a.

) Demographic Data
- Name
- Age
- Sex
- Marital Status
-Religion
- Occupation
- Socio-economic status
-Address
- Informant
- Information adequate or not

Health Perception & Health Management

1. Kumusta pangkalahatang kalusugan ninyo?
2. Asking about the chief complaint.
2.1 If yes, does it re-occur from past illnesses. Describe and compare if it is re-occur as a new.
3. Past medical history if may chronic disease
3.1 Surgery?
3.2 Immunization on childhood? Adult?
3.3 May maintaining health procedure po ba?
3.4 May mga complication po ba noong bata? Sanggol?
4. Mayroon po bang bisyo?
5. Present conditions like currently taking medications and have allergies?
6. Follow-up
6.1 Ano-ano ‘yung mga habits na ginagawa niyo to maintain health?
6.2 Kumusta ang mental health or pag-iisip?
6.3 Ano ho mga ginagawa kapag nakakaranas ng mga health problems?

Nutritional-Metabolic

1. Height ___ Weight ___ (current vs. previous 6 months)

2. May mga diet regimen po ba?
3. Nitong mga nakaraang lingo, kumusta ang pagkain?
4. May mga problema po ba sa pagkain?
4.1 Dentures and gag reflex
5. 24-hr diet call

Elimination

1. Kumusta ang pag-ihi? Pagdumi?

2. May nararamdaman na sakit sa pag-release?
3. Gaano kadalas umuhi? Dumi?
4. History of UTI ___ Constipation ___ Diarrhea ___

Activity-exercise

1. 24-hr. activity-rest table

2. Madalas gawain sa isang araw
3. Assess posture, gait, and deformities
4. Engagement in physical activities and description of breathing pattern
Sleep-rest

1. 24-hr sleep cycle pattern

2. Gaano katagal tulog
2.1 Taking naps
2.2 Problem in sleeping
2.3 Rituals before sleeping
3. Perception about when to rest and when to sleep

Cognitive-perception

1. Pain assessment
2. Visual assessment
3. Hearing assessment
4. Memory assessment – general, specific, and recent
5. Touch
6. Smell
Self-Perception and Self-Concept
1. Observation of the client on its mood on the half-way of the interview.
2. May mga isipin ho ba kayo ngayon?
2.1 Kung titingnan niyo ho ang situation, gaano ho ito kastressful sa inyo?
2.2 Paano niyo siya hinahandle?
3. Paano niyo ho nakikita ang sarili niyo ngayon?
3.1 Pisikal po, in terms of pagtingin sa salamin?
3.2 Mental terms po, may times po na mag-isa kayo, may naiisip po ba kayong mga salita about sa
sarili?
4. Observation of the client’s way of talking and maintenance of answers.

Roles-Relationships

1 May mga kasama naman po ba kayo sa bahay? Sino-sino po iyon?

1.1 Ano-ano yung mga major roles niyo sa bahay?
1.1 Madalas niyo ho ba silang kasama? Kung hindi, saan po sila madalas napunta? At ano po madalas
niyong ginagawa kapag kayo po naiiwan mag-isa?
1.2 Kumusta naman po ang interaction ninyo? May mga get-together po ba kayo o tradisyon sa loob ng
pamilya?
1.3 Komportable naman po ba kayo?
2. Sino-sino po ‘yung matuturing niyong support system niyo sa panahon na kailangan niyo ng suporta in
terms of:
2.1 Masayang kaganapan sa buhay
2.2 Kalungkutan sa buhay
2.3 Private stories in life
3. Kumusta naman po ang relasyon niyo sa pamilya ninyo, sa bawat isa?
4. Regarding Health management Naitanong ko po kanina ang patungkol sa hospitalization, usually,
noong naospital kayo o kung sakali man na may times of crisis na need talaga mahospitalize, may
magbabago ho ba sa role-taking sa family ninyo?
4.1 Sino ho ang kapalitan niyo sakali sa role-taking na nakatoka sa inyo?
Sexuality-Reproductive

