COMPREHENSIVE GERIATRIC ASSESSMENT TOOL

Biographical Data
Name: Chita Awa
Address: Tandag City, Surigao del Sur
Age: 62 years old
Sex: Female
Civil Status: Widowed
Religion: Roman Catholic
Educational Attainment: Elementary level
Employment Status: None

History of Present Illness

A case of a 62-year-old woman from Barangay Dagocdoc, Tandag City, Surigao del Sur has
signs and symptoms of tuberculosis. Experiences back pain. Patient has been taking 1 tablet of 300 mg
isoniazid (INH) and 1 tablet of 600 mg rifampin (RIF) per day to take them for 6 to 9 months.

Past Medical History

Patient has no history of infectious disease or major illness, she was hospitalized before at
Southern Philippines Medical Center due to cough in 2012, she has no major illness, no known allergies,
and she was 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 Patient
_x__ Heart Disease
_x__ Hypertension Male
_x__ Cancer
_x__ Asthma Female
_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:

Isoniazid (INH) and Rifampin (RIF) as treatment for works to kill or prevent the growth of
bacteria.
Enervon (Ascorbic Acid) as her Multivitamins

General Observation:

The patient is a 62-year-old female. She is conscious, and sitting in a chair. She wore in a blue dress that
covers her entire body and extremities. During the interview, the patient is coherent and responsive. She
responds appropriately to the questions posed to her and cooperates throughout the physical exam.

Vital Signs: T: _97.8F_________

P: 60 BPM________
R: _20 BPM________
BP: _110/80 mmHg___

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 REVIEW OF SYSTEMS

The patient's skin is cold, thin, and pale. Less elasticity is visible as a result of
Integumentary the patient's skin's saggy and crinkled appearance. There are no lumps or
swellings on the face, no masses, and no pain when palpating the face.
There are no lesions or scars on the skin. The patient's nails are well-
trimmed, have normal curvature, and the tissues surrounding the nails are
intact. Capillary refill time is 2 seconds. There was no skin irritation, no prior
allergies, and no petechiae.

Respiratory The patient’s chest walls are aligned, with no masses or signs of trauma or
surgery. With the loss of subcutaneous fat on the chest area, the bones of the
chest wall are visible. The patient’s chest is dry and warm to the touch. On
auscultation, there are no sounds of erroneous breath. The patient
experienced shortness of breath. During the assessment, the respiratory rate
is 20 beats per minute.

Strong palpations on apical, carotid, and brachial pulse sites. No bruit

Cardiovascular sounds heard upon palpation of carotid artery. Heart rate during
assessment is 60 beats per minute. Oxygen saturation is 95%. Heart sounds
are clear and strong.

The patient does not have a denture, and his teeth are white in color. The
Digestive abdominal wall is soft, symmetric, and non-tender, with no distention.
There was no abdominal mass palpated. There are no visible scars or lesions.
The aorta is midline, with no visible pulsation or bruit. Bowel sounds are
normal. The stool of the patient is brown in color and semi-formed to
watery in texture. The circumference of the abdomen to the back is 53 cm.

Excretory Patience is not diaphoretic. The patient defecates semi-formed to watery

stool that is brown in color. Urine is transparent and amber in color.

Musculoskeletal The patient is generally frail. Upper and lower extremity muscle strength of
4/5.

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Nervous The patient walks with good posture and a steady gait, walks without
assistance, and maintains balance while standing. The patient was able to
distinguish between hot and cold sensations as well as sharp sensations. When
asked, the patient displayed well-behaviors and alertness. Coherent thought
is clear, easy to follow, and logical, and oriented to time, date, and year.

Reproductive Her weight has not been taken, but her height is 5’6. There is no history of
goiter. There is no thyroid enlargement. Skin is slightly warm to the touch;
there is no eyeball protrusion; and the skin tone is brown rather than
yellowish.

Endocrine A case of a 62-year-old woman. Menarche at 14 years old and seized at

48year-old, with an obstetric history of 3 pregnancies, 3 birth on full term,
and 3 alive child.

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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
back, genital area or disabled extremity. of 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
or commode.
POINTS: _____1______

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.

Interpretation A score of 6 indicates full function, 4 indicates moderate impairment, and 2 or

less indicates severe functional impairment.

