COMPREHENSIVE GERIATRIC ASSESSMENT TOOL

Biographical Data
Name: Fatima Sarip Ampuan
Address: Paigoay, Pagayawan, Lanao del Sur
Age: 70
Sex: Female
Civil Status: Senior Citizen
Religion: Islam
Educational Attainment: College level
Employment Status: N/A

History of Present Illness

A case of 70 years old, female, Islam, from Tubaran, Lanao del Sur that is frequently
experiencing of throbbing headache at occipital region with a pain score of 8/10. Patient
verbalized that pain is consistent. Patient massage her temporal and takes Medicol to
alleviate the pain and Losartan for her hypertension. She also verbalized that she
occasionally experiencing burning sensation in her chest, and she takes Omeprazole
whenever she felt it.

Past Medical History

Patient claimed that she was admitted several times in the hospital, and she regularly visits
clinic/center for annual check-up. She was diagnosed secondary hypertension in year 2011,
UTI in year 2018, and ulcer in year 2018. She regularly takes Losartan to maintain her blood
pressure. Patient affirmed she doesn’t receive any immunization in her whole life. No known
drug allergies. No known environmental, food, or seasonal allergies.

Family History with Genogram

Acquired Diseases: Genogram

X Hypercholesterolemia
X Kidney
X Disease
X Tuberculosis
X Alcoholism
X Drug Addiction
X Hepatitis

Heredo-familial Diseases: Legend:

X Diabetes - Patient - Father
/ Heart Disease - Brother
X Hypertension - Mother
- Sister
X Cancer
X Asthma
X Epilepsy
X Rheumatism /Arthritis
X Others: _________

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 Personal Situation (Living condition, Economic situation)

Patient lived with her two daughters with their families. Her children support her in terms of
her finance.

Medication Review
(List of prescribed or over the counter medications the client is taking)

Name of drug and dosage:

_Omeprazole_______________________ as treatment for: __Ulcer_______________
_Lozartan__________________________ as treatment for: __Hypertension________
__________________________________ as treatment for: ______________________
__________________________________ as treatment for: ______________________
__________________________________ as treatment for: ______________________

General Observation: Appears well nourished, neat, clothing appropriate for age and season.
Oriented to date, time, place, and persons within the environment. Discomfort and facial
grimace are noted. Responsive and cooperative as evidenced by being able to answer all the
questions actively and appropriately. Quality of speech is loud and clear. T 36.4 ⁰C, P 90bpm, R
18 cpm, BP 140/100 mmHg,

Vital Signs: T: 36.4⁰C_______

P: 90 bpm______
R: 18 cpm______
BP: 140/100mmHg

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 REVIEW OF SYSTEMS

Uniform skin coloring, brown complexion, with pink undertones. Skin

on all areas but the hands is soft and warm. With a skin turgor normal
Integumentary to her age upon pinching. Skin is free from edema. Nails are firm and
cuticle is pink and intact and without ridging or pitting. There was a
prompt return of capillary refill for about two seconds. Hair is white,
thin, and evenly distributed with no dandruff or lice evident.

Normal breathing pattern has been observed with a respiratory rate

Respiratory of 18cpm, equal chest expansion, with clear lung sounds upon
auscultation is noted, no coughing and adventitious sounds noted.
Patient claimed no problem with respiration/breathing.

Pulse was palpated on the radial, with lub-dub sounds heard upon
auscultation. Pulse rate is 90bpm, and Blood pressure is 140/100
Cardiovascular mmHg. Patient has less than 2 seconds capillary refill. Pale
conjunctiva is noted. Pulse and heart beats are in normal rhythm with
no irregularities.

Abdomen has unblemished skin integrity, with uniform color all over
the surface of the abdomen. No known food allergy. Patient claims to
Digestive eat and digest food well. She can swallow normally without pain. The
patient defecated 5 times a week. Abdomen is free from tenderness
and discomfort.

Patient drinks 1-2 liters of water a day, does not complain of pain
when voiding, normally urinates with an amber color, has no difficulty
Excretory of voiding, no bowel movement, no tenderness in kidney, sweats
moderately when heat is felt.

Patient can perform full range of motion, no pain on the joints and
muscle is noted. She can apply force on resistance with grade 4, no
Musculoskeleta muscle spasms noted, and no stiffness on moving extremities and
l neck noted. No bone deformities, and no tenderness or swelling
noted. Patient claimed that she sometimes feels pain on her joints.