1. If female, ask about LMP, pregnancy, taking of medications for vaginal discussion, pap smear,
regularities of menstruation, and any check-ups.
2. If male, ask about the history of prostate problems, any penile discharges, bleeding or lesions, any
medications taken, or procedures to check own genitals.
3. Any history of sexual interaction?
4. Any diagnosis about sexually transmitted diseases?
5. Saan po kayo mainly attracted? Girls, boys, both, or none?
6. Paano niyo po pinepresent ang sarili niyo bilang gender chosen? (Paraan ng pananamit)

Coping-stress Tolerance

1. The questions were addressed in Self-perception #2.2

2. May recent event po ba kayo na kinokonsider niyo na sobrang stressful sa inyo?
3. Namatayan na ho ba kayo rati?
3.1 Ano-ano ho ‘yung mga paraan niyo noon para makaalpas kayo sa situation na iyon?

Value-belief

1. Religion already assessed in demographic phase

2. Ano po ang major basehan niyo ng moralidad ang values sa buhay? Sa relihiyon po ba? Or may mga
sarili po kayong ideologies or nabasang teorya ng iba na inaapply sa buhay?
3. Do these beliefs ay nakakaaffect on how you deal with life?
3.1 Can you give me examples po ng mga scenarios?
4. Kwentuhan niyo po ako ng mga gawi niyo sa religion/paniniwala na mayroon ka ngayon.
5. Ano ho ang masasabi niyong mantra niyo sa buhay na parang ayun ang vision niyo?

Nutrition Checklist for Older Adults

"DETERMINE" Mnemonic
Name: _____________________ Today's Date: _________
Score for "Yes"
Possible Problem Question to Answer Answer
(Circle if "yes")

Do you have an illness or condition that makes you change the

Disease 2
kind and/or amount of food you eat?

Eating Poorly Do you eat fewer than 2 meals per day? 3

Do you eat few fruits, vegetables or milk products? 2

Do you have 3 or more drinks of beer, liquor or wine almost every

2
day?

Do you have tooth or mouth problems that make it hard for you to
Tooth Loss/Mouth Pain 2
eat?

Economic Hardship Do you sometimes have trouble affording the food you need? 4

Reduced Social
Do you eat alone most of the time? 1
Contact
 Do you take 3 or more prescribed or over-the-counter drugs a
Multiple Medications 1
day?

Involuntary Weight Have you lost or gained 10 pounds in the last 6 months without
2
Loss/Gain trying?

Needs Assistance In Are you sometimes physically not able to shop, cook or feed
1
Self Care yourself?

Elder Years > Age 80 Are you over 80 years old? 1

TOTAL ________

 0-2--Good!
Recheck your nutritional score in 6 months.

 3-5--You are at moderate nutritional risk.

See what can be done to improve your eating habits and lifestyle. Your office on aging, senior nutrition
program (eg, Meals On Wheels), senior center or health department can help. Recheck your nutritional
score in 3 months.

 6 or more--You are at high nutritional risk.

URINARY CONTINENCE

Patient Assessment Tool--Urinary Function Assessment

Over the past month or so, how often have you...
Less than Less than About More than
Not at Almost
Symptom 1 time in half the half the half the
all always
5 time time time

1. ...had a sensation of not

emptying your bladder completely 0 1 2 3 4 5
after you finished urination?

2. ...had to urinate again less than

two hours after you finished 0 1 2 3 4 5
urinating?

3. ...found you stopped and

started again several times when 0 1 2 3 4 5
you urinated?

4. ...found it difficult to postpone

0 1 2 3 4 5
urination?

5. ...had a weak urinary stream? 0 1 2 3 4 5

6. ...had to push or strain to begin 0 1 2 3 4 5

 urination?

7. ...had to usually get up to

5
urinate from the time you went to 0 1 2 3 4
(5 times
bed until you got up in the (none) (once) (twice) (3 times) (4 times)
or more)
morning?

