NCM 114- Care of the Older Adult

Prelim Activity
COMPREHENSIVE GERIATRIC
ASSESSMENT

Part I: Socio-demographic background:

Name of Client: Pablo F. Respicio
Age: 90 years old
Civil Status: Widowed
Religion: Aglipayan
Occupation: Farmer
Address: Brgy. 16 Bugasi Banna, Ilocos Norte
Monthly family income: 5,000

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 PART II: GERIATRIC ASSESSMENT
Directions:

 Accomplish Assessment 1 by placing a specific mark on the space

provided for each area.
 Once you have completed Assessment 1, compute the total number of
points obtained and interpret the score by using what is written below.
Compose a simple analysis of this.

SCORE interpretation:
*—No supervision, direction, or personal assistance.
†—With supervision, direction, personal assistance, or total care.
‡—Score of 6 = high (patient is independent); score of 0 = low (patient is very dependent).

ASSESSMENT 1 KATZ INDEX OF INDEPENDENCE IN

ACTIVITIES OF DAILY LIVING
ACTIVITIES (1 INDEPENDENCE (1 DEPENDENCE (
OR 0 POINTS) POINT)* 0 POINT)*
Bathing Bathes self completely or
needs help in bathing only a
single part of the body, such
as the back, genital area, or
Points: 0 disabled extremity
Dressing Bathes self completely or
needs help in bathing only a
single part of the body, such
as the back, genital area, or
Points: 1 disabled extremity
Toileting Goes to toilet, gets on and
off, arranges clothes, cleans
Points: 0 genital area without help
Transferring Moves in and out of bed or
chair unassisted; mechanical
transfer aids are acceptable
Points: 0
Fecal and urinary Exercises complete self-
continence control over urination and
defecation
Points: 0
Feeding Gets food from plate into
mouth without help;
preparation of food may be
Points: 1 done by another person
Total Points:2
Needs help with bathing more
than one part of the body,
getting in or out of the
bathtub or shower; requires
total bathing
Needs help with bathing more
than one part of the body,
getting in or out of the
bathtub or shower; requires
total bathing
Needs help transferring to the
toilet and cleaning self, or
uses bedpan or commode
Needs help in moving from
bed to chair or requires a
complete transfer
Is partially or totally
incontinent
Needs partial or total help
with feeding or requires
parenteral feeding

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Analysis: Mr. Pablo F. Respicio has a total of 2 points and classified as (patient is dependent)
According to Mr. Pablo F. Respicio he cannot do bathing by himself, he cannot do proper toileting as well as he
cannot control his urination and defecation so he wear pampers, he needs help every time, but, he stated that he can
completely do to dress himself and feed himself.

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Directions: For each question put a check on the point that best applies to your client’s situation. Use the
choices below. Make a simple analysis of the data obtained.
Choices:
Without help: 3
With some help: 2
Completely unable: 1

ASSESSMENT 2 LAWTON INSTRUMENTAL ACTIVITIES OF DAILY LIVING

ACTIVITIES OF DAILY LIVING WITHOUT WITH COMPLETELY
HELP SOME UNABLE
3 HELP 2 1

1. Can you use the telephone? ü

2. Can you get to places that are out ü
of walking distance?
3. Can you go shopping for groceries? ü
4. Can you prepare your own meals? ü
5. Can you do your own housework? ü
6. Can you do your own handyman ü
work?
7. Can you do your own laundry? ü
8a. Do you use any medications? ü
8b. Do you take your own medication? ü
8c. If you had to take medication, could ü
you do it?
9 .Can you manage your own money? ü

Note: Scores have meaning only for a particular patient (e.g., declining scores over time
reveal deterioration).

Analysis: Mr. Pablo F. Respicio don’t have any gadget and stated that “da la antim ti agus usar ti cellphone neneng
ken no kasaritak ni antim a adda ballasiw taaw ket iyawat da tay cellphone”. At his age he cannot go to places that
are out of walking distance because he cannot walk anymore due to oldness and he even stated that he is a prostate
cancer survivor that’s why he cannot walk to places that are out of walking distance because his legs are now weak.
About shopping and groceries Mr. Pablo F. Respicio cannot buy groceries but his son and his daughter in law is in
charge buying his groceries together with his medications. According to Mr. Respicio he cannot prepare his own
meals , he needs help every time he eats his meal. About the housework, he cannot do it anymore. He needs help
when he take his medications and he has medications. About his money, his son and daughter in law is in charge
about his money.

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 Directions: Perform physical examination and fill up the form.