Patient is awake and active, oriented to time, place, and person. She
Nervous has coordinated bodily movements, has no speech defects, cranial
nerves are well functioning, sense of touch is intact, and can
differentiate sharp from blunt objects. She is responsive to stimuli.

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 Patient is female, 70 years old. Patient had her menarche at the age
Reproductive of 18 and menopause at the age of 54.

No thyroid enlargement, no swelling on the neck, no known allergies,

Endocrine no tenderness noted on palpation, (-) goiter or any abnormal thyroid
gland functioning, and no endocrine abnormalities.

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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: ___1______
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: ____1_____

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: ____1_____

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: ____1_____
CONTINENCE (1 POINT) Exercises complete self-control over (0 POINTS) Is partially or
urination and defecation. totally incontinent of bowel or
POINTS: ____1_____ 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: _____1____

TOTAL SCORE: ____6_______ 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.

LAWTON - BRODY
INSTRUMENTAL ACTIVITIES OF DAILY LIVING SCALE (I.A.D.L.)
Scoring: For each category, circle the item description that most closely resembles the client’s highest

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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.
3. Answers telephone but does not dial 1 3. All laundry must be done by others 0
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 rent,
domestic help") 1 bills, goes to bank), collects and keeps track of
2. Performs light daily tasks such as income 1
dishwashing, bed making 1 2. Manages day-to-day purchases, but needs help
3. Performs light daily tasks but cannot with banking, major purchases, etc.
1 3. Incapable of handling money 0
maintain acceptable level of cleanliness
4. Needs help with all home 0
maintenance tasks
5. Does not participate in any
housekeeping tasks
Score 2 Score 3

Total score: 5

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.

PATTERNS:

Health-perception-health-management pattern

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Patient considered herself as a moderate healthy person. She takes over-the-counter drugs such as Paracetamol,
Neozep or Losartan whenever she has fever, hypertension, cough. She goes to the hospital whenever she feels sick,
or her BP rose for a long time.

Nutritional-metabolic pattern

Patient eat meals 3 times a day, she drinks 1-2 liters of water a day. She always drinks coffee every morning and
occasionally drinks carbonated drink. No known allergy to any foods. Oil and sweat glands become less active, and
patient’s hair color become gray and thin. Patient claimed that she digested the food she eats very well.

Elimination pattern

Patient does not complain of pain when voiding, normally urinates with an amber color. There was no discharge upon
urination and her urine does not have a strong smell. Patient defecates five times a week.

Activity and Exercise pattern

Patient affirmed that she does walk bristly every morning, her daily exercises include cleaning the house such as
making bed, sweeping, folding clothes, and washing plates. As for her leisure and recreation, she likes to read Qur-
an and listening to her radio about Islamic sermon.

Sleep-Rest pattern

Patient affirmed that she sleeps very well at the evening and feel rested when wake up. She sleeps at around 8pm
and sometimes wake up when she feels urinate. She also takes a nap every noon. Whenever she has trouble in
sleeping, she listens to some verse in the Qur-an so she can fell at sleep.

Cognitive-perceptual pattern

Patient affirmed that she is near-sighted. She communicates and hear well.

Self-perception Self-concept pattern

Patient regularly visits clinic/health center for her annual check-up. The activities she does to keep safe, healthy, and
prevent disease is walking bristly and doing some house chores. Patient said that she is contented and happy with
the life she has now.

Role relationship pattern

Patient has a good relationship with her children and grandchildren. She is very supportive and took good care of her
grandchildren when her daughters go to work.

Sexuality reproductive pattern

Patient verbalized that she had her menarche at the age of 18, and menopause at the age of 54. She had 3
daughters and 4 sons.

Coping-Stress-Tolerance pattern

Patient becomes stress whenever she had no money. She manages her anger or stress through praying. The person
she would turn for help in a time of crisis is her children.

Value-Belief pattern

The most important thing to the patient in life is being able to pray 5 times a day. She always goes to the Islamic
seminar every last Friday of the month in the municipal hall.

