ASSESSMENT OF THE OLDER ADULT

Procedure:

1. Introduce yourself and verify the client’s identity.

2. Explain what are you going to do and why this is necessary?
3. Establish rapport to gain the client’s cooperation
4. Perform hand hygiene and observe appropriate infection control measures
5. Provide client privacy.
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NURSING HEALTH HISTORY
Part 1.

A. COLLECTION OF SUBJECTIVE DATA

I. Biographical Data
Name: Yolanda V. Atrero
Age: 77 years old
Sex: Female
Civil status: Widowed
Contact Number/s: 09954400459
Date/Time of History Taking: October 26,2021/ 12:25 pm
Source of History: Primary (direct interview and assessment to the patient)

II. Reason for Seeking Health Care:

Assessment for physical and mental evaluation.
III. History of Present Health Concerns
a. Mental Status
1. Have you noticed any changes in your ability to concentrate or think clearly enough to keep up with your
daily activities? If, so, when did this begin and describe what you have noticed?
➢ The client doesn’t have any problem in concentrating and she is able to keep up with her daily
activities.

2. Use MMSE, SLUMS or CAMS assessment tool for Mental Status

➢ Using the SLUMS assessment tool, the score of the patient is 27 this means that the client’s
mental status is normal.

3. Do you believe you have more problems with memory than most? Have you recently had to drop many
of your activities or interests?
➢ The client doesn’t have problems with her memory, she stated “Wala akong problema sa
memorya tingin ko yun yung lamang ko sa ibang kaedad ko dito kasi sila madalas naguulyanin na,
sakin masasabi ko na medyo sharp pa memory ko, may mga bagay lang ako na hindi na magawa
tulad ng dati katulad ng paglalakad ng malayo kasi mahina na tuhod ko tapos wala naman akong
gaanong interes gawin kasi dito lang ako sa bahay nanunood ng tv at yun na yung pinakalibangan
ko”

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4. Are you concern about changes in your memory?
USE THE SHORT-BLESSED TEST
Items # Errors (0-5) Weighting Factors Final Item Score
1 0 X4 0
2 0 X3 0
3 0 X3 0
4 0 X2 0
5 0 X2 0
6 0 X2 0
Sum total = 0
(Range 0-28)

The score of the patient is 0 which means that she has a normal cognition
b. Depression
USE THE SHORT VERSION OF GDS
➢ The client’s score is 5 this means that she was not depressed.

IV. Past History

● Past Illness
ILLNESS DURATION DATE TREATMENT
Chicken Pox Cannot recall Cannot recall Nonpharmacologic
Measles Cannot recall Cannot recall Nonpharmacologic
Hypertension 2013- Present 2013 Losartan-Amlodipine
Type 2 Diabetes Mellitus 2016- Present 2016 Gliclazide- Glubitor OD

● Family history of Illness

NAME RELATION ILLNESS DATE OF DURATION TREATMENT STATUS
TO THE ONSET OF ILLNESS
CLIENT
Felipe Valencia Father Liver Cannot 1-2 years Confinement Deceased
Disease recall
Andres Valencia Brother Inguinal Can’t 1 year Hospitalization Deceased
hernia recall in President
month, Ramon
2012 Magsaysay
Memorial
Hospital

● Immunization

➢ The client stated that she had received pneumococcal, flu and Covid vaccine, she stated
“Nabakunahan na ako noon ng para sa pneumonia sa barangay tapos sa plaza sa bayan para daw
sa flu nakumpleto ko na din yung dalawang dose ko ng Sinovac”

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 ● Allergy

According to the patient she doesn’t have any allergies.

● Accidents/Injuries

➢ The client had an accident two years ago, she stated “Nasubukan ko madapa nung sinundo ko
yung apo ko sa dagat kasi gabi na hindi pa sya umuuwi madilim kasi nun sumakit yung tuhod ko
pero gumaling naman nung pinahilot ko kaya sa tingin ko di naman ako nainjury nun ng malala.”

