Sima Saeed Dr.X.S.

Blessing NimaSajai

NAME OF THE STUDENT : ………………………………………………………………………… NAME OF THE EVALUATOR : ……………………………………………………….

COURSE : Geriatric Nursing -Theory YEAR/ LEVEL : 4/8 DESIGNATION : Asst. Professor In Nursing

CASE NO:3:

As a nurse during your posting in emergency department, you found a client named

Mrs. Fatima 85 years old came along with her daughter. Her daughter says that while

eating breakfast Mrs.Fatima experienced sudden onset slurring of speech, had facial droop

on his left hand side with weakness in left side upper and lower limbs. Her daughter

spotted these sudden onset of symptoms and immediately called for an ambulance, which

arrived within 15 mins. . She was examined by Dr. Hussan and diagnosed as Cerebro

Vascular Accident(CVA/Stroke). Her body weight is 110 Kg, height 165 cm, fair in

complexion and obese. While doing physical examination she looks tired, inactive,

conscious, weakness in left side of the body, unable to move, slurred speech, facial droop, .

Her Blood Pressure is 155/110 mm of Hg, Pluse 82 beats/mt, Respiration 24 breaths/mt ,

body temperature 100°F. Also while assessing cognitive function she is not oriented to time

place and person, not attentive, loss of memory and no general knowledge. She can’t able to

perform her daily activities independently.

Write geriatric/old age assessment report for Mrs.Fatima.

CLO/PLO Code (2.1:S2) (2.3:S2) (2.4:S3) (3.2:V2) (3.3:V1) Total Marks

Allotted Marks 1 1 1 1 1 5

Marks Obtained By The Students

Remarks By The Evaluator For Improvement:

Student’s Response:

Signature Of The Student Signature Of The Evaluator

KINGDOM OF SAUDI ARABIA

MINISTRY OF EDUCATION

UNIVERSITY OF BISHA

GERIATRIC NURSING

CASE SCENARIO ON

MAINTAINTING GERIATRIC/OLDAGE ASSESSMENT RECORD

Dr.X.S.Blessing NimaSajai Sima saeed

20\4\1443_25\11\2021

GERIATRIC/OLDAGE ASSESSMENT FORMATE

(FILL THE BLANK FORMATE ACCORDING TO THE GIVEN SCENARIO AND PUT √MARK ABOVE THE SUITABLE UNDERLINED WORD& BOX)

GENERAL EXAMINATION :

Consciousness : Conscious / Unconscious/ semiconscious

Orientation : Oriented / not oriented

Nourishment : Well nourished/ over nourished/ undernourished

Body Built :Moderate/thin/ obese

Health status : Healthy/ Unhealthy

Activity : Active/ inactive

Hygiene : Good/poor

Height : 165 Cm

Weight : 110Kg

Vital Signs

VITALS PATIENT VALUE NORMAL VALUE REMARK

Temperature

100F 98.6F Hyperthermia

Pulse 60 to100 Beats/mt Normal

82beats/mt

Respiration

24breaths/mt 12 to16Breaths/mt Tachypnoea

Blood Pressure

155/110 mmHg 120/80 mmHg Hypertension

Skin :

Colour : Moderate/ Dark/ Fair

Texture : Smooth/ Dry

Hydration : Adequate/ Inadequate

Any discoloration : Yes/ No

Any Lesions / masses : Yes/ No

Any subjective complaints : Yes/ No

Nails :Normal/ Abnormal

Head

Scalp : Normal/ Dandruff/ Injury/ Pediculosis

Hair : Normal/ Spaces/Brownish/Brittle/Easily pluckable

Anterior Fontanels : Closed / Not Closed

Posterior Fontanels : Closed / Not Closed

Face

Expression : Normal/ Abnormal

Skin changes : Yes/ No

Puffiness : Yes/ No

Eyes

Vision : Normal/ Short sight/ Long sight

Conjunctiva :Normal/ Conjunctivitis

Sclera : Normal/ Scleritis/ Yellowish discolouration

Pupillary Reaction :Reacted to light/ Not reacted to light

Eyelids : Normal/ Abnormal

Eyeballs : Normal/ Strabismus

Eyelashes :Normal/ Sty

Ears

Hearing :Normal/ Deaf

Any discharge :Yes/ No

Nose

Sense of smell :Present/ Absent

Any discharge :Present/ Absent

DNS : Present/ Absent

Nasal polyp : Present/ Absent

Mouth

Sense of taste :Present/ Absent

Tongue :Normal/Glossitis

Teeth : Normal/ Dental carries

Lips : Normal/ Angular stomatitis

Neck

Movement : Possible/ Not possible

Thyroid gland : Visible/ Not visible

Chest

Respiratory Rate 24
:…………………breaths/mt

Heart Sound :S1 S2 heart sound heard/ Murmur

Respiratory Sound : Normal vesicular breath sound heard/ Wheeze/ Rattle

No
: Stridor/ Other………………………………………..

Abdomen

Inspection :Normal/ Scar/ Injury/ Visible Abdominal Veins

Palpation :Normal/ Hard mass/ Tenderness

Percussion : Normal/ Collection of fluid/ gas

Auscultation : Normal Bowel Sound/ Decreased/ Increased

Breast

Size : Normal/ asymmetry

Colustrum :Present/ Absent

Nipples : Normal / Infection / Inverted

Hygiene : Good/ Poor

Upper Extremities

ROM (Range of Motion) :Possible/ Not possible

Joints :Normal/ Inflammation

Fracture :Present/ Absent

Lower Extremities

ROM (Range of Motion) :Possible/ Not possible

Joints :Normal/ Inflammation

Fracture :Present/ Absent

Varicose vein :Present/ Absent

Genito Urinary & Rectum

Any Foul Odour :Present/ Absent

Any discharge :Present/ Absent

Any Infection :Present/ Absent

Neurological Examination

All Senses :Present/ Absent

All Reflexes :Present/ Absent

Coordination Test :Coordinated/Not Coordinated

Equilibrium Test :Well balanced /Not balanced

Any physical deformity : Yes/ No

Cognitive functions

Consciousness : Conscious/ Cloudy/ Semiconscious

Orientation : Oriented/ Not oriented

Time : Time/ Date/Day/Month/Year (Oriented/ Not oriented)

Place : Area/City/Kind Of Place (Oriented/ Not oriented)
Person : Self/ Close Relation/ Hospital Staff (Oriented/ Not oriented)

Attention : Normally Aroused/ Aroused With Difficulty

Concentration : Yes / No
Memory
a. Immediate memory :Yes/No
b. Recent memory :Yes/No
c. Remote memory :Yes/No

Intelligence

General knowledge : Yes/No

Self-Care Ability

Activity Independent Assistive Dependent

Eating/Drinking

Bathing

Toileting

Ambulating