Score=sum of answers to questions 1 through 7: ______

>=8 Moderate symptoms

>=20 Severe symptoms

For each activity (No. 1 - 20), statements a - e refer to a different level of ability.
Thinking of the last 2 weeks, tick the box that represents your relative’s/friend’s AVERAGE ability. (If in doubt
about which box to tick, choose the level of ability which represents their average performance over the last 2
Weeks. Tick ‘Not applicable’ if your relative never did that activity when they were well).

1. PREPARING a) Selects and prepares food as required

FOOD b) Able to prepare food if ingredients set out
c) Can prepare food if prompted step by step
d) Unable to prepare food even with prompting and
supervision
e) Not applicable

2. EATING a) Eats appropriately using correct cutlery

b) Eats appropriately if food made manageable and/or
uses spoon
c) Uses fingers to eat food
d) Needs to be fed
e) Not applicable

3. PREPARING a) Selects and prepares drinks as required

DRINK b) Can prepare drinks if ingredients left available
c) Can prepare drinks if prompted step by step
d) Unable to make a drink even with prompting and
supervision
e) Not applicable
4. DRINKING a) Drinks appropriately
b) Drinks appropriately with aids, beaker/straw etc.
c) Does not drink appropriately even with aids but
attempts to
d) Has to have drinks administered (fed)
e) Not applicable

5. DRESSING a) Selects appropriate clothing and dresses self

b) Puts clothes on in wrong order and/or back to front
and/or dirty clothing
c) Unable to dress self but moves limbs to assist
d) Unable to assist and requires total dressing
e) Not applicable

6. HYGIENE a) Washes regularly and independently

b) Can wash self if given soap, flannel, towel, etc
c) Can wash self if prompted and supervised
 7. TEETH a) Cleans own teeth/dentures regularly and
independently
b) Cleans teeth/dentures if given appropriate items
c) Requires some assistance, toothpaste on brush,
brush to mouth etc
d) Full assistance given
e) Not applicable

8. BATH/SHOWER a) Bathes regularly and independently

b) Needs bath to be drawn/shower turned on but
washes independently
c) Needs supervision and prompting to wash
d) Totally dependent, needs full assistance
e) Not applicable

9. a) Uses toilet appropriately when required

TOILET/COMMODE b) Needs to be taken to the toilet and given assistance
c) Incontinent of urine or faeces
d) Incontinent of urine and faeces
e) Not applicable

10. TRANSFERS a) Can get in/out of chair unaided

b) Can get into a chair but needs help to get out
c) Needs help getting in and out of a chair
d) Totally dependent on being put into and lifted from
chair
e) Not applicable

11. MOBILITY a) Walks independently

b) Walks with assistance ie furniture, arm for support
c) Uses aids to mobilise ie frame, sticks etc
d) Unable to walk
 e) Not applicable

12. a) Fully orientated to time/day/date etc

ORIENTATION b) Unaware of time/day etc but seems unconcerned
– TIME
c) Repeatedly asks the time/day/date
d) Mixes up night and day
e) Not applicable

13. a) Fully orientated to surroundings

ORIENTATION b) Orientated to familiar surroundings only
– SPACE c) Gets lost in home, needs reminding where bathroom
is, etc
d) Does not recognise home as own and attempts to
leave
e) Not applicable
14. a) Able to hold appropriate conversation
COMMUNICATIO b) Shows understanding and attempts to respond
N verbally with gestures
c) Can make self understood but difficulty
understanding others
d) Does not respond to, or communicate with others
e) Not applicable

15. TELEPHONE a) Uses telephone appropriately, including obtaining

correct number
b) Uses telephone if number given verbally/visually or
predialled
c) Answers telephone but does not make calls
d) Unable/unwilling to use telephone at all
e) Not applicable
16. a) Able to do housework/gardening to previous
HOUSEWORK/ standard
GARDNEING b) Able to do housework/gardening but not to previous
standard
c) Limited participation with a lot of supervision
d) Unwilling/unable to participate in previous activities
e) Not applicable

