BICOL REGION GENERAL HOSPITAL AND GERIATRIC MEDICAL CENTER

(formerly BICOL SANITARIUM)

R.A. 11108
San Pedro, Cabusao, Camarines Sur
Telephone Nos.: (054) 473-2244; 472-4422, 881-1033, 881-1761
E-mail Address: bicolsan@yahoo.com, brghgmc@gmail.com

GERIATRIC NURSE EVALUATION REPORT

Date: Health Record No. Room no. Age Sex Civil Status
9/04/2022 ROOM 2 60 M M
BED 3
Last Name First Name Middle Name
ESPINOSA ROMEO N/A
Attending Dr. MOI PANIS MD
Physician
PARAMETERS SCORE/RESULTS INTERPRETATION
KATZ ADL 4/6 Needs Assistance in ADL’s
LAWTON’S IADL 22/27 Needs Assistance in IADLs
URINARY CONTINENCE YES/NO (-)
CONSTIPATION YES/ NO (+) constipation
DEPRESSION YES/NO (-)
COGNITIVE AD8:3/6 Normal Cognition
FALL YES/NO Moderate Risk for Fall
NUTRITION Wt: N/A
VISION YES/NO Visual Acuity
N/A
With blurring of vision (both eyes)
HEARING YES/NO N/A
SLEEP YES/NO (-)
PROBLEM/SNORING
ELDER ABUSE YES/NO (-) elder abuse
CAREGIVER BURDEN/ YES/NO None
STRESS
PRESSURE INJURY YES/NO Location: right leg
POLYPHARMACY YES/NO 3 medications

Report on Admission/ Readmission:

Date/s Diagnosis
August 31, 2022 DM; Wound on right leg; For debridement

BRGHGMC-F-NS-ACE-008 Rev 1
Effectivity Date: January 6, 2020
 BICOL REGION GENERAL HOSPITAL AND GERIATRIC MEDICAL CENTER
(formerly BICOL SANITARIUM)
R.A. 11108
San Pedro, Cabusao, Camarines Sur
Telephone Nos.: (054) 473-2244; 472-4422, 881-1033, 881-1761
E-mail Address: bicolsan@yahoo.com, brghgmc@gmail.com

I. SUMMARY OF FINDINGS:

Patient Espinosa, Romeo. is a 60 y/o male, married, Cabusao, Camarines Sur came to the
Emergency Room Department last August 31, 2020, at 2:17pm with a chief complaint of wound at
right leg. He was admitted under the care of Dr. Moises Panis with a diagnosis of DM; Wound at
right leg; For debridement. He was then admitted to ACE Unit on August 31, 2020. He also has
blurring of vision at times and Polypharmacy which puts her at risk of functional decline.

The patient is with her wife who is also her primary caregiver. At present, Romeo is dependent
on ADLs with a score of 3/ 6. He also needs assistance in IADLs .There was no depression noted.
He doesn’t have urinary incontinence, no depression noted and observed. During the GNET
evaluation, her score in Cognition is 3/6. He was unable to draw the clock which gives him a score
of 0/3 due to body weakness. He has Hearing impairment and visual problems. Furthermore, He is
also currently taking 3 medications which puts her at risk of Polypharmacy. Overall, he is also
categorized as a Mildly Frail Older person under the clinical frailty index.

II. GERIATRIC ASSESSMENT:

● Polypharmacy
● Mildly Frail Older Person
● Hearing Problem
● Visual Impairment

MEDICAL ASSESSMENT:

● BGT
● Wound

III. RECOMMENDATIONS (Interdisciplinary Management)

● Medical Management

1. For debridement
2. Wound Care
3. Diet Modification
4. Pharmacological Management

BRGHGMC-F-NS-ACE-008 Rev 1
Effectivity Date: January 6, 2020
 BICOL REGION GENERAL HOSPITAL AND GERIATRIC MEDICAL CENTER
(formerly BICOL SANITARIUM)
R.A. 11108
San Pedro, Cabusao, Camarines Sur
Telephone Nos.: (054) 473-2244; 472-4422, 881-1033, 881-1761
E-mail Address: bicolsan@yahoo.com, brghgmc@gmail.com

Care Plan

● POLYPHARMACY
1. Refer to Clinical Pharmacist for Medication Review

● HEARING PROBLEM
1. Refer to ENT for Assessment
2. Encourage the caregiver to communicate in a loud and clear voice

● VISUAL IMPAIRMENT

1. Perform Visual Acuity Test

2. Refer to Ophthalmologist
3. Advise SO to Assist PT in doing personal necessity

● DIET MODIFICATION

1. Refer to Dietician

● Other Allied Health Professionals

1. PHYSICAL THERAPIST
-weakness of hand and legs
2. ENT
-Hearing Problem
3. OPHTHALMOLOGIST
-Visual Impairment

References:

Prepared by: Clarence M. Catimbang Noted by:

FELICIDAD II A. JEREMIAS MN, RN
John Lloyd C. Namoro Clinical Instructor

_______________________________
CGA -Student Nurse

BRGHGMC-F-NS-ACE-008 Rev 1
Effectivity Date: January 6, 2020