COMPREHENSIVE GERIATRIC ASSESSMENT (3) You start to have trouble finding

your way around familiar

environments.
PSYCHOLOGICAL/ PSYCHIATRIC ASSESSMENT You become more impulsive or
show increasingly poor judgment.
Assessing the Mental Health Needs of Older People Your family and friends notice any
Assessment Tools of these changes
If you have MCI, you may also
• Assessment tools are standardized systems that experience:
help to identify and gauge the extent of specific  Depression
conditions and provide a fair approach in response.  Irritability and aggression
• They can be the means whereby individual and  Anxiety
assessments contribute to the overall picture.  Apathy
• Assessment tools can provide systematic 2. DELIRIUM
information on the needs of client populations and • Delirium is an acute confusional state,
target resources. usually with a fluctuating course,
• Assessment tools include scales, checklists, and characterized by disturbed consciousness,
interview schedules. cognitive function, or perception (NICE
• Assessment tools must be culturally sensitive, CG103, 2010)
reliable, and valid if they are to inform professional • Delirium superimposed on dementia (DSD)
judgment. is increasingly problematic as the
population ages.
The Psychological Assessment domain of
Comprehensive Geriatric Assessment (CGA) includes four 3. DEMENTIA
sub-domains, often referred to as the 4Ds: (Under each of this • Dementia is a progressive and largely
4Ds are Evaluation Tests). irreversible clinical syndrome that is
1. COGNITIVE DECLINE characterized by a widespread impairment
• In mild cognitive impairment (MCI), the of mental function.
changes in cognition exceed the normal, • Although many people with dementia retain
expected changes related to age. positive personality traits and personal
• Symptoms: Your brain, like the rest of your attributes, as their condition progresses
body, changes as you grow older. Many they can experience some or all of the
people notice gradually increasing following:
forgetfulness as they age. It may take  memory loss
longer to think of a word or to recall a  language impairment
person's name.  disorientation
• But consistent or increasing concern about  changes in personality
your mental performance may suggest mild  difficulties with activities of daily
cognitive impairment (MCI). Cognitive living
issues may go beyond what's expected and  self-neglect
indicate possible MCI if you experience any  psychiatric symptoms (for
or all of the following: example, apathy, depression or
You forget things more often. psychosis)
You forget important events such  and out-of-character behavior (for
as appointments or social example, aggression, sleep
engagements. disturbance or disinhibited sexual
You lose your train of thought or behavior, although the latter is not
the thread of conversations, books typically the presenting feature of
or movies. dementia).
You feel increasingly
overwhelmed by making 4. DEPRESSION
decisions, planning steps to • Depression in older people has a
accomplish a task or prevalence of 5-10% over those aged over
understanding instructions. 65, but is frequently under-recognized. It is
associated with higher morbidity and poorer
outcomes from physical illness.
 • Older people under-report symptoms of
depression, and may attribute them to the
effects of ageing. Somatic symptoms are
more common than in younger people with
depression.
30 Total
Two of the most common screening tools used for
Interpretation
identifying dementia and depression in older people are:
I. MINI-MENTAL STATE EXAMINATION, which tests
memory and cognitive skills Score Degree of Impairment
• One of the most widely used screening 25-30 No Impairment
instruments for dementia. In clinical as well
as research settings, it is often used to 20-24 Mild
measure cognitive change over time in
older adults. The detection of decline or 10-19 Moderate
improvement is crucial for diagnosis and
therapy.
• A set of 11 questions that doctors and other II. Four-Item Geriatric Depression Scale
healthcare professionals commonly use to
check for cognitive impairment (problems GDS- suitable as a screening test for depressive
with thinking, communication, 4 symptoms in the elderly (3 min)
understanding and memory). GDS- ideal for evaluating the clinical severity of
15 depression, and for monitoring treatment.
(10min.)
MINI MENTAL EXAMINATION GDS- the original full-length GDS (20 min)
Maximum Questions 30
Score
5 “What is the year? Season? Date? Day?
Month?” Geriatric Depression Scale
5 “Where are we now? State? County?
Town/city? Hospital? Floor?” Directions to patient: Please choose the best answer for
3 The examiner names three unrelated objects how you have felt over the past week.
clearly and slowly, then the instructor asks Directions to examiner: Present questions verbally.
the patient to name all three of them. The Circle answer given by patient. Do not show to
patient’s response is used for scoring. The patient.
examiner repeats them until patient learns all Question Score (Yes/ No)
of them, if possible. 1. Are you basically satisfied with
5 “I would like you to count backward from 100 your life?
by sevens.” 2. Have you dropped many of your
Alternative: “Spell WORLD backwards.” activities and interests?
3 “Earlier I told you the names of three things.
Can you tell me what those were?” 3. Do You feel that your life is
2 Show the patient two simple objects, such as empty?
a wristwatch and a pencil, and ask the patient 4. Do you often get bored?
to name them.
1 “Repeat the phrase: ‘No ifs, ands, or buts.’” 5. Are you hopeful about the
future?
3 “Take the paper in your right hand, fold it in
6. Are You bothered by thoughts
