COMPREHENSIVE GERIATRIC ASSESSMENT TOOL

Biographical Data
Name:
Address:
Age:
Sex:
Civil Status:
Religion:
Educational Attainment:
Employment Status:

History of Present Illness

Past Medical History

Family History with Genogram

Acquired Diseases: Genogram

Hypercholesterolemia
Kidney Disease
Tuberculosis
Alcoholism
Drug Addiction
Hepatitis

Heredo-familial Diseases:
Diabetes
Heart Disease
Hypertension
Cancer
Asthma
Epilepsy
Rheumatism /Arthritis
Others: 1
 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:

as treatment for:
as treatment for:
as treatment for:
as treatment for:
as treatment for:

General Observation:

Vital Signs: T:
P:
R:
BP:

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 REVIEW OF SYSTEMS

Integumentary

Respiratory

Cardiovascular

Digestive

Excretory

Musculoskeletal

Nervous

Reproductive

Endocrine

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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:
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:

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:

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:

CONTINENCE (1 POINT) Exercises complete self-control over (0 POINTS) Is partially or

urination and defecation. totally incontinent of bowel or
POINTS: _ 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:

TOTAL SCORE: 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.

Source: try this: Best Practices in Nursing Care to Older Adults, The Hartford Institute
for Geriatric Nursing, New York University, College of Nursing, www.hartfordign.org.

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 LAWTON - BRODY
INSTRUMENTAL ACTIVITIES OF DAILY LIVING SCALE (I.A.D.L.)
Best Practices in Nursing Care to Older Adults. The Hartford
Source: Institute for Geriatric Nursing, New York University,
College of Nursing, www.hartfordign.org
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 Score

Total score

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

Nutritional-metabolic pattern

Elimination pattern

Activity and Exercise pattern

Sleep-Rest pattern

Cognitive-perceptual pattern

Self-perception Self-concept pattern

Role relationship pattern

Sexuality reproductive pattern

Coping-Stress-Tolerance pattern

Value-Belief pattern

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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
2. Have you dropped many of your activities and interests? YES / NO

3. Do you feel that your life is empty? YES / NO

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

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

NOTE ON
SCORING
Scoring* *One more error is
allowed in the
0-2 errors: normal mental functioning scoring if a patient
3-4 errors: mild cognitive impairment has had a grade
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 PLAN
Cues Subjective

Objective

Nursing
Diagnosis

Objectives

Interventions
& Rationale

Evaluation

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