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    Assessment of Frail Elderly Client

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    Mel Cabato Lagmay
    This document contains an assessment of a frail elderly client, including: 1) Basic information about the client such as name, date of birth, address, and current health concerns including skin issues, nutrition, incontinence, and cognitive impairment. 2) Results of assessments for geriatric depression, activities of daily living, stress levels, and oral health issues experienced over the past three months. 3) Scoring of the client's independence levels for basic activities like bathing, dressing, toileting, and instrumental activities including food preparation, housekeeping, medication management, and handling finances.

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    Assessment of Frail Elderly Client

    Uploaded by

    Mel Cabato Lagmay
    53 views8 pages
    This document contains an assessment of a frail elderly client, including: 1) Basic information about the client such as name, date of birth, address, and current health concerns including skin issues, nutrition, incontinence, and cognitive impairment. 2) Results of assessments for geriatric depression, activities of daily living, stress levels, and oral health issues experienced over the past three months. 3) Scoring of the client's independence levels for basic activities like bathing, dressing, toileting, and instrumental activities including food preparation, housekeeping, medication management, and handling finances.

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    This document contains an assessment of a frail elderly client, including: 1) Basic information about the client such as name, date of birth, address, and current health concerns including skin issues, nutrition, incontinence, and cognitive impairment. 2) Results of assessments for geriatric depression, activities of daily living, stress levels, and oral health issues experienced over the past three months. 3) Scoring of the client's independence levels for basic activities like bathing, dressing, toileting, and instrumental activities including food preparation, housekeeping, medication management, and handling finances.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    53 views8 pages

    Assessment of Frail Elderly Client

    Uploaded by

    Mel Cabato Lagmay
    This document contains an assessment of a frail elderly client, including: 1) Basic information about the client such as name, date of birth, address, and current health concerns including skin issues, nutrition, incontinence, and cognitive impairment. 2) Results of assessments for geriatric depression, activities of daily living, stress levels, and oral health issues experienced over the past three months. 3) Scoring of the client's independence levels for basic activities like bathing, dressing, toileting, and instrumental activities including food preparation, housekeeping, medication management, and handling finances.

    Copyright:

    © All Rights Reserved
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    Download as docx, pdf, or txt
    of 8

    ASSESSMENT OF FRAIL ELDERLY CLIENT

    Date of Visit:____________________Initial Visit:_____Follow –up Visit:____Date of Last Check-up:_____________


    NAME:_____________________Date of Birth:_______________Age:______Sex:____Civil Status:______________
    Address: _______________________________________________________________________________________
    Spouse Name: __________________________________________
    If single Caregiver Name: __________________________________Relationship:____________________________
    Temperature: _____ CR/PR: ____ RR: _____ Height: ______ Weight: ________

    Please check the specific complaint/problem:


    Skin impairment: __________________________
    Poor Nutrition: ____________________________
    Incontinence: _____________________________
    Cognitive impairment: ______________________
    Evidence of fall:__________________________Sleep disturbances:________________________

    History of Present Health concern / Current Health Status:


    Character : _____________
    Onset : _____________
    Location : _____________
    Duration : _____________
    Severity : _____________
    Pattern : _____________
    Associated Factors: _____________
    Remedy/ Medication: _____________
    ASSESSING GERIATRIC DEPRESSION:
    (Let the patient choose the best answer for how he/she felt over the past week)

    YES NO
    1 Are you basically satisfied with your life?
    2 Have you dropped many activities/ interests?
    3 Do you feel that your life is empty?
    4 Do you often get bored?
    5 Are you hopeful about the future?
    6 Are you bothered by thoughts you can’t get out of your head?
    7 Are you in good spirit most of the time?
    8 Are you afraid that something bad is going to happen to you?
    9 Do you feel happy most of the time?
    10 Do you often feel helpless?
    11 Do you often get restless and fidgety?
    12 Do you prefer to stay at home, rather than going out and doing new things?
    13 Do you frequently worry about the future?
    14 Do you feel you will have more problems with memory than most?
    15 Do you think it is wonderful to be alive now?
    16 Do you often feel down hearted and blue?
    17 Do you feel pretty worthless the way you are now?
    18 Do you worry a lot about the past?
    19 Do you find life very exciting?
    20 Is it hard for you to get started on new projects?
    21 Do you feel full of energy?
    22 Do you feel that your situation is hopeless?
    23 Do you think that most people are better off than you are?
    24 Do you frequently get upset over little things?
    25 Do you frequently like crying?
    26 Do you have trouble concentrating?
    27 Do you enjoy getting up in the morning?
    28 Do you prefer to avoid social gatherings?
    29 Is it easy for you to make decisions?
    30 Is your mind as clear as it used to be?
    For scoring reverse the answers Nos. 1,5,7,9,15,19,21,27,29 and 30, then count the total “YES” answers.
    Scoring
    0-10 = within normal range
    More than 11 = possible indication of depression
    ASSESSMENT FOR ACTIVITIES OF DAILY LIVING
    SCORING: 1 - NO supervision, direction/ personal assistance
    1- WITH supervision, direction, personal assistance/ total care