half, and put it on the floor.”
you can't get out of your head?
1 “Please read this and do what it says.” 7. Are you in good spirits most of
1 “Make up and write a sentence about the time?
anything.” 8. Are you afraid that something
1 “Please copy this picture.” 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 SOCIAL-ENVIRONMENTAL ASSESSMENT
rather than go out and do
things?
ENVIRONMENTAL ASSESSMENT
13. Do you frequently worry about
the future? • It is important to assess areas of risk within the older
14. Do you feel you have more adult s residence.
problems with memory than • 95% of falls in older adults happen in and around the
most?
home, most in the bedroom or bathroom (Tideiksaar
15. Do you think it is wonderful to
R, 1992). For example, bathroom lighting is often
be alive now?
inadequate, and the bathtub and toilet areas lack
16. Do you feel downhearted and
blue? proper hand rails.
17. Do you feel worthless the way • In addition, unsecured scatter rugs and personal
you are now? items placed close by for convenience often create a
18. Do you worry a lot about the cluttered, dangerous pathway between the bedroom
past? and bathroom, creating a high risk for falling,
19. Do you find life very exciting? particularly at night.
20. Is it hard for you to get started • Other examples of external environmental safety
on new projects? hazards include pets underfoot, piles of papers and
21. Do you feel full of energy? personal belongings, uneven flooring or lack of home
22. Do you feel that your situation is repairs, and extension cords that present mobility
hopeless? hazards in common walkways.
23. Do you think that most people • Identifying such hazards and implementing an
are better off than you are? environmental modification plan can greatly reduce
risk within the home.
24. Do you frequently get upset
over little things? SOCIAL ASSESSMENT
25. Do you frequently feel like
crying? • An integral part of a comprehensive
26. Do you have trouble multidimensional assessment of older adult patients.
concentrating? Many studies on the effectiveness of comprehensive
27. Do you enjoy getting up in the geriatric assessment include a social worker on the
morning? assessment team, whose mandate typically includes
28. Do you prefer to avoid social identifying and addressing social and community
occasions? living needs.1 Social assessment is a broad
29. Is it easy for you to make construct, encompassing many aspects of an older
decisions? individual’s life.
30. Is your mind as clear as it used • It includes assessment of functional ability, as
to be? measured by the ability to perform the basic activities
Total Please stun all of daily living (ADLs) and instrumental activities of
bolded answers daily living (IADLs), social functioning (the older
(worth one point) adult’s social network and support system), the need
for a total score. for supportive services, screening for cognitive
Interpretation function, and an assessment of psychological well-
being (e.g. mood, quality of life, life satisfaction).
• Regardless of whether an older person lives in the
SCORES
community or in an institution, supportive activities
0-10 Normal
provided by social networks are key to ensuring
11-20 Moderate depression
adequate care and maintaining well-being. Social
21- 30 Severe depression functioning encompasses many aspects of a
person’s relationships and activities, and a social
assessment provides a snapshot of the resources
and risks related to health and wellness experienced
by an older patient.
Name of Caregiver: The GCS is scored between 3 and 15, 3
being the worst and 15 the best. It is
Caregiver relationship: Caregiver stress: composed of three parameters: best eye
Significant others: response (E), best verbal response (V), and
best motor response (M). The components
Social engagement of the GCS should be recorded individually;
for example, E2V3M4 results in a GCS
Occupation:
score of 9.
Current activities indoor: Current activities outdoor:
• What does a high score of 15 Glasgow Coma
Pets: Scale indicate?
The GCS is the summation of scores for
eye, verbal, and motor responses. The
Personal safety concerns: minimum score is a 3 which indicates a
deep coma or a brain-dead state. The
Home safety concerns:
maximum is 15 which indicates a fully
History of Abuse awake patient (the original maximum was
14, but the score has since been modified).
Emotional: • Who needs the Glasgow Coma Scale?
Sexual: Physical: The patients who need a GCS assessment
have generally suffered a traumatic brain
Smoking Habit injury and are either in the ER or ICU. An
initial GCS should be done at the time of
Age started:
admission and then every four hours unless
Age stopped: otherwise indicated by the medical team.
• Is the Glasgow Coma Scale used for stroke
Number of cigars a day: patients?
The Glasgow Coma Scale (GCS) was
developed to describe the depth and
Alcohol Abuse duration of impaired consciousness or
coma. In this measure, three aspects of
Type: Frequency:
behavior are independently measured:
Hobbies and Favorite Activities: motor responsiveness. , verbal
performance, and eye-opening. The GCS
can be used with individuals with traumatic
GLASCOW COMA SCALE brain injury, or stroke.
• For GPs, Head injury is a common cause of
hospital admission.
Head injury most commonly occurs as a
result of falls from standing height in older
adults. Older adults are frequently frail and
multi-morbid; many have indications for
anticoagulation and antiplatelet agents.
The hemorrhagic complications of head
injury occur in up to 16% of anticoagulated
patients sustaining a head injury. These
patients suffer adverse outcomes from
surgery as a result of medical
complications.