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 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
1. Operates telephone on own initiative- 1 1. Does personal laundry completely 1
looks 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 1
purchases 0 not 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
does not maintain adequate diet 0
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 needs help with banking, major purchases,
1 0
maintain acceptable level of cleanliness etc.
4. Needs help with all home 0 3. Incapable of handling money
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.

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PATTERNS:

Health-perception-health-management pattern

The patient perceives joint pain as a part of her daily life. She is restless as a result of the
constant pain, but she continues to participate in activities in order to enjoy life. The patient
follows her medication regimen religiously and consumes it on a daily basis.
______________________________________________________________________________________

Nutritional-metabolic pattern

For breakfast, the patient typically consumes coffee and bread. Lunch and dinner will consist
of fish, vegetable soup, and rice. Fruits and vegetables are consumed on a daily basis. Between-
meal snacks include bread and coffee. Inflammatory foods such as pastries, chocolate bars, sodas,
cheese, and crackers are avoided by the patient. Three liters of fluid are consumed each day. The
patient’s weight is 54 kg. The patient is on multivitamins.
______________________________________________________________________________________

Elimination pattern

The patient typically urinates five to six times per day, and the urine is amber in color and
transparent. The patient usually defecates one to two times per day, and the waste or stool is
brown in color; occasionally, the stool is quite watery, but most of the time it is formed. Excessive
perspiration occurs during morning exercise.
______________________________________________________________________________________

Activity and Exercise pattern

The patient is a very active 62-year-old woman who is very active in household activities
despite having limited ROM. In addition, the patient attends social events such as seminars,
weddings, and visits to the sick. Every other day, the patient attends a social event. She enjoys
visiting her relatives in their barangay. As a form of exercise, the patient waters and cleans the
plants every morning after breakfast. Then, in the late afternoon, she waters and tends to her
plants once more.
______________________________________________________________________________________

Sleep-Rest pattern

The patient usually goes to bed early in the evening and gets up early to do some housework and
check on her garden.
______________________________________________________________________________________

Cognitive-perceptual pattern

The patient has no hearing loss and does not wear a hearing aid. Except when reading, the
patient does not wear glasses during the day. There has been no reported change in memory.
According to the patient, making important decisions is simple. The patient occasionally complains
of back pain. Throughout the day, she reports pain on the patellar. The patient is aware of the
time, date, and year. She can hear whispers and read newsprint. During the interview, she

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demonstrates an exceptional ability to grasp ideas and questions; alternates speaking languages
of English and Filipino when responding to questions; and possesses a large vocabulary and a long
attention span.
______________________________________________________________________________________

Self-perception Self-concept pattern

The patient describes herself correctly and has a positive self-image. She claims she manages
her disease-related limited range of motion. Family problems are a frequent source of annoyance
for her. She is concerned about her children. She claims she never loses hope because she believes
in the Creator’s divine power. During the interview, the patient maintained eye contact and his
body posture was normal and relaxed.
______________________________________________________________________________________

Role relationship pattern

Patient coexists peacefully with her grandchildren. The patient is responsible for the family’s
financial accounting. Furthermore, the patient is a member of the community’s social group and
is in charge of making all group decisions. The patient expresses happiness with her family and
social groups.
______________________________________________________________________________________

Sexuality reproductive pattern

A case of a 62-year-old woman. Menarche at 14 years old and seized at 48-year-old, with an
obstetric history of three pregnancies, 3 birth on full term, and 3 alive child.
______________________________________________________________________________________

Coping-Stress-Tolerance pattern

During the interview, the patient mentions that one of the most significant changes in her
life in the last year has been the birth of her granddaughter. She reports that she only experiences
stress as a result of family problems and that she immediately organizes a proper response to the
problem in order to reduce her stress.
______________________________________________________________________________________

Value-Belief pattern

Patient reports that she generally gets what she wants in life while also constantly planning
important monthly and yearly activities. Patient emphasizes the importance of religion in her life
and claims that she has been making the right decisions since becoming a Christian. When she
faces difficulties, she says she receives light and guidance from her faith.
______________________________________________________________________________________

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 PSYLOGICAL 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
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 in good spirits most of the time? YES / NO 0
6. Are you afraid that something bad is going to happen to you? YES / NO 1
7. Do you feel happy most of the time? YES / NO 0
8. Do you often feel helpless? YES / NO 0
9. Do you prefer to stay at home, rather than going out and doing YES / NO 1
new things?
10. Do you feel you have more problems with memory than most? YES / NO 0
11. Do you think it is wonderful to be alive now? YES / NO 0
12. Do you feel worthless the way you are now? YES / NO 0
13. Do you feel full of energy? YES / NO 0
14. Do you feel that your situation is hopeless? YES / NO 0
15. Do you think that most people are better off than you are? YES / NO 1
TOTAL 3
Score 1 point for each bolded answer (highlighted red).
A score of 5 or more suggests depression

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.

