MINDANAO INSTITUTE OF HEALTHCARE PROFESSIONALS, INC.

Barrio Green, Marawi City 9700

OLDER ADULT PHYSICAL EXAMINATION FORM

Name Malawad Malangi Age 84

Address Brgy. Lama, Mulondo, Lanao del Sur

Weight 39kg
Height 137cm
Temperature 36.7c
Pulse 78bpm BP 120/80mmHg Respiration 18cpm

PHYSICAL EXAMINATION
Received geriatric client, setting on chair, awake and conscious, wearing T-shirt
General with malong and black mokna, and well groomed. Semi scoliosis noted. The
Appearance client welcome us with smily face.

The client’s skin is brown in color and it is warm to touch. The client has
slow skin turgor. No skin edema, lesion, rashes, and no presence of
Skin and scars noted. There is a presence of melasma on her face. The client
Nails temperature is 36.7c. Nail beds are slightly white in color, firm, intact, and
convex, but presence of long nails noted. Capillary refills retured to its
normal color in less than 3 seconds.
Face: The client face is symmetrically aligned. Presence of
Head and melasma on left side on her face noted. Facial grimace noted when
Neck feeling pain. Facial thin noted. And the client has smily face.
Nose: Nose are symmetrically aligned. There is no presence of
discharged upon inspection. Upon asking the client before I
palpated the nose, there is no tenderness, lesion, masses, and
nodules. The client can smell properly and differentiate aromas
upon assessment.
Eyes: The client has no blurry vision according to her. I cannot able
to use penlight to assess the eye reaction to eyes because my client
do not want to. The client blinks approximately 13 blinks per minute,
upon observation. The client eyelids are intact, no swelling and
discoloration noted. Eyelashes are present on her lower and upper
lids and it is evenly distributed.
Ears: The client’s ears are aligned with an outer cantus of the eye.
No presence of earwax noted, no inflammation noted. No pain upon
palpation. No difficulty of hearing upon communication.
Mouth: The client’s lips are semi-dry, but pink in color. No presence
of teeth noted. Oral cavity is moist, but the client has complaints of
gum pain, upon inspection there is no presence of gum lesion,
swelling, and ulcer. The client voice is loud, no horseness of voice,
no sore throat and no difficulty of swallowing noted.

Temporomandibular Joint: Upon communicating the client, no

crepitus noted. The client was able to clench her mouth even
without single tooth.
 Neck: Upon inspecting the neck, there is no presence of physical
abnormalities. No goiter or thyroid enlargement. No venous
distinction and according to the client there is no pain upon
swollowing.
Breasts: Upon asking the daughter of my client, according to her
Chest and Back my client are breast feeding and never used bottle feeding. No
history of breast cancer or breast cyst according to the client.

Lungs: Upon observation while communicating with my client, there

is no difficulty of breathing. Respiratory rate of 18 cycle per minute.
Upon using stethoscope to auscultate the lung sound broncho-
vasicular sound noted.

Heart: Upon asking the client, no heart pain noted and no family
history of heart disease.
Upon asking the client, no history of GI diseases, and according to
Gastrointestinal her, she defecated once a day, every day with light brown in color
System and sometimes yellow in color:

According to the client, she gave birth many times and all NSVD.
Reproductive She have 13 children. No removal of ovary. No family history of
System ovarian cancer

The client is able to set and stand, she can also walk without
Musculoskeletal assistance. No numbness upon assessment. The client can move
System her left and right hand with good flexion with a muscle strength of
4/5. No presence of edema noted. Fracture noted on her left hand
but is healed.
Upon inspecting the feet of my client, there is no presence of scars.
There is no edema, masses, and lesion upon palpation. The client
Feet can walk properly.

