UNIVERSITY OF SAN CARLOS

DEPARTMENT OF NURSING
CEBU CITY

ASSESSMENT TOOL FOR THR ELDERLY CLIENT

CLIENT DETAILS

Name of Client: Bernadita A. Cañeda                     Age: 68

Sex: Female                                  Date of Birth: January 4, 1953
Marital Status: Divorced                         Religion: Roman Catholic
Address: Palo, Leyte                                Occupation: None

PHYSICAL STATUS

Lying/sitting BP: N/A

Observations:  N/A (i.e the assessment was done via
google meet) Standing BP: N/A
Post ambulatory BP: N/A
Mobility:
Accommodation Type:
Apartment Independent 

Residential Home 
Rented
Stick/sticks 

Frame/Wheeled trolley

Crutches

Wheelchair 

Mobility Scooter 

Immobile
 Allergy

Food: Seafood (i.e shrimp, crab)

Drug: None  

Others:

CURRENT HEALTH STATUS

Knowledge and understanding  Limitations of health problems: Management of Limitations:

of health problems:
Arthritis Difficulty walking because of Mephinamic (250 mg)
swelling
“gas pain” Abdominal pain (i.e sharp pain) Drinking coffee

Hypertension Numbness (i.e frequently at her Neosartan (50 mg) once a

right arm) day
Impaired Vision (i.e Has difficulty looking at nearby none
Farsightedness) objects
Constipation Could not defecate for a week if the Drinking tea
client’s diet would consist solid food.

MEDICAL HISTORY
Active Medical Problems: Previous Surgery: none
Hospitalization: in St. Paul’s
 Arthritis
Hospital, Tacloban City
 “Gas pain”
Date: in 2012, and 2020
 Hypertension
 Impaired Vision (i.e Farsightedness) Duration of hospitalization:
 Constipation 1 week in both years (i.e 2012,
and 2020)
Reason: Mild stroke (i.e for both
2012, and 2020 hospitalization)
Status after DC: The patient has
fully recovered; rest, and
medications would need to be
maintained. No need for
observations (i.e for both 2012,
and 2020 hospitalization)

FUNCTIONAL ASSESSMENT
Functions Present Condition

Stairs Has difficulty walking up and down the stairs without

assistance or rails to support her.
Transfers Needs assistance with traveling due to impaired vision
(i.e farsightedness), the patient has a hard time seeing
nearby objects.
Continence Has difficulty defecating when eating solid foods.

Washing /Dressing In washing; the client sits down in fear of falling—the

client verbalized that her knees ache whenever she
stands up for a relatively long time.
In dressing; the client can dress herself without
anyone’s assistance.
Meal Preparation Can cook for herself.

Shopping The client would buy home economic products online

whenever she has the budget.
Cleaning The client can clean by herself.

Finances Her daughters provide for her finances.

MEDICATIONS
        Name of Drug Dose Frequency

Neozartan 50 mg Once a day

Mephinamic 250 mg Whenever the client’s joints would

ache
Alkaline C 500 mg Once a day

Centrum - Once a day

ALLERGIES AND REACTION

Allergies: Seafood (i.e shrimp, and crab)

Reaction: Itching, Rashes

SKIN CONDITION:

Intact Rash (describe) None

Dry Discoloration (describe) None

Pruritus   Abnormal findings (describe) None

Wound(describe) None

Hair Condition: Thin, full grey

Nail Condition: Short, smooth, no indentations, has nail polish on the toe nails.

EXTREMITY FUNCTION:

Location Degree of Assistive/Relief

Limitation Measures
Contracture None N/A N/A

Arthritis Lower extremities - Medications,

substitute cane
Painful   Movement Lower extremities - Topical Ointments

Paralysis None N/A N/A

Spasm None N/A N/A

Amputation None N/A N/A

BLADDER:

Nocturia Burning  Incontinence

5x a
Frequency  Urgency 
day

Voiding pattern: Voids regularly, 30 mins – 1 hour after drinking water

BOWEL:

Pain during 
Hemorrhoids Chronic constipation
movement

Straining Ostomy Chronic diarrhea

Bowel movement pattern: 1x a day, however; the patient would sometimes couldn’t defecate for a week
whenever her diet would only be consisted of solid food.

Characteristics: 

Urine is light yellow

Feces is brown in color and firm

SENSORY STATUS:
 Degree of Assistive/Relief
Limitation Measures

All sounds None N/A

Hearing
High Frequency None N/A

Full vision None N/A

Night Vision None N/A

Vision Peripheral Vision None N/A

Reading Farsighted none

Color discrimination None N/A

Taste None N/A

Smell None N/A

Feels pressure & pain Normal N/A

Touch Differentiates temp Normal N/A

Pain Normal N/A

Other sensory data:

Date of last ear exam:

Hearing aid: None
Unknown
Eye Glasses: None
Date of last eye exam:
Contact lenses: None
Unknown
RESPIRATORY:

Precipitating Factors Degree of Assistive/Relief

Limitation Measures
Orthopnea When sick; with cold or a cough Limits ADL Topical ointments,
lagundi (medication)
Dyspnea None N/A N/A

SOB None N/A N/A

When working (i.e chores) for a long Limits ADL rest

Wheezing
period of time.