● Hospitalization
ILLNESS DURATION DATE TREATMENT
High Blood 5 days 2008 and 2010 Confinement and
Medication

● Past and Present Medication (Prescription and Non-Prescription)

MEDICATION DOSAGE ROUTE FREQUENCY REASON FOR
ADMINISTRATION
Tramadol 100 mg Oral 1 tablet 3x a day, Prescribed for pain
after every meal
Paracetamol 500 mg Oral 1 tablet every 6 For fever
hours

Urovil 300 mg Oral 1 capsule 3x a day, Prescribed for stomach

after every meal pain
Buscopan 10 mg Oral 1 tablet 3x a day, Prescribed for stomach
after every meal pain
Losartan 50 mg Oral Once a day, every Maintenance for
morning hypertension
Amlodipine 5 mg Oral Once a day, every Maintenance for
morning hypertension
Gliclazide 30 mg Oral Once a day, every Maintenance for type 2
morning DM
Atorvastatin 20 mg Oral Once a day, before Maintenance for
sleep cholesterol

V. Functional Ability to Perform ADLs

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 a. ADLS/IADLS (OR USE KATZ AND LAWTON SCALE FOR IADL)

WITHOUT
COMPLETELY
ADL DIFFICULTY OR WITH SOME HELP NOT SURE
UNABLE
HELP
BATHING ✓
DRESSING ✓
GROOMING ✓
FEEDING ✓
TOILETING ✓
TRANSFERS ✓

Can the patient perform Instrumental Activities of Daily Living (IADL)?

WITHOUT
COMPLETELY
IADL DIFFICULTY OR WITH SOME HELP NOT SURE
UNABLE
HELP
USING THE
✓
TELEPHONE
LAUNDRY ✓
PREPARING MEALS ✓
HOUSEKEEPING ✓
HANDLING OWN
✓
MONEY
ADMINISTERING
✓
OWN MEDICATION
GROCERY
✓
SHOPPING
DRIVING AND
✓
TRANPORTATION

b. FALLS
1. Do you ever need to grab onto something because you feel like you are going to stumble or fall?
Have you ever used anything to steady yourself when walking?

➢ “Kapag mababa yung upuan kelangan ko ng alalay or hawakan para di ako ma tumba kasi medyo
hirap na ko dahil sa tuhod ko ganun din pagka tatayo ako galling sa duyan, kapag wala naman
mga apo ko dahan dahan ko inaangat sarili ko kasi baka magkamli ako tapos mabalian.” as stated
by the client.

2. Have you had any recent falls? what were you doing? When did it occur? What are other kinds of
feelings or symptoms did you have when you fell (e.g.headache, confusion…)
➢ According to the patient she has no history of any fall.

3. Did you ever feel lightheaded or dizzy when you wake up from a chair or bed?
➢ “Pagkagising hindi naman pero minsan pag pagod ako o kaya sobrang init ng panahon nahihilo
ako kahit nakaupo lang naman ako.” as stated by the client.

4. Do you have difficulty getting out of bed or from sitting in a chair? Does stiffness or soreness inhibit
your ability to move? Did you ever feel like your legs is falling apart or feel that they are weak? If so
describe. What is your usual pattern of activity? Exercise routine?

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 ➢ “Hindi naman ganun kahirap bumangon sa kama kaya ko pa naman kahit ako lang basta
nagdadahan dahan ako dahil sa tuhod ko mahina na kasi tsaka madalas sumasakit nahihirapan na
ako makalakad ng malayuan ang pinakaexercise ko na lang ay yung pagwawalis paminsan minsan
saka yung pagikot ikot sa loob ng bahay ganyan sabi ng kapatid ko sedentary lifestyle daw yung
meron ako” as stated by the client.

