UNIVERSITY OF SAN CARLOS

COLLEGE OF NURSING
CEBU CITY

ASSESSMENT TOOL FOR THE ELDERLY CLIENT

Name of Patient _________________________________________________

Sex _______ Age ________ Date of Birth _________________
Religion ___________________

PROFILE OF FAMILY

Spouse: Living ______________________ Deceased ____________________

Health Status ________________
Age ________________________
Occupation __________________
Children: Living ______________________
Names and Addresses:
Year deceased ________________
Cause of death ________________
Deceased ____________________
Year deceased:

_________ Allergies __________ Hospitalizations:

Food: __________ Surgery:
Drug: __________ Fractures:
Others: __________ Major Health Problems:
_________ Diabetes __________ Others
_________ Hypertension

CURRENT HEALTH STATUS

Knowledge and understanding of health problems:

Limitations of function or performance of ADL:

Management of limitations:

PHYSICAL STATUS

T ______________ Height ________________

P ______________ Weight ________________
R ______________ BP ____________________
CURRENT MEDICATIONS
NAME DOSAGE FREQUENCY
1.
2.
3.
4.

SKIN CONDITION

________ Intact _________ Rash (describe) _______ Wounds (describe)

________ Dry _________ Discoloration (describe)
________ Pruritus _________ Abnormal finding (describe)

Hair condition __________________________

Nail condition __________________________

Mobility
________ Ambulatory _________ Able to rise from chair to toilet
________ Non-ambulatory _________ Able to climb stairs
________ Ambulatory with assistance _________ Able to transfer

Extremity Function
Location Degree of Limitation Assistive/
Relief Measures

1. Contracture ________________ _________________

__________________
2. Arthritis ________________ _________________
__________________
3. Painful movement ________________ _________________
__________________
4. Paralysis ________________ _________________
__________________
5. Spasm ________________ _________________
__________________
6. Amputation ________________ _________________
__________________

BLADDER

_______ Nocturia ________ Burning _______Incontinence

_______ Frequency ________ Urgency
Voiding pattern:
Urine characteristics:

BOWEL

_______ Hemorrhoid _______ Pain during movement _______Chronic constipation

_______ Straining ________ Recent change in pattern ________ Chronic diarrhea
_______ Incontinence
_______ Ostomy

STOOL
Bowel movement pattern:
Characteristics:

SENSORY STATUS
Degree of limitation Assistive/Relief Measures
Hearing
All sounds _________________
________________________
High frequency _________________
________________________
Vision
Full vision _________________
________________________
Night vision _________________
________________________
Peripheral vision _________________
________________________
Reading _________________
________________________
Color discrimination _________________
________________________
Taste _________________
________________________
Smell _________________
________________________
Touch
Feels pressure & pain _________________
________________________
Differentiates temp. _________________
________________________
Pain _________________
________________________
Other sensory data:
________ Hearing aid ________ Eyeglasses Date of last ear exam:
________ Contact lenses Date of last eye exam:

RESPIRATION

Precipitating Degree of Assistive/Relief Measures

Factors Limitation

Orthopnea _________________ _________________ ______________________

Dyspnea _________________ _________________ ______________________
Shortness of
breath _________________ _________________ ______________________
Wheezing _________________ _________________ ______________________
Asthma _________________ _________________ ______________________
Coughing _________________ _________________ ______________________

Sputum characteristics:
Smoking history:
Tracheostomy:
CIRCULATION

Precipitating Degree of Assistive/Relief Measures

Factors Limitation

Chest pain _________________ _________________ ______________________

Tachycardia _________________ _________________ ______________________
Edema _________________ _________________ ______________________
Cramping in
extremities _________________ _________________ ______________________

NUTRITION

Teeth: Dentures: Chewing problems:

Status: Partial/Complete Swallowing problems:
Date of last dental exam: Feeding tube:

Precipitating Factors Assistive/Relief Measures

Indigestion _________________________ _______________________
Constipation _________________________ _______________________
Diarrhea _________________________ _______________________

Usual meal pattern: Fluid intake: Alcohol use:

REST AND SLEEP

_________ Insomnia (describe) Medicines and alcohol used to induce sleep:

_________ Night restlessness Factors interfering with rest:
_________ Night confusion Usual sleep and rest pattern:

FEMALE REPRODUCTIVE FACTORS

_________ Vaginal discharge _________ Nipple discharge

_________ Itching _________ Breast pain (describe)
_________ Lesions _________ Breast mass

MALE REPRODUCTIVE FACTORS

_________ Scrotal discharge _________ Lesions

_________ Impotency

SEXUAL PROFILE

_________ Interest _________ Dyspareunia ________ Attitude

_________ Sexually active _________ Limitations ________ Frequency

MENTAL STATUS

_________ Alert Orientation

_________ Rapid response to verbal stimuli _________ Person
_________ Slow response to verbal stimuli _________ Place
_________ Confused _________ Time
_________ Stuporous Attention span:
_________ Comatose
Memory of present events:
Memory of past events:

EMOTIONAL STATUS

________ Anxious ________ Hyperactive ________ Disinterest in life

________ Fearful ________ Hypoactive ________ Emotionally labile
________ Depressed ________ Suspicious ________ Suicidal
________ Hostile ________ Euphoric ________ Others (describe)

SELF-CONCEPT

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
____

CURRENT STRESS SITUATION AND ITS FACTORS

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
___

ATTITUDE AND CONCERNS ABOUT DEATH

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
___

OTHER DATA:

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
___

Date of Interview:
Name of Student Nurse: