COR JESU COLLEGE, INC.

COLLEGE OF HEALTH SCIENCES

Tres De Mayo Campus, Brgy. Tres De Mayo, Digos City, Province of
Davao Del Sur
Website: www.cjc.edu.ph

GERIATRIC PATIENT PROFILE

Name:
_______________________________________
Age:
_______________________________________
Date of Birth:
_______________________________________
Sex:
_______________________________________
Occupation:
3R PHOTO
_______________________________________
Address:
_______________________________________
Civil Status:
_______________________________________
Number of Children:
_______________________________________
Spouse Name: _______________________________________ Please provide documentary evidence (photos during interview, with
Occupation: date stamp on the photo, photo with the interviewer and interviewee.
_______________________________________ May also provide video evidence of interview.
Mother’s Name:
Page 1 of 7
 COR JESU COLLEGE, INC.
COLLEGE OF HEALTH SCIENCES
Tres De Mayo Campus, Brgy. Tres De Mayo, Digos City, Province of
Davao Del Sur
Website: www.cjc.edu.ph

GERIATRIC NURSING ASSESSMENT

ONGOING ASSESSMENT
GUIDELINES PATIENT DAY 1 DAY 2 DAY 3
I. MENTAL STATUS
A. STATE OF MENTAL
CONCIOUSNESS
B. ORIENTATION
C. INTELLECTUAL CAPACITY
D. VOCABULARY LEVEL
E. ATTENTION SPAN
F. ABILITY TO UNDERSTAND

II. STATUS OF SPATIAL SENSES

A. AUDITORY PROBLEM
B. VISUAL PROBLEM
C. SPEECH PERCEPTION
D. TACTILE PERCEPTION
E. OLFACTORY PERCEPTION
Submitted By: Submitted to:

Page 2 of 7
 _______________________________________________________
______________________________________________________

COR JESU COLLEGE, INC.

COLLEGE OF HEALTH SCIENCES
Tres De Mayo Campus, Brgy. Tres De Mayo, Digos City, Province of
Davao Del Sur
Website: www.cjc.edu.ph

GERIATRIC NURSING ASSESSMENT

ONGOING ASSESSMENT
GUIDELINES PATIENT DAY 1 DAY 2 DAY 3
III. MOTOR ABILITY
A. CURRENT MOBILITY
B. POSTURE
C. RANGE OF JOINT MOTION
D. MUSCLE AND NERVE STATUS
E. LOSS OF EXTREMITIES

Submitted By: Submitted to:

_______________________________________________________
______________________________________________________

Page 3 of 7
 COR JESU COLLEGE, INC.
COLLEGE OF HEALTH SCIENCES
Tres De Mayo Campus, Brgy. Tres De Mayo, Digos City, Province of
Davao Del Sur
Website: www.cjc.edu.ph

GERIATRIC NURSING ASSESSMENT

ONGOING ASSESSMENT
GUIDELINES PATIENT DAY 1 DAY 2 DAY 3
IV. BODY TEMPERATURE
A. RANGES

V. RESPIRATORY STATUS
A. CHARACTER
B. USE OF RESPIRATORY AIDS
C. INTERFACES WITH
RESPIRATIONS
D. ABNORMAL RESPIRATORY
OPENING
VI. CIRCULATORY STATUS
A. CHARACTERISTIC OF ARTERIAL
PULSE
B. BLOOD PRESSURE
C. APICAL-RADIAL PULSE
D. INTRAVENOUS FLUIDS

Page 4 of 7
 Submitted By: Submitted to:

_______________________________________________________
______________________________________________________

COR JESU COLLEGE, INC.

COLLEGE OF HEALTH SCIENCES
Tres De Mayo Campus, Brgy. Tres De Mayo, Digos City, Province of
Davao Del Sur
Website: www.cjc.edu.ph

GERIATRIC NURSING ASSESSMENT

ONGOING ASSESSMENT
GUIDELINES PATIENT DAY 1 DAY 2 DAY 3
VII. NUTRITIONAL STATUS
A. CONDITION OF BUCCAL
ACTIVITY
B. DIGESTION FOODS

VIII. ELIMINATIONS STATUS

A. BOWEL
B. BLADDER
C. ABNORMALITIES

IX. MALE REPRODUCTIVE STATUS

A. PROSTATE GLAND

X. FEMALE REPRODUCTIVE STATUS

A. AGE OF MENARCHE
B. PREGNANCY
C. VAGINA

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 D. CERVIX
E. VAGINAL DISCHARGE
F. VAGINAL BLEEDING
G. LAST MENSTRUAL PERIOD (LMP)

COR JESU COLLEGE, INC.

COLLEGE OF HEALTH SCIENCES
Tres De Mayo Campus, Brgy. Tres De Mayo, Digos City, Province of
Davao Del Sur
Website: www.cjc.edu.ph

GERIATRIC NURSING ASSESSMENT

ONGOING ASSESSMENT
GUIDELINES PATIENT DAY 1 DAY 2 DAY 3
XII. STATE OF SKIN AND APPENDAGES
A. SKIN
B. HAIR
C. NAILS

XIII. STATE OF PHYSICAL ARREST AND COMFORT

A. SLEEP/REST PATTERN
B. PRESENCE OF
PAIN/DISCOMFORT
C. USE OF SUPPORTIVE AIDS

XIV. EMOTIONAL STATUS

A. EMOTIONAL REACTIONS
B. BODY IMAGE
C. ABILITY TO RELATE OTHERS

XIV. NURSING DIAGNOSES

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 Submitted By: Submitted to:
_______________________________________________________
______________________________________________________

GERIATRIC INITIAL ASSESSMENT

CENTRAL NERVOUS SYSTEM GASTRO-INTESTINAL SYSTEM
_______________________________________ _______________________________________
_______________________________________ _______________________________________
_______________________________________ _______________________________________
_______________________________________ _______________________________________
________________ ________________

RESPIRATORY SYSTEM GENITO-URINARY SYSTEM

_______________________________________ _______________________________________
_______________________________________ _______________________________________
_______________________________________ _______________________________________
_______________________________________ _______________________________________
________________ ________________

MUSCULO-SKELETAL SYSTEM CIRCULATORY SYSTEM

_______________________________________ _______________________________________
_______________________________________ _______________________________________
_______________________________________ _______________________________________
_______________________________________ _______________________________________
________________ ________________

REPRODUCTIVE SYSTEM Page 7 of 7 INTEGUMENTARY SYSTEM

_______________________________________ _______________________________________
_______________________________________ OTHER SIGNIFICANT DATA OBTAINED _______________________________________
_______________________________________ ___________________________________________________________________ _______________________________________
_______________________________________ ___________________________________________________________________ _______________________________________