5. Do you have any discomfort in your legs with activity? Would you describe the discomfort as pain,
cramping, aching, fatigue, or weakness in the calf? Do your hips, thigh, hips/buttocks hurt in
ambulation? If so, how far can you walk when the pain occurs? Does the pain go away with rest?
➢ “Yung tuhod ko talaga yung iniinda ko kasi mahina na pag medyo malayo yung nilalakad ko
nanginginig sya tsaka sumasakit, kumikirot parang nakukuryente tapos para akong matutumba
hanggang sa legs humuhupa naman yung sakit pag naiipahinga pero yung balakang ko hindi
naman sya sumasakit” as stated by the client.

Use the Morse Fall Scale or Tinetti Gait and Balance Assessment
➢ The result of Morse Fall Scale is 23 it means that the risk of fall is moderate. The Tinetti tool score
is equal to 28 if the score falls between 19-23 the risk for fall is moderate.

c. WEAKNESS: FATIQUE AND DYSPNEA

1. How has your energy level change in the last few days or weeks? How does it affect your daily
activities such as cooking, household chores or activities outside home? Was your energy at its
lowest level? when does it seems to be at its best?
➢ The client verbalized “Paminsan minsan nanghihina ako at nahihilo dahil siguro sa init tsaka
minsan feeling ko kulang yung kinakain ko sa umaaga pero kahit na ganun nakakapagluto pa din
ako at nakakapaglinis pero minsan gusto ko lang uupo at magpahinga pag nakakaramdam ako ng
panghihina. Malakas ako tuwing umaga pagkagising dahil siguro nakatulog ako kaya ganun.”

d. WEAKNESS: NUTRITION AND HYDRATION

USE MNA (MINI NUTRITIONAL ASSESMENT)
➢ In MNA screening the score of the patient is 12 it means that the client has normal nutritional
status.

e. URINARY INCONTINENCE
1. Do you have a difficulty starting a stream of urine? Frequency? Nighttime Frequency?
➢ The client verbalized “Di naman ako nahihirapan umihi sa araw mga apat na beses ako umiihi
tapos sa gabi isa hanggang dalawang beses ako bumabangon para umihi.”

2. Dribbling? If yes, do you ever take cold or sinus medication to help you sleep?
➢ According to the client she does not experience dribbling

3. How long is the leakage (use client’s descriptive words) been going on? Has it suddenly
gotten worse?
➢ “Hindi ko naman nararanasan yung ganyan kasi pag naiihi ako pumupunta na agad sa banyo” as
stated by the client.

4. What activities are associated with your urine’s loss of control?

➢ The client stated “Nakokontrol ko pa naman yung pantog ko minsan nakakapagpigil pa ko lalo nap
ag nasa ibang bahay ako pero pag dito lang pumupunta na agada ko sa banyo kapag naiihi na ko”

f.BOWEL ELIMINATION
1. Do you have problems in bowel elimination?
➢ The patient doesn’t have any problem regarding bowel elimination.

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 2. Have you had a change of bowel movement lately?
➢ “Wala naman normal naman yung pagtae ko maliban na lang pag may nakakain ako na na
nakakapagpasama sa tyan ko.” as stated by the client.

3. Have you ever had blood in your stools?

➢ According to the client she does not experience having blood in her stools.

4. Have you had your stool tested for blood?

➢ According to the client she does not experience having her stool tested for blood.

5. What medication do you take?

➢ The client stated “Kapag sumasakit yung tyan ko o kaya nagtatae loperamide yung iniinom ko.”

g. PAIN ASSESSMENT
use the COLSPA MNEMONIC
1. Character
● Describe the signs and symptoms (feeling, appearance) of pain?
➢ “Kapag medyo malayo yung nilalakad ko nanginginig sya tsaka sumasakit, kumikirot parang
nakukuryente tapos para akong matutumba” as stated by the client.

2. Onset
● When did it begin?
➢ The client stated “Matagal na, nagumpisa sya mga 60 years old ako nung tumigil na ako magtinda
ng isda pero nararanasan ko lang to tuwing maglalakad ako lalo na pag medyo malayo.”

3. Location
● Where is it?
“Sa tuhod”
● Does it radiate?
“Kung minsan umaabot yung sakit pababa sa legs.”
● Does it occur anywhere else?
“Sa tuhod lang madalas, tuhod din naguumpisa minsan lang umaabot sa legs.”