• It is used to objectively describe the extent of

impaired consciousness in all types of acute medical
and trauma patients. The scale assesses patients
according to three aspects of responsiveness: eye-
opening, motor, and verbal responses.
• What's the highest GCS score?
 PHYSICAL AND FUNSTIONAL ASSESSMENT (1) Mobility
Ambulates and transfers
with unsteady gait and no
PHYSICAL AND JUSTIFICATION/ assistance or assistive
FUNCTIONAL PATHOPHYSIO devices = 2pts
ASSESSMENT LOGICAL BASIS
Current Activity:(active, Ambulates and transfers
wheelchair/bedbound) with assistance or
Sleep: (insomnia, irregular assistive devices= 2 pts
sleep pattern, normal)
Body Frame: (thin, Visual or auditory
masculine, normal) impairment affecting
Gait: (symmetrical, mobility = 4 pts
asymmetrical) Elimination
Coordination: Urgency/Nocturia= 2pts
(coordinated/unccordinated)
Balance: (steady,unsteady) Incontinence = 5 pts
Muscle Strength: Medications
Right upper extremity:0-5 One present= 3 pts
Left upper extremity:0-5
Right lower extremity:0-5 Two or more presents = 5
Left lower extremity:0-5 pts (Psychotropis, Anti-
Motor convulsants,
Fine (+/-) Diuretics/Cathartics,
Gross (+/-) Patientcontrolled
Range of Motion Abduction analgesia, narcotics,
Adduction opiates and
Flexion antihypertensives
Extension Patient care equipment
Pain (iv, Feeding tubes,
Provocation: indwelling catheters, etc)
Palliation Quality: One present = 1 pt
Region:
Radiation: Two or more presents = 2
Severity scale: pts
Time onset/timing: IV
Feeding tubes
IFC
Others:
O-5= no need for referral
>6 = high risk, refer

