Far Eastern University

Institute of Nursing
Assessment Tool for the Geriatric Patient
I. Personal Data
Name: Aurora S. Manoos
Address: Phase 1 Blk 39 Lot 12 San Lorenzo Ruiz Taytay Rizal
Birth date: February 15, 1952
Birth place: Marinduque
Religion: Roman Catholic
st
Educational Attainment: 1 year high school
Occupation: Housewife
Age: 61
Nationality: Filipino
Civil Status: Married
II. Patterns of Functioning
A. Psychological Health
1. Coping Pattern
1.

2.

Who are the people significant to you?

___Family
___Friends
___Siblings
___Relatives
Whom do you talk on regular basis?
___Family
___Friends
___Siblings
___Relatives

3.

How many people do you relate on a regular basis?

__10___

4.

Do you go out with and see other people in a regular

basis?
___Yes
___No
Why?
_____________________________________________

5.

Do you exercise regularly?

___Yes
___No
Why?
_____________________________________________
How many times a week? _______everyday__________

6.

Do you have anyone to go to in times of need?

___Yes
___No
Why?
______________________________________________
Who are these people? __________________________

7.

How do you handle stressful situations?

Physical:
___Eat
___Drink alcoholic beverages
___Sleep
___Exercise
Psychological:
___Become angry with self
___Solve Problem
___Become angry to others
___Deny
___Accept
Sociological:
___Talk with person involved with the
stress
___Talk to uninvolved person
___Blame others
Spiritual:
___Talk with clergy
___Pray
___Listen to music/watch TV
___Read religious books
___Read mind-soothing books
Others:
______________________________________________
2. Interaction Patterns
1.

How do you express your feelings and thoughts to

others?
___Verbally
___Non-verbally

2.

How do you feel about the way you interact with

others?
___Satisfied
___Non satisfied
___Happy
___Sad

3.

Cognitive Patterns

1.

How much formal education have you had?

___Elementary under graduate
___Elementary Graduate
___High School undergraduate
___High School graduate
___College undergraduate
___College graduate; Course:
___________________________
Vocational:
___________________________________________

2.

Can you read?

___Yes
___No

3.

How can you learn best?

___Studying by yourself
___Through listening to others
___Through reading

6. Sexuality
1. How do you express yourself as a woman/man?
___Nagdadamit
ako
ng
pambabae____________________________________

4.

How are you doing in school or at work?

___________none_______________________________
_____________________________________________

2.

Has your health concern changed the way you express

yourself as a woman/man?
__oo
kasi
tingin
ko
hindi
ako
normal_______________________________________

3.

What do you enjoy/ not enjoy about being a

woman/man?
_>magtatrabaho
at
nakakatulong
________>makikipag barkada____________________

4.

Do you have any problems regarding what others want

you to do as a woman/man and what you want others
to show affection toward you?
___Yes
___No
Why?
_____________________________________________
____________________________________________

5.

How do you show affection toward others? How do

you want others to show affection toward you?
_>nakikipag usap at nakikipag tawanan
pag hug at pag kiss ________________________

4. Emotional Pattern
1. What type of mood are you usually in?
___Calm
___Depressed
___Pleasant
___Happy
___Excited
___Agitated
Others:
________________________________________________
________________________________________________
2. How do you express yourself during mood changes?
___Verbally
___Non-Verbally
3. Do your relations with others changes with your moods?
___Yes
___No
How?
________________________________________________
_______________________________________________
5. Self-concept
1. What was your highest weight? ___120 lbs__
2. How do you feel about your weight and appearance?
___Satisfied
___Non-satisfied
3. Have you had any physical alteration to your body?
___Yes
___No
4. How do you see yourself in relation to others?
___Equal
___Better than
___Less than

7. Family Copping Patterns

1. How does your family handle stress? Be specific for
each member of the family?
>
pinag
uusapan
naming
lahat
______________________________________________
2. How does your family make decisions? Who has the last
word?
>nag
uusap
at
nagbibigay
ng
opinion.
Ako____________________________________________
3. If someone in the family gets sick, who is the care
taker?
Anak kong babae________________________________
_____________________________________________
4. What is your role or place in the family?
_tagapayo_______________________________________
_____________________________________________

5. What are your goals for the next 5 years?

___mamasyal
kasama
buong
family
ko
________________________________________________

B. Socio-cultural Health
1. Cultural Pattern

6. What are your good and bad qualities?

_Mabait sa mga bata at naninigaw ako pag
galit_____________________________________________

2. Significant Relationships

3. Recreational Activities

4.

d.

Environment
1.

What type of indwelling do you live in?

___Multiple dwelling
___Single dwelling

2.

Are you comfortable where you live?

