist and toes.
 Gait changes
Pain scale of 7 out of 10

Pain related to inflammation as evidenced by fatigue and pain score of 7 out

Nursing
of 10.
Diagnosis

Objectives Within my hours of nursing care, patient will incorporate relaxation skills and
diversional activities into the pain control program.

Interventions  Maintain bed rest or chair rest when indicated. Schedule

& Rationale frequent rest periods and uninterrupted nighttime sleep.
Systemic rest is mandatory during acute exacerbations and
important throughout all phases of disease to reduce fatigue,
improve strength.
 Assess home environment for factors that create barriers to
physical mobility. To know if client needs referral.
 Consider reports of pain, noting location and intensity. Note
nonverbal pain cues.
 Assess and manage chronic and acute pain. Favorable in
determining pain management needs and effectiveness of the
program.
 Administer medication appropriately To reduce inflammation
and slow joint damage.
 Urge patient to perform ADLs such as practicing good hygiene,
dressing, and feeding himself to promote self-care ADLs that

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 can be done should be encouraged to maximize and function.
 Promote positive self-image. Patients with joint deformities may
experience a negative body image
 Discuss and provide safety needs such as raised chairs and
toilet seat, use of handrails in shower and toilet, proper use of
mobility aids. Relieves pressure on tissues and promotes
circulation. Facilitates self-care and patient’s independence.
 Encourage activity/exercise as tolerated. Patients feel fatigue
easily, but daily exercise can help loosen joints. Promotes joint
stability to reduce risk of injury, maintain proper body position.
 Nutrition and lifestyle education. Educate patients make
healthy diet choices by following an anti-inflammatory diet.
Encourage hydration.
 Evaluate clients for signs of depression (flat, affect, insomnia,
anorexia). Multiple studies demonstrated that depression and
decreased cognition in the elderly correlate with decreased levels of
functional capability.

Evaluation After my hours of nursing care, patient will incorporate relaxation skills
and diversional activities into the pain control program

DOCUMENTATION
Comprehensive Geriatric Assessment

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