17. SHOPPING a) Shops to previous standard

 b) Only able to shop for 1 or 2 items with or without
a list
c) Unable to shop alone, but participates when
accompanied
d) Unable to participate in shopping even when
accompanied
e) Not applicable
18. FINANCES a) Responsible for own finances at previous level
b) Unable to write cheque. Can sign name &
recognises money values
c) Can sign name but unable to recognise money
values
d) Unable to sign name or recognise money values
e) Not applicable

19. GAMES/HOBBIES a) Participates in pastimes/activities to previous

standard
b) Participates but needs instruction/supervision
c) Reluctant to join in, very slow needs coaxing
d) No longer able or willing to join in
e) Not applicable

20. TRANSPORT a) Able to drive, cycle or use public transport

independently
b) Unable to drive but uses public transport or bike etc
c) Unable to use public transport alone
d) Unable/unwilling to use transport even when
accompanied
e) Not applicable

Abnormal Involuntary Movement Scale (AIMS)

The original reference for the AIMS seems to be Guy W. ECDEU Assessment Manual for
Psychopharmacology, revised ed. Washington, DC, US Department of Health, Education, and Welfare,
1976. A nice practical discussion can be found in Munetz MR, Benjamin S. How to examine patients using the
Abnormal Involuntary Movement Scale. Hospital and Community Psychiatry Nov 1988, 39 (11):1172-1177.

Most of the below was kindly submitted by Whit Garberson <jwgg@world.std.com>, Albert Maramis
<almarams@server.indo.net.id>, and Matthew J. Merkley <merkley@databank.com>. Mr Garberson also
notes:

Federal regs here require this test be administered every 6 mos. for nursing home patients currently on
antipsychotic meds. I'm not sure if there are similar regs for other populations/settings.
 Instructions
There are two parallel procedures, the examination procedure, which tells the patient what to do, and
the scoring procedure, which tells the clinician how to rate what he or she observes.

Examination Procedure
Either before or after completing the examination procedure, observe the patient unobtrusively at rest (e.g., in
the waiting room).

The chair to be used in this examination should be a hard, firm one without arms.

1. Ask the patient whether there is anything in his or her mouth (such as gum or candy) and, if so, to
remove it.
2. Ask about the *current* condition of the patient's teeth. Ask if he or she wears dentures. Ask whether
teeth or dentures bother the patient *now*.
3. Ask whether the patient notices any movements in his or her mouth, face, hands, or feet. If yes, ask the
patient to describe them and to indicate to what extent they *currently* bother the patient or interfere
with activities.
4. Have the patient sit in chair with hands on knees, legs slightly apart, and feet flat on floor. (Look at the
entire body for movements while the patient is in this position.)
5. Ask the patient to sit with hands hanging unsupported -- if male, between his legs, if female and
wearing a dress, hanging over her knees. (Observe hands and other body areas).
6. Ask the patient to open his or her mouth. (Observe the tongue at rest within the mouth.) Do this twice.
7. Ask the patient to protrude his or her tongue. (Observe abnormalities of tongue movement.) Do this
twice.
8. Ask the patient to tap his or her thumb with each finger as rapidly as possible for 10 to 15 seconds, first
with right hand, then with left hand. (Observe facial and leg movements.) [±activated]
9. Flex and extend the patient's left and right arms, one at a time.
10. Ask the patient to stand up. (Observe the patient in profile. Observe all body areas again, hips
included.)
11. Ask the patient to extend both arms out in front, palms down. (Observe trunk, legs, and mouth.)
[activated]
12. Have the patient walk a few paces, turn, and walk back to the chair. (Observe hands and gait.) Do this
twice. [activated]

Scoring Procedure
Complete the examination procedure before making ratings.

For the movement ratings (the first three categories below), rate the highest severity observed. 0 = none, 1 =
minimal (may be extreme normal), 2 = mild, 3 = moderate, and 4 = severe. According to the original AIMS
instructions, one point is subtracted if movements are seen only on activation, but not all investigators follow
that convention.