4. Duration
● How long does it last?
➢ The client stated “Hanggat hindi ko sya naiipahinga hindi tumitigil yung sakit para akong
matutumba.”
● Does it recur?
➢ “Pag pinapahinga ko na o kaya pinapahiran ng efficascent oil humuhupa naman na yung sakit.” As
stated by the client.

5. Severity
● How bad it is?
➢ I asked the patient to rate the pain using the pain scale (1-10) “Kapag medyo malayo yung
nilalakad ko nanginginig sya tsaka sumasakit, kumikirot parang nakukuryente tapos para akong
matutumba siguro yung sakit mga nasa 6/10” as stated by the patient.

● How much does it bother you?

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 ➢ “Kapag dito lang ako sa bahay hindi ko naman gaano iniinda kasi sumasakit lang talaga sya pag
naglalakad ako or napapagod yung tuhod ko pag medyo malayo nilalakad ko.” as stated by the
patient.
6. Pattern
● What makes it better or worse?
➢ The patient stated “Kapag kailangan ko maglakad ng malayo lalo na pag walang masakyan o kaya
pag namamalengke ako ikot ako ng ikot sa palengke talagang sumasakit sya tapos gumagaan lang
pakiramdam ko kapag naipahinga ko o napapahidan ng oil.”

7. Associated Factors/How it alerts the Client

● What other symptoms occur with it?
➢ “Wala naman na bukod sa panginginig pagkirot tapos parang nakukuryente ganun lang naman” as
stated by the patient.

● How does it affect you?

➢ The patient stated “Hindi nya naman naapektuhan yung mga gagawin ko kasi pag dito lang naman
ako sa bahay hindi naman sya sumasakit kasi nakaupo lang naman ako maghapon pagtapos ko
gawin yung mga dapat kong gawin.”

Part 2

B. COLLECTION OF OBJECTIVE DATA

PHYSICAL EXAMINATION
a. Preparation of the Client
● Provide privacy and a comfortable environment that is free from noise
● Provide assistance in dressing or repositioning
● Allow additional time in deference to the client’s need for independency
b. Materials and Equipment Needed
● Newspaper or book and lamplight for vision testing
● Lemon slice or mint or any scent for sense of smell test
● Pudding or food of pudding consistency and spoon for swallowing test or a
teacup of water can also be used
● Food or fluid diary sheet or forms
● MNA elderly nutritional assessment form (no need if accomplished already)
● 2 or 3 pillows for client comfort and positioning
● Straight back chair for “Go and Get up” test

ASSESSMENT PROCEDURE NORMAL FINDINGS OR ABNORMAL FINDINGS

VARIATIONS

1. Measure the height and weight of - According to the - Normal findings

the client, noting weight changes, MNA (Mini
changes in appetite, nausea and Nutritional
vomiting and problems in swallowing Assessment) a
or chewing. (See assessment tool score of 24-30
MNA) indicates normal
nutritional status
the patient scores
24 meaning she
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 has a normal
nutritional status
2. Review laboratory (If any) test values, - 187.5 mg/dL - Cholelithiasis
CBC, and Vitamin B12, cholesterol, cholesterol shown in the
albumin and pre albumin levels - 56.51 mg/dL high ultrasound
density lipoprotein - 166.4 mg/dL
triglycerides
- 227.8 mg/dL low
density lipoprotein

3. Evaluate hydration status and - Stable weight and - Normal findings

nutritional status stable mental
status
SKIN AND HAIR

Inspect and Palpate skin lesions - Skin varies from - Normal Findings
white to light
brown

- Skin is wrinkled
due to aging

- Generally uniform
except in areas
exposed to the sun;
areas of lighter
pigmentation
(palms, lips, nail
beds) in dark
skinned people

- Freckles and
lentigines, some
seborrheic
keratoses or warts
in sun exposed
areas
Inspect hair and scalp - Evenly distributed - Normal Findings
hair
- Silky, resilient hair
- The roots of the
hair of the client
are turning white.
HEAD AND NECK

Inspect head and neck for symmetry and - Head is - Normal findings
movement. Observe facial expression normocephalic

- Symmetric facial
expression.