PSYLOGICAL ASSESSMENT

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 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 0
2. Have you dropped many of your activities and interests? YES / NO 1
3. Do you feel that your life is empty? YES / NO 0
4. Do you often get bored? YES / NO 1
5. Are you in good spirits most of the time? YES / NO 0
6. Are you afraid that something bad is going to happen to you? YES / NO 1
7. Do you feel happy most of the time? YES / NO 0
8. Do you often feel helpless? YES / NO 0
9. Do you prefer to stay at home, rather than going out and doing YES / NO
1
new things?
10. Do you feel you have more problems with memory than most? YES / NO 0
11. Do you think it is wonderful to be alive now? YES / NO 0
12. Do you feel worthless the way you are now? YES / NO 0
13. Do you feel full of energy? YES / NO 1
14. Do you feel that your situation is hopeless? YES / NO 0
15. Do you think that most people are better off than you are? YES / NO 0
TOTAL 5
Score 1 point for each bolded answer (highlighted red).
A score of 5 or more suggests depression

This is the original scoring for the scale: One point for each of these answers.
Cutoff: normal-0-9; mild depressives-10-19; severe depressives-20-30.

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.

COGNITIVE ASSESSMENT

SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE (SPMSQ) version 1

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

(2) NURSING CARE PLANS

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Cues Subjective
“Madalas akong nahihilo”, as verbalized by the patient.

Objective
 Decreased cardiac output
 Decreased stroke volume
 Increased peripheral vascular resistance
 Vital Signs:
T: 36.4⁰C_______
P: 90 bpm______
R: 18 cpm______
BP: 140/100mmHg

Nursing Decreased cardiac output related to malignant hypertension as

Diagnosis manifested by decreased stroke volume.

Objectives Short term:

After 6 hours of nursing interventions, the client will have no elevation
in blood pressure above normal limits and will maintain blood pressure
within acceptable limits.

Long term:
After 5 days of nursing interventions, the client will maintain adequate
cardiac output and cardiac index.

Interventions  Monitor blood every 1-2 hours, or every 5 minutes during active
& Rationale titration of vasoactive drugs. Changes in blood pressure may
indicates changes in patient status requiring prompt attention.
 Suggest frequent position changes. It may decrease peripheral
venous pooling that may be potentiated by vasodilators and
prolonged sitting or standing.
 Encourage patient to decrease intake of caffeine and
carbonated drinks. Caffeine is a cardiac stimulant and may
adversely affect cardiac function.
 Observe skin color, temperature, and capillary refill time.
Peripheral vasoconstriction may result in pale, cool, clammy
skin, with prolonged capillary refill time due to cardiac
dysfunction and decreased cardiac output.
 Auscultate heart tones. Hypertensive patients often have S4
gallops caused by atrial hypertrophy.
 Administer medicines as prescribed by the physician. To
promote wellness.
 Instruct client and family on fluid and diet requirements and
restrictions of sodium. Restrictions can assist with decrease in
fluid retention and hypertension, thereby improving cardiac

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 output.
 Instruct client and family on medications, side effects,
contraindications, and signs to report. Promotes knowledge and
compliance with drug regimen.

Evaluation Short term:

After 6 hours of nursing interventions, the client had no elevation in
blood pressure above normal limits and maintain blood pressure within
acceptable limits. Goal was met.

Long term:
After 5 days of nursing interventions, the client maintained an adequate
cardiac output and cardiac index. Goal was met.

Cues Subjective
“Paminsan-minsan naman kumakalam tiyan ko kaya sumasakit yung
dibdib ko, yun bang parang ulcer.”, as verbalized by the patient.

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 Objective
 Guarding chest and stomach area
 Discomfort and facial grimacing are noted.

Nursing Chest pain related to inflammation of esophageal tissues caused by

Diagnosis gastric reflux.

Objectives After 6 hours of nursing interventions, the client will have relief from
pain and demonstrate relaxed body posture.

Interventions  Assess level of pain using appropriate pain scale. Provides

& Rationale information of severity of pain.
 Identify factors that cause pain or increase it. Enhances
management of condition and helps to formulate teaching plan.
 Provide medications to relive acidity of gastric contents as
ordered. Helps decrease gastric acidity to promote comfort.
 Position patient in a Fowler’s position. Helps prevent reflux of
gastric contents into esophagus.
 Provide small frequent meals and avoid foods that trigger
heartburn. Prevents pain caused by heartburn and gastric
contents from reaching esophagus.

Evaluation After 6 hours of nursing interventions, client verbalized relief from pain
with a pain score of 2/10, and demonstrated relaxed body posture.

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