    I. PERFORMING BASIC PERSONAL TOOL ( KATZ)


    ACTIVITIES INDEPENDENCE SCORE DEPENDENCE SCORE
    BATHING Bathes self completely, or needs help in Needs help with bathing more than one
    bathing only a single part of the body such part of the body getting in or out of the
    as the back, genital area/ disabled tub or self shower. Requires total bathing.
    extremity.
    DRESSING Get clothes from closets and drawers and Needs help with dressing or needs to be
    puts on clothes and outer garments completely dressed.
    complete with fasteners. May have help
    tying shoes
    TOILETING Goes to toilet, gets on and off, arranges Needs help transferring to the toilet,
    clothes, cleans genital area without help. cleaning of self uses bedpan/commode.
    TRANSFERRING Moves in and out of bed or chair Need help in moving from bed to chair or
    unassisted. Mechanical transferring aides requires a complete transfer
    are acceptable
    CONTINENCE Exercises complete self control over Is partially or totally incontinent of bowel/
    urination and defecation. bladder
    FEEDING Gets food from plate into mouth without Needs total help with feeding or requires
    help. Preparation of food may be done by parenteral feeding.
    another person.
    TOTAL POINTS

    II. LAWTON SCALE FOR INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL)

    SCORE 0 – unable to perform


    1 – able to perform
    ACTIVITIES 0 1
    I ABILITY TO TELEPHONE
    a. Operate telephone on own initiative: looks up and dial number.
    b. Answer telephone and dials a few well known numbers.
    c. Answers telephone but does not dial.
    d. Does not use telephone at all.
    II SHOPPING
    a. Takes care of all shopping needs independently.
    b. Shops independently for small purchase.
    c. Needs to be accompanied on any shopping trip.
    d. Completely unable to shop.
    III FOOD PREPARATION
    a. Plans, prepares and serve adequate meals independently.
    b. Prepares adequate meals if supplied with ingredients.
    c. Heats and serves prepared meals, or prepare meals but does not maintain adequate diet.
    d. Needs to have meals prepared and served.
    IV HOUSEKEEPING
    a. Maintains house alone or with occasional assistance (e.g. heavy work done by domestic helper.)
    b. Performs light daily task such as dishwashing and bedmaking.
    c. Performs light daily task but not maintain acceptable level of cleanliness.
    d. Needs help with all home maintenance tasks.
    e. Does not participate in any housekeeping tasks
    V LAUNDRY
    a. Does personal laundry completely
    b. Laundries small items; rinse socks, stockings and so on.
    c. All laundry must be done by others
    ACTIVITIES 0 1
    VI MODE OF TRANSPORTATION
    a. Travels independently on public transportation/ drives own car
    b. Arranges own travel via taxi, but does not otherwise use public transportation.

    c. Travels on public transportation when assisted or accompanied by another.

    d. Travel is limited to taxi, automobile or ambulate with assistance.


    e. Does not travel at all.
    VII RESPONSIBILITY FOR OWN MEDICATION
    a. Is responsible for taking medication in correct dosage and correct time.
    b. Takes responsibility if medication is prepared in advance, in separated dosages.
    c. Is not capable of dispensing own medication.
    VII ABILITY TO HANDLE FINANCES
    I a. Manage financial matter independently (budgets, write checks, pays rent and bills, goes to bank)
    collect and keep track of income.
    b. Manages day-to-day purchases but needs help with banking, major purchases, controlled spending
    and so on.
    c. Incapable of handling money.
    TOTAL SCORE
    Note : Total score can be range from 8-28. The lower the score, the more independence

    STRESS ASSESSMENT
    Reason/ examples YES NO
    a. Sleep is disturbed
    b. It is inconvenient
    c. It is a physical strain
    d. It is confining
    e. There have been family adjustment
    f. There have been changes in personal plan
    g. There have been emotional adjustment
    h. Some behavior is upsetting
    i. It is upsetting to find
    j. There have been work adjustment
    k. Feeling completely overwhelmed
    NOTE: Count “YES” response. Any positive answer may indicate a need for intervention in that area. A score of 7 or higher indicates a
    high level of stress

    GERIATRIC ORAL HEALTH ASSESSMENT INDEX (Indicates in the last 3 months)


