Geriatric functional

assessment tools
Bautista, Barrion, Beseril, Bitte, Buenaflor
Definition of terms
Gerontology
● From the greek geron meaning “old man”
● The scientific study of the process of aging and the
problems of aged people
● Includes biologic, sociologic, psychologic, and economic
aspects
Definition of terms
Gerontological Nursing
● Specialty of nursing that involves assesing the health
and status of older adults
● Involves planning and implementing healthcare and
services to meet the identified needs and evaluating the
effectiveness of such care
Definition of terms
Geriatrics
● From greek word “geras” meaning of old age”
● Branch of medicine that deals with the disease and problems
of old age

Geriatric Nursing
● The nursing care of the older people with health problems,
or those requiring tertiary care
● Used to define the study of aging and/or the aged
HEALTH HISTORY: basic components
➔ Patient profile/ Biographical Data
➔ Family profile
➔ Occupational Profile
◆ current work/retirement status

➔ Living environment profile

◆ type of dwelling

➔ Recreation/Leisure Profile
◆ Hobbies, organization membership
➔ Resources/Support System
◆ Community services used, name of physicians

➔ Description of a typical day

◆ Type and amount of time spent in each activities.

➔ Past health history

➔ Present health history
◆ Symptom analysis

➔ Review of system
TOols for assessment
1. Biological Assessment
i. Assessment of physical health / Physical Assessment
ii. Functional status
2. Psychological Assessment
i. Cognitive Assessment
ii. Affective Assessment
3. Sociological Assessment
i. Social Network Assessment
01 physical
assessment
Physical assessment
Definition
A. The physical examination or physical assessment is a systematic data collection
method that uses observation (i.e., the senses of sight, hearing, smell, and
touch) to detect health problems. To conduct the examination, the nurse uses
techniques of inspection, palpation, percussion, and auscultation.

The physical examination is carried out systematically. It may be organized

according to the examiner’s preference, in a head-to-toe approach or a body
systems approach.

The nurse takes such measurements as vital signs, height, and weight. The
cephalocaudal or head-to-toe approach begins the examination at the head;
progresses to the neck, thorax, abdomen, and extremities; and ends at the toes
Head To Toe Framework
General Survey
Vital Signs
Head Neck
● Hair, Scalp, Face Muscles
● Eyes and Vision Lymph Nodes
● Ears and hearing Trachea
● Nose Thyroid gland
● Mouth and oropharynx Carotid arteries
● Neck veins
Head to toe framework
Upper Extremities Chest and Back

● Skin and nails Skin

● Muscle strength and tone Thorax shape and size
● Joint range of motion Lungs
● Brachial and radial pulses Heart
● Sensation Spinal column
● Breast and axillae
Head to toe framework
Abdomen Lower Extremities
● Skin Skin and toenails
● Abdominal sounds Gait and balance
● Femoral pulses Joint range of motion
Popliteal
Posterior tibial
Dorsalis pedis pulses
External Genitals
Anus
Supplies needed in physical assessment
● Flashlight or Penlight
● Opthalmoscope
● Otoscope
● Percussion (reflex) hammer
● Tuning fork
● Cotton applicators
● Gloves
● Tongue blades (depressors)
Physiologic changes
1. Heart - Your heart pumps all day and night, whether you
are awake or asleep. As we age, blood vessels lose their
elasticity, fatty deposits build up against artery walls
and the heart has to work harder to circulate the blood
throughout your body. This can lead to high blood
pressure (hypertension) and atherosclerosis (hardening of
the arteries).
Physiologic changes
2. Bones Muscles & Joints - As we age, our bones shrink in size
and density. Some people actually become shorter. Others are more
prone to fractures because of bone loss. Muscles, tendons, and
joints may lose strength and flexibility.
Exercise is a great way to slow or prevent the problems with
bones, muscles and joints. Maintaining strength and flexibility
will help keep you strong. In addition, a healthy diet including
calcium can help strengthen the bones. Be sure to talk to your
doctor about what types of diet and exercise are right for you.
Physiologic changes
3. Digestive System - swallowing and digestive reflexes slow
down as we age. Swallowing may become harder as the
esophagus contracts less forcefully. The flow of secretions
that help digest food in the stomach, liver, pancreas and
small intestine may also be reduced. The reduced flow may
result in digestive issues that weren’t present when you
were younger.
Physiologic changes
4. Kidneys and Urinary Tract - Kidneys may become less
efficient in removing waste from the bloodstream because
kidneys get smaller as they lose cells as we age. Chronic
diseases such as diabetes or high blood pressure can cause
even more damage to kidneys.
Urinary incontinence may occur due to a variety of health
conditions. Changes in hormone levels in women and having an
enlarged prostate in men are contributing factors that lead
to urinary incontinence.
Physiologic changes
5. Brain and Nervous System - As we age, we naturally lose
cells. This is even true in the brain. Memory loss occurs
because of the number of brain cells decreases. The brain
can compensate for this loss by increasing the number of
connections between cells to preserve brain function.
Reflexes may slow down, distraction is more likely and
coordination is affected.
Physiologic changes
6. Eyes - There are many vision changes that occur as we
age. We may need help seeing objects that are closer as our
lens stiffens. We may have a more difficult time seeing in
low-light conditions, and colors may be perceived
differently. Our eyes may be less capable of producing tears
and our lenses may become cloudier.