ASSESSMENT 3 GERIATRIC PHYSICAL EXAMINATION

SIGNS DATA
Vital signs:
Blood pressure: 100/90
Heart rate: 90
Respiratory rate: 22
Temperature: 36.1
General: Neat, relaxed, personal hygiene maintained , well nourished, lying down

Head: Symmetrical, round no tenderness and no lesions

Eyes The shape of his eyes is round and normal, he can see or identify big letters but
had difficulty in identifying small letters
(Snellen Test/Chart)
Ears Symmetrical, normal in shape, no lesions, no tenderness. Cannot hear sometimes

Mouth, throat Has no problem in mouth, incomplete teeth, tongue pink in color, gums no
bleeding
Cardiac Normal heart rate and cardiac rhythm

Pulmonary Normal breathing, no signs of shortness of breath

Breast Rounded nipples, equal in size, similar in color in both nipples are smooth and
nipples point in same directions
Abdomen Symmetrical in each side, no lesions

Gastrointestinal, Normal bowel movement, two testicles removed due to his prostate cancer
genital/rectal

Extremities He has edema on his ankle and feet (Pitting Test 2+ for 15 seconds), no lesions,
limited movement and cannot stand by himself
Muscular/skeletal There is swelling (ankle and feet area), no pain in his knees but they support him
to walk or stand
Skin Presence of wrinkles in his face, dry skin, brown in color

Neurologic According to the client sometimes he experienced easily forget things so quickly

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Analysis: Vital signs are in normal range, normal findings in his eyes and ears especially in his head. But
sometimes he is having a problem related to hearing. No problem in his mouth, throat and in the cardiac and
pulmonary. Breast and abdomen are in good condition. Well and good about his bowel movement and two testicles
removed due to his prostate cancer, he is a cancer survivor for 5 years now. He has edema on his lower extremities
(ankle and feet) and have a pain on his knees when they support him to walk or stand. Normal aging skins such as
wrinkle and color brown skin. Having a problem in neurologic response such as forgetting sometimes things so
quickly.

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 Directions: Read the statements below, and put a check on the columns for each statement that
applies to your clients. Add up the numbers to get the nutritional score.
Utilize the scoring provide below and make a simple analysis on the findings.

Scoring:
0 to 2 The client has good nutrition. Recheck the nutritional score in six months.
3 to 5 The client is at moderate nutritional risk, and client should see what they
can do to improve your eating habits and lifestyle. Recheck their
nutritional score in three months.
6 or more The client is at high nutritional risk, and client should bring this checklist
with them the next time they see their physician, dietitian, or other
qualified health care professional.

ASSESSMENT 4 NUTRITIONAL HEALTH

STATEMENT YES NO
I have an illness or condition that made me change the kind or amount of 2 0
food I eat. ü
I eat fewer than two meals per day. 3 0
ü
I eat few fruits, vegetables, or milk products. 2 0
ü
I have three or more drinks of beer, liquor, or wine almost every day. 2 0
ü
I have tooth or mouth problems that make it hard for me to eat. 2 0
ü
I don't always have enough money to buy the food I need. 4 0
ü
I eat alone most of the time. 1 0
ü
I take three or more different prescription or over-the-counter drugs per 1 0
day. ü
Without wanting to, I have lost or gained 10 lbs. in the past six months. 2 0
ü
I am not always physically able to shop, cook, or feed myself. 2 0
ü

Analysis: Mr. Pablo F. Respicio is not able to walk or stand by himself now because his ankle and feet has edema
and cannot stand anymore but that does not affect his food amount intake. He completely eat three times a day, he
often eat vegetables and fruits and he don’t drink alcohol beverages, he didn’t experience mouth problems . He also
told me that he had enough money to buy his foods and needs. Most of the time they eat together with his family
He take three or more prescription or OTC drugs per day. Mr. Pablo F. Respicio was able to maintain his weight in
the past six months. He needs some help when it comes to cook or to eat because he cannot feed himself.

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 Directions:
 Accomplish the hearing screening of an adult client using the assessment tool.
 Use the scoring provided to interpret the data.
 Make a simple analysis on the data obtained.

SCORING:
0 to 8 13 percent probability of hearing impairment (no handicap/no referral);
10 to 24 50 percent probability of hearing impairment (mild to
moderate handicap/referral);
26 to 40 84 percent probability of hearing impairment (severe handicap/referral).

ASSESSMENT 5 SCREENING VERSION OF THE HEARING

HANDICAP INVENTORY FOR THE ELDERLY
QUESTION YES SOMETIMES NO
(4 POINTS) (2 POINTS) (0 POINTS)
Does a hearing problem cause you to feel
embarrassed when you meet new people?
ü
Does a hearing problem cause you to feel
frustrated when talking to members of your
ü
family?
Do you have difficulty hearing when someone
speaks in a whisper? ü
Do you feel impaired by a hearing problem?
ü
Does a hearing problem cause you difficulty
when visiting friends, relatives, or neighbors?
ü
Does a hearing problem cause you to attend
religious services less often than you would like?
ü
Does a hearing problem cause you to have
arguments with family members?
ü
Does a hearing problem cause you difficulty
when listening to the television or radio?
ü
Do you feel that any difficulty with your hearing
limits or hampers your personal or social life?
ü
Does a hearing problem cause you difficulty
when in a restaurant with relatives or friends?
ü
Raw score (sum of the points assigned to each of 4 8 0
the items)