FALL RISK JUSTIFICATION/PATHOP

HYSIOLOGICAL BASIS
AGE
19-64 years old= 2pts
65-79 years old= 2 pts
80 years old and above =
3 pts
FALL HISTORY
Fall within 3 months from
admission= 5 pts
Fall during this admission=
11 pts
 TINETTI ASSESSMENT TOOL
LAWTON INSTRUMENTAL ACTIVITIES OF DAILY • Performance-Oriented Mobility Assessment
LIVING SCALE (POMA).
• assess more complex activities necessary for • Published by Mary Tinetti (Yale University) to
functioning in community settings. assess the gait and balance in older adults and to
• 8 domains assess perception of balance and stability during
• The capacity to handle these complex functions activities of daily living and fear of falling.
normally is lost before basic “activities of daily • INTERPRETATION:
living” (e.g., eating, bathing, toileting) which are ❖18 POINTS OR LESS= HIGH RISK FOR FALLS
measured by ADL scales. Therefore, assessing ❖19-23 POINTS=MODERATE RISK
IADLS may identify incipient decline in older adults
❖24 OR MORE POINTS= LOW RISK
or other individuals who are otherwise capable and
healthy

NUTRITIONAL ASSESSMENT
• Each domain should have justification or
pathophysiological basis.
NUTRITIONAL JUSTIFICATION/
• INTERPRETATION:
ASSESSMENT PATHOPHYSIOL OGICAL BASIS
❖ Women= 0 (low function, dependent) to
Diet Restriction
8 (high function, independent)
Fluid Intake:
❖ Men=0 to 5
Weight: Height:
BMI:
Interpretation:
Skin turgor:
Gag reflex:
Swallow:
Appetite:
Food likes:
Food dislikes:
Elimination- bowel:
Stool Frequency:
Consistency:
Color:
Elimination- 5. Neuropsychological
bladder: problems
Urine
Frequency: 0= severe dementia or
Color: depression
Amount: 1= mild dementia
Transparency: 2= no psychological
problem
Abdomen Contour: 6. Body mass index
Bowel Sounds (BMI)
Right lower:
Right upper: 0= less than 19
Right upper: 1= 19-21
Left lower 2= 21-23
3= 23 or greater -OR Calf
circumference (CC) in cm
MINI NUTRITIONAL ASSESSMENT-SCREENING 0= less than 31
3= 31 or greater
SCREENING SCORE JUSTIFICATION/ TOTAL:
PATHOBASIS
1. Has food intake INTERPRETATION
declined over the past 3 12-14 NORMAL NUTRITIONAL STATUS
months due to loss of 8-11 AT RISK OF MALNUTRITION
appetite, digestive 0-7 POINTS MALNOURISHED
problems, chewing or
swallowing difficulties?
MINI NUTRITIONAL ASSESSMENT-SCREENING
0= severe decrease in
food intake
1= moderate decrease in ASSESSMENT SCORE JUSTIFICATION/
food intake PATHOBASIS
2= no decrease in food 1. Lives independently
intake (not in a nursing home)?
2. Weight loss during
last 3 months 0= NO
1= YES
0= greater than 3 kg/6.6 2. Takes more than 3
lbs prescription drugs per
1= does not know day
2= between 1 and 3 kg
(2.2 and 6.6 lbs) 0= NO
3= no weight loss 1= YES
3. Mobility 3. Pressure sores or
skin ulcers
0= bed or chair bound 1=
able to get out of bed/chair 0= NO
but does not go out 1= YES
2= goes out 4. How many full meals
4. Has suffered does the patient eat
psychological stress or daily?
acute disease in the past
3 months 0= One meal 1= Two
meals 2= Three meals
0= yes 5. Selected consumption
2= no markers for protein
intake
 0.0= less than 21
• At least one serving of 0.5= 21-22
dairy products (milk, 1.0= 22 or greater
cheese, yogurt) per 12. Calf circumference
day? (Yes/No) (CC)
• Two or more servings
of legumes or eggs per 0= less than 31
week? (Yes/No) 1= 31 or greater
• Meat, fish or poultry TOTAL:
every day? (Yes/No)

0.0= if 0 or 1 Yes answer INTERPRETATION

0.5 = if 2 Yes answers 1.0 24-30 NORMAL NUTRITIONAL STATUS
= if 3 Yes answers 17-23.5 AT RISK OF MALNUTRITION
6. Consumes two or < 17 MALNOURISHED
more servings of fruit or
vegetables per day?