    Indicators 1 – Always
    2 – Often
    3 – Sometimes
    4 – Seldom
    5 – Never
    1 2 3 4 5
    1 How often did you limit the kind of amounts of food you eat because of problem of your teeth
    / denture
    2 How often did you have trouble biting/ chewing any kinds of food such as firm meat or apple?
    3 How often were you able to swallow comfortably?
    4 How often your dentures / teeth were prevented you from speaking the way you wanted?
    5 How often were you able to eat anything without feeling discomfort?
    6 How often did you limit contacts with people because of the condition of your teeth/
    dentures?
    7 How often were you pleased/ happy with the looks of your teeth and gums/ dentures?
    8 How often did you use medication to relieve pain /discomfort from around your mouth?
    9 How often were you worried/concerned about the problems with your teeth, gums/dentures?
    10 How often did you feel nervous or self conscious because of problems with your teeth,
    gums/dentures?
    1 2 3 4 5
    11 How often did you feel uncomfortable eating in front of people because of problems with your
    teeth/ dentures?
    12 How often were your teeth, and gums sensitive to hot, colds/ sweets

    DETERMINING NUTRITIONAL HEALTH

    YES NO
    1 Is there any condition or illness that made you change the kind of food you eat?
    2 Is there a time you ate fewer than two meals per day?
    3 Do you eat fruits, vegetables or any milk products?
    4 Do you drink alcoholic beverages (liquor, wine beer)?
    5 Do you have mouth / tooth problem that makes you hard to eat?
    6 Is your money sufficient to buy food that you need?
    7 Do you eat alone most of the time?
    8 Is there any medication you take for at least 3 or more drugs / day?
    9 Are there any weight gain / loss for the past 6 months?
    10 Do you able to feed, cook, shop for yourself?

    PHYSICAL ASSESSMENT
    BODY PARTS ASSESSED NORMAL TECHNIQUE ACTUAL FINDING INTERPRETAT ANALYSIS
    FINDINGS USED (IPPA) ION
    GENERAL APPEARANCE
    A. Hygiene
    B. Interaction/behavior
    C. Facial expression
    D. Posture
    E. Attention span
    F. Level of cooperation
    HEAD:
    A. Size/Shape
    B. ROM
    - Head control
    - Head posture
    C. Color of Hair
    FACE:
    A. Appearance
    B. Symmetry
    C. Movement
    EYES:
    A. Position
    B. Slant/epicanthal folds
    C. Eyelids placement
    - Swelling
    - Discharges
    - Lesions
    D. Sclera/ conjunctiva
    - Color
    - Discharges
    - Lesion
    - Laceration
    E. Iris/ pupils
    - Color
    - Shape
    - PERRLA
    F. Visual Acuity Test
    G. Hirschberg Test
    H. Opthalmoscopic
    Examination

    EARS:
    External:
    a. Placement
    b. Discharges
    c. Lesion
    Internal :
    a. Discharges
    b. Lesion
    c. Excoriation
    d. Presence foreign body
    e. Hearing acuity
    - Reaction to noise
    MOUTH:
    a. Lips
    b. Palates
    c. Tongue
    d. Buccal mucosa
    e. Gums
    f. Teeth
    -age of eruption
    -number of teeth
    -Location of teeth
    g. Throat/tonsils

    NOSE/SINUSES:
    a. Structure and patency of
    nares
    b. Discharges
    c. Tenderness
    d. Color and problem of
    turbinate

    NECK:
    a. Mobility
    b. Cervical lymph nodes
    c. Swelling
    d. Temperature
    e. Tenderness

    SKIN:
    A. color
    B. odor
    C. lesion
    D. moisture
    E. temperature
    F. texture
    G. turgor
    H. edema
    THORAX/LUNGS:
    a. shape
    b. respiratory effort
    c. breath sounds
    BREAST:
    a. shape
    b. symmetry
    c. color
    d. discharges
    e. lesion
    f. masses
    g. tenderness
    HEART
    a. location apical pulse
    b. rate
    c. rhythm

    ABDOMEN:
    a. shape
    b. color umbilicus
    c. herniation of umbilicus
    d. bowel sounds
    e. masses/tenderness

    GENITALIA:
    1. MALE
    a. Size for age
    -scrotum
    -testes
    -pubic hair
    b. Lesions
    c. Inguinal hernias
    2. FEMALE
    a. Color
    b. Discharges
    c. Pubic hair
    d. Lesion

    ANUS/ RECTUM:
    a. Patency
    b. Lesion
    c. Fissure
    d. Color
    e. Bowel movement
    MUSCULOSKELETAL SYSTEM
    -Upper extremities
    a. ROM
    b. Symmetry
    c. shape
    d. Posture
    e. Fracture
    f. Bone deformity
    g. Size/strength muscle
    -Lower extremities
    a. Symmetry
    b. Shape
    c. Movement
    d. position
    e. Fracture
    f. Bone deformity
    g. ROM
    h. Size and strength
    muscle
    -Spinal Alignment
    a. spine
    b.posture
    NEUROLOGIC SYSTEM
    a. Cerebral function
    b. Cranial nerve function
    c. Deep tendon/superficial
    reflexes
    d. balance and coordination
    e. sensory function
    f. motor function
    June 10, 2016

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