CN I: The client have a good CN1 which is olfactory because she

Neurologic can smell aromas and identify it.
System CN II: The client have a good CN2 which is optic because according
to her she has no blurry vision and can even do “kapangantweras.”
CN III: The client has a good eye movement and can blink
appropriately 13 blinks per minute.
CN IV: Trochlear of my client is good because she can move her
eyes downward and inward.
CN V: The client has good CN5 which is trigeminal because she is
able to feel facial sensation.
CN VI: The client have a good CN6 which is abducens, because
she can move her eyes laterally upon observation.
CN VII: Facial. The client can express her facial expressions like
facial grimace, and when she’s happy.
 CN VIII: Acoustic. The client has good auditory. She can hear me
without a problem and no difficulty of communication.
CN IX: Glossopharengeal. The client is able to swallow food withou
pain according to her.
CN X: Vagus. The client is able to speak properly without a
problem.
CN XI: She also have a good spinal accessory, she is able to move
her head to left, right, up, and down. And she can also shrig her
shoulder.
CN XII: The client has good CN12 which is hypoglossal. The clien is
able to stick out her tongue.

Motor Function: My client has good motor function and can even
walk without further assistance.
Muscle Strength: Upon assessment with the permission of my
client, I applied manual muscle testing scale in which I could give
4/5 muscle strength. My client is stong even though she is
advanced age.
Coordination: The client has good balance. She can stand alone
and according to her “Di ako pn dinguguray” as verbalized by the
client.
Gait and Posture: My client is old and unabl to walk with straight
back but in terms of walking and standing she can do it without furth
assistance.
Reflexes: My client has a good reflexes upon assessment using a
reflex hammer.
Sensation: The client can smell different aromas, can identified
sweet and salty foods, can hear me while communicating without a
problem, can see clearly without wearing eye glasses, and can able
to feel or sense sharp and dull upon assessment.
Mental Status: My client is forgetful, she sometimes forget the
faces of her children and she admitted that to me. “Pkalipat ako
mambo igera ka myakaidad ako dn” as verbalized by the client.
BMI: Wt/Ht
20.8 – this indicates that the BMI of the client is within normal range.

Nutrition History: No diet restrictions

Name of the Student Nurse: Pangcoga, Nor-aleah Sultan

Date(s) of Assessment: July 18, 2023

DAILY LIST OF ACTIVITIES

Name of
Malawad Malangi Age 84
Older Adult
Address Brgy. Lama, Mulondo, Lanao del Sur
Days Date Activities Implemented with the Older Adult
 - Orientation day
Day 1 07/17/2023 - We have no place to stay and our CI allowed us to find
where to stay before we finalized everything.

- Find Geriatric client

Day 2 07/18/2023 - Geriatric assessment done
- Took v/s accurately
- Provided sample and short health teaching
- Basic exercise done
Note: We aren’t able to visit our client because we are
Day 3 07/19/2023 assigned at Mulondo Municipality to assist for Nutritional
Month and RHU for EPI. We also finalized our needs for
culmination program.

- Did assessment such: Modified katz ADL scale,

Day 4 09/20/2023 Geriatric Depression scale, and Lawton instrumental
ADL scale.
- Invited my client on culmination program
- Assisted my client on culmination program
- Farewell to the client
Note: We didn’t come back to our clients because we already
Day 5 07/21/2023 have our farewell during culmination program and this day
instead we did our final exam and continued the case sharing.

Name of PANGCOGA, NOR-ALEAH SULTAN

Student Nurse
Area BRGY. LAMA, MULONDO, LANAO DEL SUR
Assigned

DAILY LIST OF tasks

Days Date Daily Tasks done by the Student Nurse

 - Courtesy call in Mulondo RHU
Day 1 07/17/2023 - Find temporary place to stay in
- Prepared everything that I need on Geriatric
Assessment

- Pre-conference with pre test

Day 2 07/18/2023 - Courtesy call with Barangay Chairwomen
- Assessed client and Physical examination done
- Case sharing about the case of my client
- Post-conference
- Assist at Mulondo Municipality for nutrition month.
Day 3 07/19/2023 - EPI
- Dengue Awareness health teaching
- Finalized the needs for culmination
- Made the invitation for program and the pumpletes for
culmination
- Preperation for culmination program
Day 4 07/20/2023 - Culmination program
- Invited the client
- Assisted the client on program
- Distribution of the certificates
- Study for exam
Day 5 07/21/2023 - Case sharing continuation
- Final exam
- After care

Name of PANGCOGA, NOR-ALEAH SULTAN

Student Nurse
Area BRGY. LAMA, MULONDO, LANAO DEL SUR
Assigned