0= NO
1= YES
7. How much fluid is
consumed per day?

0.0= less than 3 cups 0.5=

3 to 5 cups
1.0= more than 5 cups
8. Mode of feeding

0= Unable to eat without

assistance
1= Feeds self with some
difficulty
2= Feeds self without any
problems
9. Self- view of
nutritional status

0= Views self as being

malnourished
1= Is uncertain of
nutritional state
2= Views self as having
no nutritional problems
10. In comparison with
other people of the
same age, how does the
patient consider his/ her
health status?

0.0= Not as good

0.5= Does not know 1.0=
As good
2.0= Better
11. Mid- arm
circumference (MAC)
COMPREHENSIVE GERIATRIC ASSESSMENT (2) LIVING WILL

• A legal document with your wishes about medical

• A multidimensional interdisciplinary diagnostic treatment
process focused on determining a frail older person’s • A route marked on a map
medical, psychological & functional capability in • You choose what you do want and don’t want
order to develop a coordinated & integrated plan for • It is YOUR journey
treatment & long term follow up.
Similarities and Differences from Standard Medical
Evaluation MEDICAL POWER OF ATTORNEY

• A legal form that states who you want to make

• Incorporates all facets of a conventional medical decisions about medical care
history: the approach being more specific to older • The person is authorized to speak for you ONLY if
person you are unable to make your own medical decisions,
• Including non-medical domains like a ‘back up driver’
• Emphasis on functional capacity and quality of life • May also be called:
• Incorporating a multidisciplinary team Health care proxy or agent
• Diagnosis of medical conditions Health care surrogate
• Development of treatment and follow-up plans Durable power of attorney for healthcare
• Coordination of management of care
• Evaluation of long term care needs and optimal
placement