Asthma None N/A N/A

Getting wet/exposed to the rain Limits ADL Rest, lagundi

Coughing
(medication)

Sputum Characteristics: yellowish, more solid

Smoking history: none

Tracheostomy: None

CIRCULATION:

Precipitating Factors Degree of Limitation Assistive/Relief

Measures
Chest pain Cough Limits ADL Topical ointment: Vicks
vaporub
Tachycardia Cough Limits ADL Drinking lemon tea

Edema None N/A N/A

Cramping in Standing for a long period Limits ADL rest

extremities of time
NUTRITION:

Teeth: Status: no teeth

Date of last exam:  during the 1980’s
Dentures: Partial/Complete: none

Chewing  Swallowing 
Feeding tube:
problem: problem: none

Special Diet: none

Recent weight changes:  none

Precipitating Factors Degree of Limitation Assistive/Relief

Measures
Indigestion Solid food Limits ADL Drinks tea

Constipation Solid food Limits ADL Drinks tea

Diarrhea None N/A N/A

Usual meal plan Fluid Intake Alcohol use

 Breakfast: sweet potato, and bread

 Lunch: fried meat, rice, vegetables 4 glasses of water/ day = 1L Coconut Wine
 Dinner: fast food
REST AND SLEEP:

Insomnia (describe)  None Medicines & Alcohol used to induce sleep: None

Factors interfering with rest: startled by the loud noise made by the
Night restlessness
other members of the house.
Night confusion  Usual sleep & rest pattern: Sleeps at 8pm – 9pm; Wakes up at 6
 am- 7am

FEMALE REPRODUCTIVE FACTORS:

Vaginal discharges: none Nipple discharges: none

Itching: itching when not cleaned immediately

Breast mass: none
after relieving herself.

Lesions: none Breast pain (describe): none

MALE REPRODUCTIVE FACTORS:

Scrotal discharges: N/A Lesions: N/A

Impotency: N/A Others: N/A

SEXUAL PROFILE:

Interest: None  Dyspareunia: None

Sexually Active: No Limitations: None

Attitude: not interested Frequency: None

MENTAL STATUS:

Alert Orientation

Rapid response to verbal stimuli Person: oriented to person

Slow response to verbal stimuli Place: oriented to place

Confused Time: oriented to time

Stuporous
Attention span: Alert, and can focus
Comatose

Memory of present events: Can recall

Memory of past events: Can still recall

EMOTONAL STATUS:

Anxious  Hostile Suspicious  Emotionally labile

Fearful Hyperactive  Euphoric Suicidal

Depressed Hypoactive Disinterest  Others (describe)

 in Life
SOCIAL HISTORY

Hobbies: 
Pastoral/Spiritual Activities:
 Gossiping with friends
 Attending online mass
 Shopping Online  Goes to the nearby church when
 Drinking coconut wine with friends there is only a small amount of active
Other Social activities: going on outings with the covid cases in the area.
family  Prays the rosary everyday (i.e when
waking up, and before sleeping)

MOOD STATUS

Answers in bold indicate depression. Score 1

1. Are you basically satisfied with your life? YES / NO point for each bolded answer.
2. Have you dropped many of your activities and interests?
YES / NO
Score >5 points is suggestive of depression.
3. Do you feel that your life is empty? YES / NO
4. Do you often get bored? YES / NO
Score ≥10 points is almost always indicative of
5. Are you in good spirits most of the time? YES / NO depression.
6. Are you afraid that something bad is going to happen to
you? YES / NO
Score >5 points warrants follow-up with
7. Do you feel happy most of the time? YES / NO comprehensive assessment.
8. Do you often feel helpless? YES / NO
9. Do you prefer to stay at home, rather than going out and
doing new things? YES / NO
10. Do you feel you have more problems with memory than
most? YES / NO
11. Do you think it is wonderful to be alive now? YES / NO
12. Do you feel pretty worthless the way you are now? YES /
NO
13. Do you feel full of energy? YES / NO
 14. Do you feel that your situation is hopeless? YES / NO
15. Do you think that most people are better off than you
are? YES / NO

 
SELF-CONCEPT
the client verbalized: “malipayon la ak inday na nanay, na aadi ak nakapaligid tak
pamilya ngan mga sangkay na pwede ko maka chismis.” Translation: the client states
that she is a happy, and contented mother that has her family caring, and supporting
her. Along with having friends who she enjoys gossiping with. The client has expressed
her disinterest in partaking in sexual relations, and has denied to have any factors
present in her life that has been causing her stress aside from not being able to go out
and explore with her family and friends due to the quarantine restrictions implemented
due to the pandemic. 
 
CURRENT STRESS SITUATION AND ITS FACTORS
The client denied to have any factors present in her life that has been causing her
stress. However, she admits that not being able to go out and explore with her family
and friends due to the quarantine restrictions implemented due to the pandemic--
makes her frustrated seldom times.
 
ATTITUDE AND CONCERNS ABOUT DEATH
the client verbalized: “nakakabassle kun nakakaisip ak ito, as much as possible diri ko
ito gin iisip. It kamatayan bagat amo na it katapusan han natanan. Gusto ko pa mabuhi
hin maiha pa kay gusto ko pa liwat na makasama ko pa tak pamilya, ngan damo pa
liwat gusto ko himuon bisan lagas na ak. Pero bangin na magigin kontentado nala ak
kun panahon ko na kay bagat maupay naman it kabutangan hit ak mga anak, pero
gusto ko pa hira makasama hin maiha pa.” Translation: the client states that as much
as possible, she doesn’t want to think nor talk about death—as it makes her
uncomfortable. The client also stated that even if her time were to come, she has to be
contented—as her children are already well taken care of by their own families,
however the client verbalizes her desire to spend more time with her family as much as
possible, and partake in many activities with them as long as the Christian God she
believes in lets her to. The client’s relieving interventions when it comes to coming in to
terms with the idea of death are to: attend online masses, and praying the rosary every
morning, and before going to sleep.
OTHER DATA:
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Date of Interview: September 18, 2021
Name of Student Nurse: Nicole Chloe C. Ocaña