Facial and Oral Movements

1. Muscles of facial expression,

e.g., movements of forehead, eyebrows, periorbital area, cheeks. Include frowning, blinking, grimacing
of upper face. 0 1 2 3 4
2. Lips and perioral area,
e.g., puckering, pouting, smacking. 0 1 2 3 4
3. Jaw,
e.g., biting, clenching, chewing, mouth opening, lateral movement. 0 1 2 3 4
4. Tongue.
Rate only increase in movement both in and out of mouth, not inability to sustain movement.0 1 2 3 4

Extremity Movements

5. Upper (arms, wrists, hands, fingers).

Include movements that are choreic (rapid, objectively purposeless, irregular, spontaneous) or athetoid
(slow, irregular, complex, serpentine). Do not include tremor (repetitive, regular, rhythmic movements).
01234
6. Lower (legs, knees, ankles, toes),
e.g., lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot.
01234

Trunk Movements

7. Neck, shoulders, hips,

e.g., rocking, twisting, squirming, pelvic gyrations. Include diaphragmatic movements. 01234

Global Judgments

8. Severity of abnormal movements. 0 1 2 3 4

based on the highest single score on the above items.
9. Incapacitation due to abnormal movements.

0 = none, normal
1 = minimal
2 = mild
3 = moderate
4 = severe

10. Patient's awareness of abnormal movements.

0 = no awareness
1 = aware, no distress
2 = aware, mild distress
3 = aware, moderate distress
4 = aware, severe distress

Dental Status

11. Current problems with teeth and/or dentures.

0 = no
1 = yes

12. Does patient usually wear dentures?

0 = no
1 = yes
 CLINICAL DEMENTIA RATING (CDR)

CLINICAL
DEMENTIA
RATING 0 0.5 1 2 3
(CDR):

Impairment

None Questionable Mild Moderate Severe

1 2 3
0 0.5

No memory Consistent Moderate memory loss; Severe memory loss; Severe memory loss;
loss or slight slight more marked for recent only highly learned only fragments remain
inconsistent forgetfulness; events; defect interferes material retained; new
forgetfulness partial with everyday activities material rapidly lost
Memory
recollection of
events;
"benign"
forgetfulness

Fully oriented Fully oriented Moderate difficulty with Severe difficulty with Oriented to person only
except for slight time relationships; time relationships;
difficulty with oriented for place at usually disoriented to
Orientation time examination; may have time, often to place
relationships geographic
disorientation
elsewhere

Solves Slight Moderate difficulty in Severely impaired in Unable to make

everyday impairment in handling problems, handling problems, judgments or solve
problems & solving similarities, and similarities, and problems
handles problems, differences; social differences; social
Judgment &
business & similarities, and judgment usually judgment usually
Problem
financial affairs differences maintained impaired
Solving
well; judgment
good in relation
to past
performance

Independent Slight Unable to function No pretense of Appears too ill to be

function at impairment in independently at these independent function taken to functions
Community usual level in these activities activities although may outside home outside a family home
Affairs job, shopping, still be engaged in
Appears well enough to
volunteer and some; appears normal
be taken to functions
social groups to casual inspection
outside a family home

Life at home, Life at home, Mild but definite Only simple chores No significant function in
hobbies, and hobbies, and impairment of function preserved; very
intellectual intellectual at home; more difficult restricted interests, home
Home and
interests well interests chores abandoned; poorly maintained
Hobbies
maintained slightly more complicated
impaired hobbies and interests
abandoned

Fully capable of self-care Needs prompting Requires assistance in Requires much help with
Personal dressing, hygiene, personal care; frequent
Care keeping of personal incontinence
effects
 Score only as decline from previous usual level due to cognitive loss, not impairment due to
other factors.

XIII. CASE MANAGEMENT

A. Medical (present only those that are applicable and w/c have been done for the patient)
1. Pharmacologic Intervention
Drug Features Therapeutic Effects Nursing
Responsibilities
- Brand / Generic Name Indication Contraindicatio Desired Untoward
- Classification n
- Prescribed Dosage
- Route
- Frequency
2. Dietary Prescription / Restriction