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 - No swelling and
masses.

- Coordinated,
smooth
movements with
no discomfort.

- Muscles equal in
strength.

- Muscles equal in
size, head
centered.

- Trachea is in the
middle.

- No spasm and
stiffness.
MOUTH AND THROAT

Inspect the gums and buccal mucosa for color - There is no - Normal findings
and consistency increase in saliva
production
Examine the tongue. Observe for symmetry - Tongue is pink and - Normal findings
and size moist

- Smooth tongue
base with
prominent veins
- Central position
Observe for client swallowing foods or fluids - The client doesn’t - Normal findings
have any problem
in swallowing foods
or fluids.
Test gag reflex. Depress the posterior third of - Equipment to be - Equipment to be
the tongue and note gag reflex used for this test is used for this test is
not available not available

NOSE AND SINUSES

Inspect the nose for color or consistency - Nose is midline, - Normal findings
septum is straight
- No discharge or
flaring
Evaluate the sense of smell. Have the client - Patient was able to - Normal Findings
close the eyes and smell a common distinguish the
substance, such as mint, lemon or soap different smells

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Test the nasal patency. Ask the client to - Nares are patent. - Normal findings
breath while blocking one nostril at a time No flaring.

- Air moves freely as

the client breaths
through nares

Palpate the frontal and maxillary sinuses for - No tenderness - Normal findings
consistency and to elicit possible pain

EYES AND VISION

Inspect, eyelids, eyelashes, and conjunctiva, - Hair evenly - Normal findings

also observe eye or conjunctiva for dryness, distributed; skin
redness, tearing or increased sensitivity to intact
light and wind - Eyebrows
symmetrically
aligned, equal
movement
- Equally distributed;
curled slightly
outward
Inspect the cornea and lens, also ask the - Transparent, shiny, - Normal findings
client when he or she last had an eye and and smooth;
vision examination by an optometrist or details of the iris
ophthalmologist are visible
- Presence of arcus
senilis
Inspect the pupils with penlight or similar - The equipment to - The equipment to
device, test pupillary reaction to light be used for this be used for this
assessment is not assessment is not
available. available.

Test vision. Ask the client to read from a - Able to read - Normal findings
newspaper or magazine. Use room lighting magazine
for initial reading. Use task lighting for
second reading

Ask about changes in vision, trouble with - The client does not - Normal findings
night vision, or differences in vision with left experience any
vs right eye problems regarding
her vision.
- The client can’t see
anything when its
dark.
Ask client about small specks or “clouds” that - The client doesn’t - Normal findings
moves across the field of vision see any presence
of small specks or
clouds to her visual

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 field.
EARS AND HEARING

Inspect the external ear. - Color same as - Normal findings

Observe shape, color, and hair growth. Also facial skin
look for lesion or drainage - Symmetrical
- No presence of
lesion or drainage.
Perform an otoscope examination to - Otoscope is not - Otoscope is not
determine quantity, color, and consistency of available. available.
cerumen

Perform the voice whisper test. This is a - Able to hear - Normal findings
functional examination to detect obvious whisper in both
(conversational) hearing loss. Instruct the ears.
patient to put a hand over one ear and repeat
the sentence you say

Stand approximately 2 ft away from the client -Able to hear - Normal findings.
and whisper a sentence whisper in both
ears.
THORAX AND LUNGS

Inspect the shape of the thorax. Note Anteroposterior to

- - Normal findings
respiratory rate, rhythm, and quality transverse
diameter in ratio of
1:2
- Thorax symmetric
- Client RR is 15 Bpm
Percuss lung tones the same as you do for - Percussion notes - Normal findings
younger adult resonate, except
over scapula
Auscultate lung sounds the same as you do - Vesicular and - Normal findings
for younger adult bronchovesicular
breath sounds
HEART AND BLOOD VESSELS