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.

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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 0
NOTE ON
SCORING
Scoring* *One more error is
allowed in the
0-2 errors: normal mental functioning scoring if a patient
has had a grade
3-4 errors: mild cognitive impairment school education or
5-7 errors: moderate cognitive impairment less. One less error
8 or more errors: severe cognitive impairment 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 PLANS
Cues Subjective

“Dili tadong ang ako ginhawa ug magasakit pud akong likod.” As verbalized
by the patient.

Objective

Received patient, conscious, and sitting in a chair, wearing a blue dress covering
her body and extremities.

Patient has initial vital signs:

• BP: 110/80 mmHg

• PR: 60 bpm
• RR: 20 bpm Temperature: 97.8F
• O2 Sat: 95%

• Pale
• Active and responsive
• Shortness of breath
• Back pain
• Limited ROM
• Gait changes

Pain scale of 7 out of 10

Nursing Ineffective Breathing pattern related to shortness of breath.

Diagnosis

Objectives After 8 hour of nursing care, patient will be able to verbalize pain is relieved
from 7/10 to 5/10.

Interventions • Assess and record RR and depth at least one hour. To detect early signs of
& Rationale respiratory compromise.
• Assess patient to comfortable position such as supporting upper
extremities with pillows. These measures promote comfort and chest
expansion.
• Schedule necessary activities to provide periods of rest. Prevents fatigue
and reduces Oxygen demands.

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 • Note emotional responses; crying and grasping. Hyperventilation may be
a factor.

Evaluation Goal partially met. After an 8 hour of nursing care, patient verbalized pain was
controlled with pain scale of 4/10.

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 NURSING CARE PLANS
Cues Subjective

“Dili tadong ang ako ginhawa ug magasakit pud akong likod.” As verbalized
by the patient.

Objective

Received patient, conscious, and sitting in a chair, wearing a blue dress covering
her body and extremities.

Patient has initial vital signs:

• BP: 110/80 mmHg

• PR: 60 bpm
• RR: 20 bpm Temperature: 97.8F
• O2 Sat: 95%

• Pale
• Active and responsive
• Shortness of breath
• Back pain
• Limited ROM
• Gait changes

Pain scale of 7 out of 10

Nursing Impaired physical mobility r/t pain

Diagnosis

Objectives After 8 hour of nursing care, the patient will:

• Report that the pain has been relieved or controlled.
• Appear relaxed, capable of sleeping/resting and appropriately
participating in activities.
• Adhere to the pharmacological regimen prescribed.
• Incorporate relaxation techniques and diversionary activities into your
pain management program.

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 • Assist patient for muscle exercises as able or when allowed out of bed;
execute abdominal-tightening exercises and knee bends; hop on foot;
Interventions
stand on toes. Adds to gaining enhanced sense of balance and
& Rationale
strengthens compensatory body parts.
• Present a safe environment: bed rails up, bed in a down position,
important items close by. These measures promote a safe, secure
environment and may reduce risk for falls.
• Execute passive or active assistive ROM exercises to all extremities.
Exercise enhances increased venous return, prevents stiffness, and
maintains muscle strength and stamina. It also avoids contracture
deformation, which can build up quickly and could hinder prosthesis
usage.
• Promote and facilitate early ambulation when possible. Aid with each
initial change: dangling legs, sitting in chair, ambulation. These
movements keep the patient as functionally working as possible. Early
mobility increases self-esteem about reacquiring independence and
reduces the chance that debilitation will transpire.
• Let the patient accomplish tasks at his or her own pace. Do not hurry
the patient. Encourage independent activity as able and safe.
Healthcare providers and significant others are often in a hurry and do
more for patients than needed. Thereby slowing the patient’s recovery
and reducing his or her confidence.

Evaluation Goal met, patient has Verbalize relief of pain. Demonstrated relaxed body
posture and be able to sleep/rest appropriately.

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