COMPREHENSIVE GERIATRIC ASSESSMENT FORM

Date of Assessment: _____________________

A. PERSONAL DATA ASSESSMENT
Advanced Health Directive Planning
DNR Directive: none
Living Will: none
Medical Power of Attorney: none
Financial Health Planning
Primary source of healthcare:Kiangan
Medical Care Dialysis Center and
Panopdopan District Hospital
Financial resources related to illness: PCSO,
PhilHealth, Senior Citizen, Children
Justification/ Pathophysiological basis
The patient haven’t secured any of the
documents mentioned because she
feels like “she is ready for whatever
may happen because she accepted the
fact that she going to die someday”.
Patient seeks financial health planning
from the nearest medical care unit
depending on condition.
Senior citizen health care benefits is
one of the financial resources related
to illness of the patient because she is
over 60 years old.

B. MEDICAL ASSESSMENT Justification/ Pathophysiological basis

Vital Signs Normal according to Armstrong
Temperature (2020)
Rate: 35.6 ̊ C
Route: axillary
Peripheral pulse Normal PR and rhythm: 60-100 bpm,
Rate: 80 bpm so Sinus Rhythm (Regular). Pulse
Rhythm: regular amplitude: absent 1+ = diminished,
Location: radial barely palpable, easy to obliterate 2+
Pulse amplitude: strong = easily palpable, normal 3+ = full,
increased 4+ = strong, bounding,
cannot be obliterated
Apical pulse *see above rationale There are two
Rate: 80 bpm types of murmurs (innocent and
Rhythm: regular abnormal) the former is commonly
Murmurs: none present in children and not worrisome.
However, the latter is commonly
present in adults with abnormal heart
conditions.
Respirations Normal RR and rhythm: 12-20 cpm,
Rate: 16 cpm so eupnea. No indication of labored
Rhythm: normal breathing, no use of
Use of accessory muscles: none sternocleidomastoid, spinal, and neck
Lung sounds:Bronchial, Vesicular, Bronchovesicular: muscles in respiration. Normal
no adventitious lung sounds sounds: Loud, high-pitched bronchial
breath sounds over the trachea.
Medium pitched bronchovesicular
sounds over the mainstream bronchi,
between the scapulae, and below the
clavicles. Soft, breezy, low-pitched
vesicular breath sounds over most of
the peripheral lung fields.
General appearance:patient lying in bed: fatigued The patient is lying in bed because she
just had her dialysis, also she is
feeling sleepy because of fatigue.
Allergic reactions on As per the patient
 Medication: none
Food: none
Environment: Dust and animal scurf
Vaccinations: The patient’s vaccines were mostly
1. Hepatitis B from neonate to childhood.
2. Influenza
Health promotion activities: All measures aforementioned were
1.Visit optometrist every year given to suit the patient need as well
2. Eating only allowed food. as her condition.
3.Moving around the house as a form of
exercise.

Long term conditions: ---

1. Myopia
2. N/A
Recurring conditions: ---
1. N/A
2. N/A
Regular clinics and therapies: Due to current condition
1. Dr. Sandra Bonay
2. N/A
3. N/A
Surgical history: ---
1. Breast Cyst
2. N/A
Eyes/ Vision Normal as per Weber and Kelley
Eyes: redness and swelling of the eye (2018)
Pupil:Pupils are equally round but the right
pupil does not react properly to light, and has
also problems with accommodation in right
pupil.
Use of glasses: Yes
Ears/ Hearing Normal as per Kozier and Erb (2015)
Hearing: responds appropriately
Hearing aid: none
Skin integrity
Sacar/s: None
Wound/s: None
Surgical incisions/s: None
Mucous membranes: Oral cavity is moist and intact
Lips are well hydrated
Airway clearance Normal as per Kozier and Erb (2015)
Mouth: clear airway clearance without
obstruction
Nose: clear airway clearance without
obstruction

Color Patient’s skin is tan because she is

Skin: brown Filipino. Assessments regarding the
Nails: pinkish color of the nails and lips reveal
Lips: pinkish normal as per Kozier&Erb (2015).
Capillary refill:color returns within 2-3 seconds Normal: In the Blanch Test, the color
of the nail of the patient in the index
finger returned to usual color in 2-3
seconds.
Oxygen therapy: none ---
C. PHYSICAL AND FUNCTIONAL Justification/ Pathophysiological basis
ASSESSMENT
Current Activity: lying in bed: sedentary lifestyle Unhealthy, but the patient is fatigued.
Sleep: 5-8 hrs. Normal
Body Frame: mesomorph Normal
Gait: movements are coordinated Normal
Coordination: well-coordinated Normal
Balance: able to balance Normal
Muscle Strength 1-Visible muscle contraction with no
Right upper extremity:4/5 or trace movement.
Left upper extremity: 4/5 2-Limb movement, but not against
Right lower extremity: 4/5 gravity.
Left lower extremity: 4/5 3-Movement against gravity but not
resistance.
4-Movement against at least some
resistance supplied by the examiner.
5-Full strength.
Motor
Fine: can hold pen and write in paper Positive
Gross: can get and hold bottle of water Positive
Range of Motion 1-Visible muscle contraction with no
Abduction: 4/5 or trace movement.
Adduction: 4/5 2-Limb movement, but not against
Flexion: 4/5 gravity.
Extension: 4/5 3-Movement against gravity but not
resistance.
4-Movement against at least some
resistance supplied by the examiner.
5-Full strength.
Pain: none
Provocation:when eyes are blinking
Palliation:when eyes are blin king
Quality:shooting pain
Region:eyes are
Radiation:Yes. Pain to headache
Severity scale:6
Time onset/ timing: Gradual pain felt,