Take blood pressure to detect actual or Standing - Normal findings

potential orthostatic hypertension for risk of
falling. Measure in lying, sitting, and standing - 110/80 mmHg
position. Also measure the pulse rate - 77 bpm

Sitting

- 120/80 mmHg
- 69 bpm

Lying

- 120/70 mmHg
- 72 bpm
Have the client lie down for 5 mins, take the Pulse at 1 minute - Normal findings
pulse at 1 minute, take blood pressure and
pulse after client is sitting and again at 1 min - 75 bpm
after client stands

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 After sitting

- 120/90 mmHg
- 70 bpm

After client stand

- 120/70 mmHg
- 72 bpm
Measure activity tolerance. Evaluate either - The patient doesn’t - Normal findings
by reviewing results of stress testing or by have any problem
observing the client’s ability to move from with sitting and
sitting to a standing position or to flex and standing.
extend fingers rapidly - Patient was able to
flex and extend
fingers rapidly.
Determine the adequacy of blood flow by - Radial, brachial, - Having difficulty to
palpating the arterial pulses in all locations ulnar, and carotid palpate distal
(carotid, brachial, radial, femoral, popliteal, pulses are easily pulses which are
posterior tibial and dorsalis pedis) for palpable. Femoral popliteal, posterior
strength and quality pulse was not able tibial, and dorsalis
to be palpated pedis.
since the patient
refuses

Palpate the carotid arteries gently at one side - Symmetric - Normal findings
at a time to avoid stimulating vagal receptors pulsations
in the neck, dislodging an existing plaque, or
causing syncope or stroke

ARTERIES AND VEINS

Auscultate the carotid, abdominal and - No unusual sound - Normal findings

femoral arteries heard

Evaluate arterial and venous sufficiency of - The skin color - Thickened nails
extremities. Evaluate the legs above the level varies from white
of the heart and observe color, temperature, to light brown.
size of the legs and skin integrity - Temperature is
normal
- No presence of skin
lesions and edema
Inspect and palpate the veins while client is - Prominent but not - Normal findings
standing bulging veins

HEART

Inspect or palpate precordium - The precordium is - Normal findings

still, not visible no
thrills, heaves, and
palpable pulsations
Auscultate heart sounds - No abnormal heart - Normal Findings
sounds
BREAST

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Inspect and auscultate breast and axillae. - Patient refuses to
When viewing axillae and contour of the do this assessment
breast, assist client with arthritis to raise the
arms over the head. Do this gently and
without force and only if it is not painful to
the client

If breast is pendulous, assist the client to lean - Patient refuses to

slightly so that the breast hangs away from do this assessment
the chest wall, enabling you to best observe
symmetry and form

Inspect the skin under the breast - Patient refuses to

do this assessment

ABDOMEN

Assess GI motility and auscultate bowel - 12 normoactive - Normal findings

sounds. Review fiber and laxative use bowel sounds/min

Determine absorption or retention problems - Not receiving

in older adult clients receiving enteral enteral feeding
feedings

Inspect and percuss the abdomen in the same - Tympany over the - Normal findings
manner as you do for younger adults stomach and gas-
filled bowels;
dullness, especially
over the liver and
spleen, or a full
bladder
Palpate the bladder. Ask the client to empty - Not palpable - Normal findings
bladder before the examination. If the
bladder is palpable, percuss the symphysis
pubis to umbilicus. If the client is incontinent,
post void residual content may also need to
be measured