___Yes
___No
Why?
_________________________________________
________________________________________

2.

3.

Do you feel you have enough space to yourself?

___Yes
___No
Why?
_________________________________________
________________________________________

4.

Is your place easy to move in?

___Yes
___No

5.

Are the sounds, noises or odors in the

environments that are concern to you?
___Yes
___No
What?
_________________________________________
________________________________________

C. Spiritual Health
1. Religious beliefs and practices
usog, patawas, bawal magwalis pag gabi, bawal maligo pag
may dalaw kasi nakakabaliw at bawal matulog ng basa ang
buhok kasi nakakabaliw

3.

Hygiene
a. How many times do you take a bath in a day?
___1_____________________
b.

How many times do you brush your teeth?

__2______________________

c.

How many times do you trim your nails in a

week?
__2______________________

d.

Dou you use cologne or perfume?

___Yes
___No

e.

Are you able to attend to your personal self-care

needs?
___Yes
___No
Why?
_______________________________________
_______________________________________

Rest and sleep

a. How many hours do you sleep in a day?
________6__________________
b.

Do you take naps?

___Yes
___No
Why?__kasi nakakahigh blood______________
_______________________________________
How many hours? _________________________

2. Values and valuing

magdasal bago kumaen

c.

Do you have any difficulty in getting sleep?

___Yes
___No
Why?
______________________________________
_______________________________________

d.

What do you do with these difficulties?

_______________________________________
______________________________________

III. Activities of Daily Living

1. Nutrition
a. How many times do you eat in a day?
___3________
b.

Do you have any difficulty in eating?

___Yes
___No

c.

Do you avoid certain foods?

___Yes
___No

How many glasses of fluid do you take in a day?

________12_______________
What kind of fluid do you usually drink?
___Coffee
___Soft drinks
Others:
_______________________________________
_______________________________________

4.

Exercise
a. Do you exercise regularly?
___Yes
___No

Why?
_______________________________________
_______________________________________

5.

b.

How many times do you exercise in a week?

________evryday________________________

c.

What form of exercise?

_______walking and sweeping______________

Elimination
a. How many times do you urinate/void in a day?
___________8_________________
b.

Do you have difficulty in void?

___Yes
___No
What?
_______________________________________
______________________________________

c.

How many times do you defecate in a day?

______________________________________

d.

6.

Do you have difficulty in defecating?

___Yes
___No
Why?
______matagal matunawan________________
_____________________________________
Sexual Activity
a. Do you still engage in sexual activities?
___Yes
___No
Why?
_______________________________________
_______________________________________
b.

Do you have difficulties in engaging in sexual

activities?
___Yes
___No
What?
_______________________________________
______________________________________

Far Eastern University

Institute of Nursing

Assess Tool for Elderly

INTEGUMENTARY CHANGES
___Dry skin
___Itchiness of skin
___Decrease sensation
___Lentigo senilus (Brown age spots)
___Pale skin
___Hollow or gaunt hand
___Baldness and hair loss
___Loss of hair and color (gray/white hair?
___Thickened and brittle fingernails ang toenails
___Double chin
___Sagging eyelids and earlobe
___Wrinkles
___(In women) breast are smaller amd may sag
___Decrease tolerance to cold

BODY TEMPERATURE
___Decreased body temperature

NEUROMUSCULOSKELETAL CHANGES
___Slowed voluntary or automatic reflexes
___Decreased ability to respond to multiple stimuli
___Easy tiring
___Kyphosis (humpback to upper spine)
___Stiffness of joint
___Visible bony prominences
___Limited range of motion

CARDIOPULMONARY CHANGES
___Short breaths taken
___Dyspnea
___High blood pressure

SENSORY PERCEPTUAL CHANGES

Visual:
___Shrunken eyes
___Slowed blink reflexes
___Blurry vision
___Decreased color perception
___Decreased night vision
___Decreased tear production
___Increased sensitivity to glare
Hearing:
___Decreased ability to distinguish high frequency sounds
___Decreased ability to hear

Taste and Smell

___Less stimulated by food
Pain and Touch
___Increased threshold for sensations

GASTROINTESTINAL SYSTEM
___Impaired mastication
___Decreased gag reflex
___Decreased salivary production
___Increased incidence of haiatus hernia
___Constipation

URINARY CHANGES
___Urinary urgency
___Urinary frequency
___Nocturnal frequency
___Increased concentration of urine

MOOD
___Nervous with strangers
___Difficulty in making decisions
___Lack of concentration of memory
___Lonely or depressed
___Cries often
___Hopeless outlook
___Difficulty relaxing
___Worries a lot
___Frightening dreams or thoughts
___Shy or sensitive
___Dislikes criticism
___Losses temper
___Annoyed by little things