Basic Activities of the Daily Living

Activity Score Justification/ Pathophysiological basis
1. Bathing 1 Can bath self, yet needs assistance in
washing her back.
2. Dressing 1 Can do all the dressing by herself.
3. Toileting 1 Goes to toilet, gets on and off,
arranges clothes, washes genitalia by
herself.
4. Transferring 1 Moves in and out of bed or chair
unassisted
5. Continence 1 Exercises complete self-control over
urination and defecation.
6. Feeding 1 Can feed herself, route is oral.
Total 6
Interpretation Independent
Morse Scale (Falls Risk) Score
Age 0
Fall History 0
Mobility 0
Elimination 0
Medications 0
Patient care equipment (IV, Feeding Tubes, 0
Indwelling Catheters, etc.)
Total 0
Interpretation

Instrumental Activities of the Daily Living

Activity Score Justification/ Pathophysiological basis
1. Telephone 1 Was seen using her phone on initiative
2. Traveling 1 Able to travel
3. Shopping 1 Takes care of all shopping need
independently
4. Preparing meals 1 Plan, prepare, and serves adequate
meals independently
5. Housework 1 Able to do majority of housework’s
6. Medication 1 Is responsible for taking medication in
correct dosages at correct time.
7. Money 1 Launders small items
Total 7
Interpretation Independent

D. NUTRITIONAL ASSESSMENT Justification/ Pathophysiological basis

Diet Restriction: DASH diet
Fluid Intake: limited fluid intake
Weight: 42.5 kg
Height: 150 cm
BMI: 18.89
Interpretation: normal
Skin turgor: intact, goes back immediately
Gag reflex: active
Swallow: able
Appetite: good appetite
Food likes: vegetables
Food dislikes: salty foods
Elimination- bowel:
Stool
Frequency: 2-3 times a week
Consistency: soft
Color: brown
Elimination- bladder: Voluntary control of the external
Urine sphincter muscles enables healthy
Frequency: 1-2 times a day adults to hold larger amounts within
Color: yellow the bladder until urination is
Amount: approximately 100 ml convenient. Most adults void between
Transparency: clear to transparent 6 and 10 times per day, but this may
vary greatly, depending on fluid
consumption, personal habits, and
emotional state.
Abdomen
Contour: scaphoid
Bowel Sounds
Right lower: gurgles, 5-30/min
Right upper: gurgles, 5-30/min
Right upper: gurgles, 5-30/min
Left lower: gurgles, 5-30/min
Mini Nutritional Assessment- Screening
Screening
1. Has food intake declined over the
past 3 months due to loss of
appetite, digestive problems,
chewing or swallowing
difficulties?
2. Weight loss during last 3 months
3. Mobility
4. Has suffered psychological stress
or acute disease in the past 3
months
5. Neuropsychological problems
6. Body mass index (BMI)
Total 10
Interpretation Possible malnutrition—continue assessment
Mini Nutritional Assessment
Assessment
1. Lives independently
2. Takes more than 3 prescription
drugs per day
3. Pressure sores or skin ulcers
4. How many full meals does the
patient eat daily?
5. Selected consumption markers for
protein intake
6. Consumes two or more servings
of fruit or vegetables per day?
7. How much fluid is consumed per
day?
8. Mode of feeding
9. Self- view of nutritional status
10. In comparison with other people
of the same age, how does the
patient consider his/ her health
A scaphoid or boat-like abdomen
suggests weight loss, with possible
malnutrition.
Score Justification/ Pathophysiological basis
1 According to the patient there is
moderate decrease in food intake
because of the diet she follow.
3 The patient did not lose weight
2
2 The patient did not suffered
psychological stress or acute disease
in the past 3 months
2 The patient has no psychological
problems
0 The patient BMI is 18.89
Score Justification/ Pathophysiological basis
0 The patient lives with her husband and
grandchildren together.
1 The patient does not take more than 3
drugs in a day.
1 There are no presence of pressure or
skin ulcers during the assessment.
1 According to the patient she eat one
full meal daily.
0.5 The client eats oneor more servings
fish and small amount of meat
1 The client usually eats green leafy
vegetables like bitter gourd, Chinese
cabbage and the likes, fish and small
amount of meat when served in the
table.
0 The patient consume less than 3 cups
per day
2 The patient feeds herself without any
problems
2 According to the client, she views
herself as having no nutritional
problems
0 According to the patient her health
status is not good as other people of
the same age.
 status?
11. Mid- arm circumference (MAC) 1 The client's MAC is 22, which is a
measurement that helps medical staff
to easily assess whether a patient is
acutely malnourished.
12. Calf circumference (CC) 1 The patient's CC is 31, an
anthropometric parameter that has
been linked to the nutritional status of
the elderly population and is closely
related to whole-body muscle mass.
Total 10.5
Interpretation At risk for malnutrition