MUSCOLUSKELETAL SYSTEM

Observe the client’s posture and balance - Patient stands - Normal findings
when standing during the first seconds reasonably straight
with feet
positioned fairly
widely apart
- Body usually bends
forward as well
Observe the client’s gait by performing the
timed” get and go” test
● Have the client rise from a straight- - Widening of pelvis - Normal findings
backed armchair, stand momentarily, and narrowing of
and walk about 3 m towards a wall shoulders
● Ask the client o turn without touching - The clients walk
the wall and walk back to the chair, steadily and don’t
then turn around and sit down have any trouble.
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 ● Using a watch or clock with a second - The client
hand, time how long it takes the completes the test
client to complete the test within 10 seconds
Score performance to 1-5 scale
1- normal Score:
2- very slightly abnormal 1 - normal
3- mildly abnormal
4- moderately abnormal
5- severely abnormal
Inspect the general contour of limbs, trunks, - No enlargement of - Normal findings
and joints. Palpate wrist and hand joints distal,
interphalangeal
joints of the
fingers.
Test ROM. Ask client to touch each finger - Patient successfully - Normal findings
with the thumb of the same hand, to turn the do the ROM test
wrist up toward the ceiling and down towards without any
the floor, to push each finger against yours trouble.
while you apply resistance and to make a fist
and release it

Assess ROM and strength of shoulders and - Equal strength - Normal findings
elbows

Assess hip joint for strength and ROM in the - Intact flexion, - Normal findings
same manner as you do for a younger adult extension, and
internal and
external rotation.
Inspect and palpate knees, ankles, and feet. - Patient does not - Normal findings
Also assess comfort level, particularly with experienced pain
movement (flexion, extension, rotation) during palpation,
flexion, extension,
and rotation
Inspect muscle bulk and tone - No presence of - Normal findings
atrophy
NEUROLOGIC SYSTEM

Observe for tremors and involuntary - Absence of tremors - Normal findings

movements and involuntary
movement
SENSORY SYSTEM

Test sensation to pain, temperature, touch - Patient’s touch and - Normal findings
position and vibration as you would do for a vibratory
younger adult sensations is not
diminished
Assess positional sense by using the - The patient was - Normal findings
Romberg’s test. The exception to the test is able to perform
clients who must use assistive devices such as Romberg’s test
walker without difficulty.

Note: Validating and Documentation of findings: The subjective and Objective data must reflect the
functional and physical assessment. Please document properly your findings using this tool.

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 II. Analysis of Data: Diagnostic Reasoning

After clustering the data based from subjective and objective data, note any significant patterns or
abnormalities
- From the gathered subjective and objective data, the significant patterns or abnormalities are the
presence of stones on patient’s gallbladder presented through ultrasound result also elevated levels of
triglycerides and low- density lipoprotein as shown in the patient’s laboratory result. During the interview
the client also stated that she was previously diagnosed with hypertension and type 2 diabetes mellitus.
In terms of pain assessment, the client complains about her knee pain which she experiences when se
walks with a pain scale of 6 out of 10.

III. Nursing Diagnosis:

Identify the appropriate actual or risk nursing diagnosis
- Imbalanced nutrition more than body requirement related to sedentary lifestyle as evidenced by
a BMI of 31.6, elevated levels of triglycerides and low-density lipoprotein

- Acute pain due to degenerative joint disease related to age

- Risk for unstable blood glucose level related to inadequate blood glucose monitoring

IV. Collaborative Problems

Abnormalities identified in the nursing assessment including functional deficits which requires
collaborative approach
- The patient has hypertension, type 2 diabetes mellitus and cholelithiasis, this requires
collaborative approach for prescribed medications and treatment plan. Patient stated that she
was already diagnosed by the health care provider and was taking maintenance medication for
management of such illnesses.

V. Medical Problems for Referral

After grouping the data, identify the signs and symptoms that requires medical diagnosis and treatment.
Please note if it is for referral to a primary care provider as necessary.
- During the interview the patient stated that she experiences 6 out of 10 pain level on both of her
knees during walking characterized by shaking/trembling, pain, and electrified feeling. We think
that this needs to be addressed and requires referral because such symptoms may indicate
osteoarthritis, or any disease related to joint.
Submitted by:
Ordillas,Romelyn A.
Eguna, Alexis Claire R.
Apino, Mereline Genesis D.

Block: BSN 3B1

Date:

Evaluated by:
_______________________________
Printed Name and Signature

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Clinical Instructor

Score/Rating:________________________

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