PERSONAL DATA ASSESSMENT

ADVANCE DIRECTIVES

• A written statement of your wishes, preferences, and

choices regarding end-of-life health care decisions
• A tool to help you think through and communicate
your choices
• It is a road map for your future health care
• Written instructions about future medical care
• Only used: if you are seriously ill or injured and
unable to speak for yourself
  Is in a non-cognitive state with no
reasonable possibility of regaining
cognitive functions
 Is a person for whom
cardiopulmonary resuscitation
would be medically futile in that
such resuscitation would likely be
unsuccessful in restoring cardiac
and respiratory function or will only
restore cardiac and respiratory
function for a brief period of time
so that the patient will likely
experiences repeated need for
cardiopulmonary resuscitation
over a short period of time or that
such resuscitation would be
otherwise medically futile
• WHAT DNR ORDER SHOULD INCLUDE
DO NOT RESUSCITATE (DNR)
Documentation or co-signing of the order by
• Every patient is presumed to consent to the the attending
administration of CPR in the event of cardiac or Th discussion the provider had with the
respiratory arrest, unless a DNR order is written patient and healthcare agent
• A DNR order is an order to refrain from using Specific orders about what treatments are
measures to restore or support a cardiac or to continue
respiratory function in the event of arrest Orders should be reviewed at least every 7
• DNR orders are compatible with maximal therapeutic days
care
• DNR orders never imply withdrawal of all medical
and nursing care FINANCIAL HEALTH PLANNING
• WHO CAN MAKE DNR DECISIONS
When the patient has decision making
• Primary source of healthcare
capacity a DNR decision will be reached
consensually by the patient and provider • Financial resources related to illness
When the patient is incapacitated and has MEDICAL ASESSMENT
a healthcare agent, a DNR decision will be
reached consensually between the health
care agent and provider HEART
When the patient is incapacitated and has
• it grows slightly larger with age.
no healthcare agent, the provider can
initiate the “Candidate for Non- • Maximal oxygen consumption during exercise
Resuscitation” process declines in men by about 10% with each decade of
• A candidate for non-resuscitation is a patient who life while women is about 7.5%.
meets the following criteria: • Cardiac output stays nearly the same as the heart
Lacks decision making capacity pumps more efficiently
Has no authorized person who is LUNGS
reasonably available to make decision with
regard to DNR order • maximum breathing (vital) capacity may decline by
Has been determined to a reasonable about 40% between ages 20 and 70.
degree of medical certainty by the patient’s • Decreased cough reflex
attending and one licensed physician, to • Mucociliary clearance slower and less effective
meet any one of the following 3 criteria:
 Has a medical condition which can SKIN
reasonably be expected to result • Structural changes such as dryness, roughness,
in the imminent death of the wrinkling, laxity and increased incidence of
patient neoplasms, both benign and malignant.
 • Functional changes such as decline in cell BRADEN SCALE
replacement, barrier function, wound healing,
immunologic response and thermoregulation.
• Dermis thins by 20 % with age, ecchymoses may • Developed 1984 by Braden and Bergstrom
occur readily when skin is traumatized • Six elements that contribute to either higher intensity
• Melanocytes are progressively lost= uneven tanning and duration of pressure or lower tissue tolerance to
may be normal pressure therefore increasing the risk of pressure
ulcer development.
HAIR Sensory perception
Mobility (ability to change own position)
• Substantially grays in about 50% of persons by age
Nutrition
50 due to loss of melanocytes. Moisture
• Hair loss from the vertex and fronto-temporal regions Friction and shear
in men begins between the late teens and the late Activity
20’s, by the time they reach 60’s, 80% of men are • Each item is scored between 1 and 4 guided by a
substantially bald. descriptor. The lower the score, the greater the risk
• Same pattern of hair loss for women after
menopause. Sensory Perception- Ability to respond meaningfully to
pressure-related discomfort
Leading causes of Illness (morbidity) among older
1. Completely Limited
Filipinos
- Unresponsive (does not moan, flinch or gasp) to painful
• Influenza stimuli, due to diminished level of consciousness or
• Bronchitis sedation. OR limited ability to feel pain over most of body
• TB surface.
• Diarrhea 2. Very Limited
• Hypertension Leading - Responds only to painful stimuli. Cannot communicate
discomfort except by moaning or restlessness
Cause of death (mortality) 3. Slightly Limited
- Responds to verbal commands, but cannot always
• Diseases of the heart communicate discomfort or need to be turned OR has
• Diseases of the vascular system some sensory impairment which limits ability to feel pain or
• Pneumonias discomfort in 1 or 2 extremities
• TB (all forms) 4. No Impairment
• Malignant neoplasms - Responds to verbal commands. Had no sensory deficit
which would limit ability to feel or voice pain or discomfort.
SIGHT

• Difficulty focusing close up may begin in the 40’s

Moisture- Degree to which skin is exposed to moisture
• Ability to distinguish fine details may begin to decline
in the 70’s 1. Constantly Moist
• From 50 onwards, there is increased susceptibility to - Skin is kept moist almost constantly by perspiration, urine,
glare, greater difficulty in seeing at low levels of etc. Dampness is detected every time patient is moved or
illumination, and more difficulty in detecting moving turned.
targets. 2. Very Moist
- Skin is often, but not always moist. Linen must be
changed at least once a shift.
HEARING
3. Occasionally Moist
• It becomes more difficult to hear higher frequencies - Skin is occasionally moist, requiring an extra linen change
with age approximately once a day.
• hearing declines more quickly in men than women. 4. Rarely Moist
- Skin is usually dry. Linen only requires changing at routine
intervals.
Activity- Degree of physical activity Friction and shear
1. Bedfast 1. Problem
- Confined to bed. - Requires moderate to maximum assistance in moving.
2. Chairfast Complete lifting without sliding against sheets is impossible.
- Ability to walk severely limited or non-existent. Cannot Frequently slides down bed or chair, requiring frequent
bear own weight and/or must be assisted into chair or repositioning with maximum assistance. Spasticity,
wheelchair. contractures or agitation lead to almost constant friction.
3. Walks Occasionally 2. Potential Problem
- Walks occasionally during day, but for very short - Moves feebly or requires minimum assistance. During a
distances, with or without assistance. Spends majority of move, skin probably slides to some extent against sheets or
each shift in bed or chair. other surfaces. Maintains relatively good position in chair or
4. Walks Frequently bed most of the time, but occasionally slides down.
- Walks outside the room at least twice a day and inside 3. No apparent problem
room at least once every 2 hours during waking hours - Moves in bed and in chair independently and has sufficient
muscle strength to lift up completely during move. Maintains
good position in bed or chair at all times
Mobility- Ability to change and control body position
1. Completely Immobile
- Does not make even slight changes in body or extremity
position without assistance.
2. Very Limited
- Makes occasional slight changes in body or extremity
position but unable to make frequent or significant changes
independently.
3. Slightly Limited
- Makes frequent though slight changes in body or
extremity position independently.
4. No Limitations
- Makes major and frequent changes in position without
assistance