E. PSYCHOLOGICAL/ PSYCHIATRIC Justification/ Pathophysiological basis

ASSESSMENT
Level of Consciousness
E:open and blink eye spontaneously
V:converses normally, responds appropriately
M:follows instructions
Orientation
Person:knows husband’s name
Place:knows where she is
Time:knows what day today
Memory
Immediate:Patient is able to repeat Numbers
that is previously told
Recent:Patient knows what meal she had
eaten at breakfast
Remote:Patient knows her husband’s birthday
and death anniversary
Health attitude: positive attitude
Nonverbal Behaviors:Patient maintain eye contact
and nods when she agrees to a certain statement

Mini Mental State Examination

Questions Score Justification/ Pathophysiological basis
“What is the year? Season? Date? 5 The patient is oriented to date and
Day? Month?” time
“Where are we now? State? 5 The patient is oriented to place where
County? Town/city? Hospital? she/he is in.
Floor?”
The examiner names three unrelated 3 The patient’s registration is normal
objects clearly and slowly, then the
instructor asks the patient to name all
three of them. The patient’s response
is used for scoring. The examiner
repeats them until patient learns all of
them, if possible.
“I would like you to count backward 4 The patients attention and calculation
from 100 by sevens.” is in sync
Alternative: “Spell WORLD
backwards.”
“Earlier I told you the names of three 3 The patient’s recall is good
things. Can you tell me what those
were?”
Show the patient two simple objects, 2 The patient’s language is good
such as a wristwatch and a pencil,
and ask the patient to name them.
“Repeat the phrase: ‘No ifs, ands, or 1 The patient’s language is good
buts.’”
“Take the paper in your right hand, 3 The patient’s three stage command is
fold it in half, and put it on the floor.” good
“Please read this and do what it 0 The patient’s reading and writing is
says.” not good
“Make up and write a sentence about 0 The patient’s reading and writing is
anything.” not good
“Please copy this picture.” 1 The patient’s construction is good
TotalA total score of 27 indicates that the patient is normal
and has no cognitive impairment.
Interpretation Normal

Geriatric Depression Scale

Question Score Justification/ Pathophysiological basis
1. Are you basically satisfied with 0
your life?
2. Have you dropped many of your 0
activities and interests?
3. Do you feel that your life is 0
empty?
4. Do you often get bored? 0
5. Are you hopeful about the future? 0
6. Are you bothered by thoughts you 0
can't get out of your head?
7. Are you in good spirits most of 0
the time?
8. Are you afraid that something bad 1
is going to happen to you?
9. Do you feel happy most of the 0
time?
10. Do you often feel helpless? 0
11. Do you often get restless and 0
fidgety?
12. Do you prefer to stay at home 0
rather than go out and do things?
13. Do you frequently worry about 0
the future?
14. Do you feel you have more 0
problems with memory than
most?
15. Do you think it is wonderful to be 0
alive now?
16. Do you feel downhearted and 0
blue?
17. Do you feel worthless the way 0
you are now?
18. Do you worry a lot about the 0
past?
19. Do you find life very exciting? 0
20. Is it hard for you to get started on 0
new projects?
21. Do you feel full of energy? 0
22. Do you feel that your situation is 0
hopeless?
23. Do you think that most people are 0
better off than you are?
24. Do you frequently get upset over 0
little things?
25. Do you frequently feel like 0
crying?
26. Do you have trouble 0
concentrating?
27. Do you enjoy getting up in the 0
morning?
28. Do you prefer to avoid social 0
occasions?
29. Is it easy for you to make 1
decisions?
30. Is your mind as clear as it used to 1
be?
TotalA total of 3 indicates that the patient has no syptoms
of depression.
Interpretation Normal

F. SOCIAL- ENVIRONMENTASSESSMENT Justification/ Pathophysiological basis

Name of Caregiver: Mrs. P
Caregiver relationship: mother and daughter
Caregiver stress: none
Significant others: daughter
Social engagement: work
Current social support: family
Pets: 3 dogs
Personal safety concerns: none
Home safety concerns: none
Signs of neglect or abuse: none
Hobbies and favorite activities: watching