Common eye problems associated with age include cataracts,

glaucoma and macular degeneration.
Physiologic changes
7. Ears - Excessive noise throughout your lifetime can cause
hearing loss as you age. Many older adults have difficulty
hearing higher pitched voices and sounds, trouble hearing in
busy places and more frequently accumulating earwax.
Physiologic changes
8. Hair, Skin and Nails - As you age, your skin becomes more
dry and brittle, which can lead to more wrinkles. The fat
layer under the skin thins, which results in less sweating.
This may seem like a good thing, but it makes you more
susceptible to heat stroke and heat exhaustion in the
summer. Hair and nails grow slower and become brittle. Hair
will thin and turn gray.
Physiologic changes
9. Weight - Decreasing levels of physical activity and a
slowing metabolism may contribute to weight gain. Your body
may not be able to burn off as many calories as it once
could, and those extra calories will end up being stored as
fat.

While you can't prevent aging, you can prepare yourself for
the various effects of aging, both outside and inside the
body.
functional
Definition
Functional assessment is important in understanding our
patient’s

● Overall functional capabilities

● Insight into their independence
● How much assistance they need
Key terms to understand
- Functional Status
- Functional Performance
- ADLs
So What exactly are ADLs?
- Activities of Daily Living These activities include:
- Necessary activities performed
- Bathing
throughout the day
- Dressing
- Using the restroom
- Moving from place to place
(transferring)
- Grooming
- Eating (feeding)
Now that we know what ADLs are…What are IADLs?
- Instrumental Activities of These activities include
Daily Living
- Administering own medication
- Activities done in the
- Grocery Shopping
community to maintain
- Preparing food
independence
- Using the phone
- Driving and transportation
- Finance
- Housekeeping
- Doing the laundry
Question Time!
What tools can we use to assess our client’s Functional status?
- Sickness Impact Profile
- Pain Assessment Scales
- Timed Up and Go Test
- Katz index of ADL
- FANCAPES
Sickness Impact profile
- 136 item checklist
- 3 different domains
- Independent functional category (I)
- Physical function (II)
- Psychological function (III)
- If client says:
- YES = 1 pt
- NO = 0 pt
Pain Assessment - Why should we assess for pain?
Pain Assessment - Visual Scales (Faces pain Scale)
Pain assessment - Visual Scale (Visual Analog Scale)
Timed up and go test
Scoring
- 10 sec or less = normal

- 11 - 20 sec = within
normal limits for frail
elderly patients

- 30 sec or more = prone to

fall
Katz index of ADL
Things to note:

● 1 pt - task is done without

direction; pt is independent
while performing

Scoring:

6 pts = full function

4 pts = moderate impairment

2 pts or less = severe functional

impairment

0 pts = pt can’t perform

independently are dependent on
others to help them
FANCAPES
F - luid
A - eration
N - nutrition
C - ognition, communication
A - activity, abilities
P - ain
E - lamination
S - kin/socialization
02 psychological
assessment
Definition
● Screening for cognitive impairment
● Differential diagnosis
● Rating for severity-progression
○ Dementia
○ Depression
Cognitive
assessment
 ● Most widely used brief screening instrument to

Mini mental state detect cognitive impairment

exam (mmse) ● Developed by Dr. William Molloy

● pen‐and‐paper test of cognitive function based

on a total possible score of 30 points; it includes

tests of orientation, concentration, attention,

verbal memory, naming and visuospatial skills.

Score Interpretation
 ● Brief cognitive screening test that is frequently

Mini -Cog test

used to evaluate cognition in older adults in

various settings:

● Developed by Soo Borson

Definition
1. Three-word registration
a. Look directly at the person and say “please listen carefully, I am
going to say three words that i want you to repeat back to me now and
try to remember the words
i. 3/3 - no cognitive impairment
ii. ⅔ - mild cognitive impairment
iii. ⅓ - moderate cognitive impairment
2. Clock Drawing Test
a. To check verbal understanding, visual memory, abstract thinking
i. 2/2 = pass clock drawing test
ii. 0/2 = failed clock drawing test
3. Three-word recall
affective
Tools used in assessment
Geriatric Depression Scale- Although a depression
diagnosis should not be based on GDS results alone, it’s
often included in assessment because of its established
reliability and validity.
Geriatric depression scale

● The interviewer asks the older person a set of 30

questions with possible answers of yes or no.
● A negative response is scored as 1 point.
● With 0-9 being normal, 10-19 indicating mild
depression and 20-30 indicating severe depressive
symptoms.
Geriatric depression scale
Available Forms:

● The long-form GDS which consists of 30 questions.

● The short-form GDS which has 15 questions.
03 sociological
assessment
SOCIAL ASSESSMENT CARE
Objectives:
● To gain an understanding on social assessment care and
lubben social network scale;
● To manifest understanding on social assessment care for
our elderlies;
● Promote wholesome intrapersonal and interpersonal
communication which fosters harmonious relationship among
individual.
● Apply communications skills necessary for individuals;
● Show comprehensive goal directed and efficient management
for the improvement of a person's psychological emotional
social spiritual and biological approach.
why do we need to asses the
social network capabilities
of our elderlies?

To provide an assessment of
individual functioning in
elderly individuals
What are the five domains under
social assessment care or Lubben
social network scale?

● Social Resources
● Economic resources
● Mental health
● Physical Health
● Participation in physical
health of daily living
What is Lubben social network scale?