Nutrition- Usual food intake pattern

1.. Very Poor
- Never eats a complete meal. Rarely eats more than 1/3
of any food offered. Eats 2 servings or less of protein per
day. Takes fluids poorly. Does not take a liquid dietary
supplement. OR is NBM and/or maintained or clear liquids
or IVs for more than 5 days.
2. Probably Inadequate - Rarely eats a complete meal
and generally eats only about ½ of any food offered. Eats
only 3 servings of protein per day. Occasionally will take a
dietary supplement. OR receives less than optimum
amount of liquid diet or tube feeding.
3. Adequate
- Eats over half of most meals. Eats a total of 4 servings of
protein each day. Occasionally will refuse a meal, but will
usually take a supplement if offered. OR is on a tube
feeding or TPN regimen which probably meets most of
nutritional needs.
4. Excellent
- Eats most of every meal. Never refuses a meal. Usually
eats a total of 4 or more servings of protein per day.
Occasionally eats between meals. Does not require
supplementation.
 PERSON ASSESSMENT normal for age; poor muscle tone; thin; cachectic appearance;
weight normal for height, age & body build, poor muscle tone;
wasted appearance; well-developed firm muscles; good tone;
Health History moderate muscle mass; with subcutaneous fat loss, trim &
1. Current Health Problems - This refers to the muscular, with well-developed musculature
present problem the patient is experiencing: include b. Color or skin and quality of skin:
the chief complaint or the conditions that prompted
him to seek for medical or surgical consultation. Example: Slightly cyanotic, with peripheral cyanosis or
2. Past Health Problems - Any sickness or ailments circumoral cyanosis; with generalized jaundice, flushed skin;
experienced in the past. pale skin, pale palpebral conjunctiva; pigmented; with bruises
3. Surgical History - Any surgery experienced in the with petechiae: with popular rashes all over body, with
past, be it minor or major. maculo-papular rashes; with mottling skin; with skin
4. Obstetrical History (applicable to women only) desquamation; with necrotic, gangrenous wounds over lower
5. Accidents - Accidents, falls, injuries, chemical, extremities, with incisions etc.
mechanical, physical trauma for that matter (With
PSYCHOSOCIAL
treatment or without treatment)
6. Patient Education Needs - This refers to the 1. Significant Others
component where in you evaluate or judge your • These are the people who had played great
patient as "Knowledge deficit" on a particular area of influence to the patient's life.
his/her health and needs further instructions and • Who are the people who had great influence
guidance. on the patient's life? Husband? Mother?
Example: Father? Brother? Sister? Son? Daughter?
Friend?
• Needs further instruction on personal hygiene • Note: indicate the significant other, and then
• Needs further instruction on medical asepsis during indicate the "bonding" or describe the
colostomy care or wound care "relationship" with the patient.
• Needs further instruction on medication regimen
Example; Loving husband who is always supportive during
7. Family Risk Factors
times of difficulties Caring sister, who is always ready to
a. Habits - Smokers in the family, alcohol
extend help in times of need
drinkers in the family; tea-drinkers; eat raw
vegetables; family practices and rituals You may also include the structure of family in which the
b. Health maintenance practices - Families patient belongs, like nuclear family or extended family: family
practices, rituals in terms of maintenance of with a single-parent; alternate family structure like cohabiting
health families (with friends or with other individuals who live together
8. Medications (include vitamins and minerals, oral for variety of reasons)
contraceptives and over the counter drugs
taken) 2. Coping Mechanisms- There are 2 ways in which a
person copes with a problem
List the: Names of the drugs Dose. Route Problem-focused
Frequency Period of intake a. Flight - escapes away from the problem or avoids
the problem; (running away from the problem,
Physical-Physiological General Appearance evading the problem, avoiding the problem) Sample:
runs away, stays-away, goes to the other place just