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 Analysis: Mr. Pablo F. Respicio has a total of 12 points and classified as 50 percent probability of
hearing impairment (mild to moderate handicap/referral)

On this part of assessment, Mr. Respicio comes out that he has 50% probability of hearing impairment (mild to moderate
handicap/referral). Hearing problem cannot affect him to feel embarrassed when meeting new people because that just
normal at his age. Mr. Pablo F. Respicio sometimes feel frustrated when talking to his family member and he cannot hear
when someone is whispering to him due to difficulty in hearing and stated that” makangngeg nak pela met ngem no arasaas
neneng ko ket saanen, narigat ko a mangngeg nukwan”. When visiting a friend or neighbor Mr. Pablo F. Respicio didn’t find
any problem to communicate related to hearing problem. Upon asking attending religious services related to hearing problems
he insist “ awan problemak papan panakisimba maipapan kadetoy pinagdengngeg ko neneng ko, isunga dinak mapmapanen ta
dinak makapagnan ken nasakit saksakak no tulungan dak a tumakder”, he stated. According to him sometimes they had a
simple arguments with his family members because of hearing problem and also stated that “dadduma neneng ko ket adda
sulsul-ot ko, haan ko maaw awatan ibagbaga da isunga dadduma ket maaddaan kami iti pinagbibinnugkaw”. Mr. Pablo F.
Respicio has no hearing problem when listening to television, radio and he do not find difficulty hearing limits in his personal
or social life. When going to restaurant with relatives and friends he didn’t find any hearing problem because he is not the one
who is responsible for their orders.

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 NURSING CARE PLAN

Asessment:
Subjective:
“Jak pulos makapagnan neneng sanak la makakuti nukwa no adda mangtulong kenyak , ul-uludek sakak no kayat
ko mapan agmeryenda wenno uminom”.

Objective:
-Difficulty in walking
-Limited movement
-Facial grimace when trying to move his legs or trying to move his lower extremities
-Inability to turn in bed, transfer or ambulate.

Nursing Diagnosis
- Impaired physical mobility related to decrease muscle strength as manifested by limited movement and difficulty
in walking as verbalized by “Jak pulos makapagnan neneng sanak la makakuti nukwa no adda mangtulong kenyak ,
ul-uludek sakak no kayat ko mapan agmeryenda wenno uminom”.

Inference
Mobility is the ability of a patient to change and control their body position. Physical mobility requires sufficient
muscle strength and energy, along with adequate skeletal stability, joint function, and neuromuscular
synchronization.. Mobility limitations have been reported as increasingly prevalent in older persons affecting about
35% of persons aged 70 and the majority of persons over 85 years. The signs and symptoms are difficulty with
transfers, motor skill limitation, muscle strength decreased, range of motion limitation, reluctance to attempt
mobility, requires assistance with ambulation, shortness of breath during or after activity, and unable to reposition
self independently.

Nursing Goal
Short term goal
- After 1-4 weeks of rendering nursing interventions, the patient will be able to have at least 10 steps as signs of
recovery thru therapy and medications (limited of assistance)

Long term goal

-After 10 months of rendering nursing interventions, the patient will be able display improvement in physical
mobility by transferring from bed to wheelchair independently.

Nursing Interventions:
 Assist or have client reposition self on a regular schedule from side to side (bed ridden)
Rationale: To decrease numbness and pain in the affected area

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 Assess client’s developmental level, motor skills, ease and capability of movement and posture
Rationale: To determine presence of characteristics of client’s unique impairment and to guide choice of
interventions.

 Encourage the patient to do as much as they can

Rationale: To decreases dependence on others and increases the patient’s self-esteem

 Encourage patient to take a few steps a day

Rationale: This will help the patient to mobilize and recover faster.

 Support affected body parts or joints using pillows, rolls, foot supports or shoes, gel pads, foam, etc.
Rationale: To maintain position of function and reduce the risk of pressure ulcers

 Demonstrate use of standing aids and mobility devices (e.g., walkers, strollers, scooters, braces, prosthetic) and
have client/care provider demonstrate knowledge about, and safe use of device.
Rationale: Promotes safety and independence and enhances quality of life.

 Collaborate with physical medicine specialist and occupational or physical therapists in providing range of
motion exercises ( active or passive), isotonic muscle contractions (e.g. flexion of ankles, push-and-pull
exercises).
Rationale: To develop individual exercise and mobility program and to limit or reduce effects and complications of
immobility.

 Do the range of motion to the patient like hip and knee bends, leg lifts, leg movement (side to side), leg
rotation and knee rotation (in and out) ankle bends and ankle rotation.
Rationale: This will help the patient to improve strength and flexibility and increased ability to perform activities
of daily living.

Nursing Evaluation:
Goal met.

After 1-4 weeks of nursing interventions, the patient was able to take 10 steps even in a slowed manner thru
therapy and medications (limited of assistance).

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DOCUMENTATION:

This is my documentation, I interview my grandfather and do the geriatric physical examination on him.

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