• The general appearance would consist of the
to evade the problem; isolation when with problem,
following:
indifferent b. when with problem; ignores the
Level of consciousness (examples: stupurous, problem; suicide attempts; indulgence to drugs and
conscious, coherent, unconscious, disorganized, alcohol intake
disoriented, conversant, etc.) b. Fight (facing the problem, trying to find solutions to
problems, all efforts done to decrease or eliminate
a. Nourishment/hydration (weight against height) the problem), finds ways to solve the problem
Example: underweight skin and bones or emaciated body, Emotion-focused
with thin, wasted body, sunken eyeballs, protruberant bony a. Repression - impulses or memories that are too
prominences; obese; overweight; with edema on upper and frightening, painful, or unpleasant, are to be
lower extremities, with ascites with abdominal girth of 35 excluded from conscious awareness
inches; or with facial or peri-orbital edema; poor skin turgor, b. Rationalization - this is the search for the good
dehydrated with dry mucous membranes, cracked lips; weight reason rather than the true renson: "sour-graping"
 c. Reaction-formation - an individual conceal a motive Here are some examples of specific terms used in making
by giving strong expression of the opposite motive A assessments of general appearance and motor behavior:
mother who feels guilty about not wanting her child
may become overindulgent and over-protective to a) Automatisms: these are repented, purposeless
assure the child of her love and to assure herself that behavior often indicative of anxiety such as
drumming of fingers, twisting locks of hair, or tapping
she is a good mother.
d. Projection - recognizing our undesirable qualities by the foot, swaying the arms or legs, etc,
assigning them in exaggerated amount to other b) Psychomotor retardation; over-all slowed
movements
people
e. Intellectualization - this is an attempt to gain c) Waxy flexibility: maintenance of posture or position
detachment from a stressful situation by dealing with over time even when it is awkward or uncomfortable
it in abstract intellectual terms Doctors and nurses ✓ Assess for client's speech for quantity,
quality, and any abnormalities
detach themselves from the emotion they feel at
sight of a grieving family ✓ Does the client talk non-stop?
f. Denial - a person denies the presence of an ✓ Does the client preservate (seem to be
stuck on one topic and unable to move to
unpleasant experiences.
g. Displacement -shifting of impulses from un another idea)
acceptable target. ✓ Are responses minimal "yes" or "no" without
elaboration?
h. Religion - indicate the religious group Religion
would also touch something on the spirituality, his ✓ Is the content of the client's speech relevant
relationship with the deity, with self and with nature to the questions being asked?
✓ Is the rate of speech fast or slow?
Example: Goes to church every Sunday.. Joins vigil every ✓ Is the tone audible or loud?
Wednesday.... Joins bible study ✓ Does the client speak in a rhyming manner
✓ Does the client use neologisms (invented
3. Primary Language - Dialect used in his immediate
words that the meaning only to the client)
family and neighborhood. Ilocano, Tagalog, Isinay,
etc Note for any speech difficulties such as stuttering or
4. Primary Source of Health Care - RHU, Barangay stammering
Health Centers, hilots, quack doctors, private clinics,
tertiary hospitals like VRH, Health Spa 7. Affect - It is the person's feelings as they appear to
5. Financial Resources Related to Illness - others. A person's mood or emotional state and is
expressed verbally and nonverbally.
Supported by DSWD; with Phil health; with Medical
Insurance; asks heip from relatives; Barangay Health Here are common terms used in assessing affect:
Scholar, from salary and saving; benefits from his
employer e.g. Doctors and nurses detach a) Blunted affect - showing little or a slow-to-respond
themselves from the emotion they feel at sight of a facial expression
grieving family b) Broad affect - displaying a full range of emotional
6. Occupational/Education - Has no education at all; expressions
Elementary undergraduate, elementary graduate; c) Flat affect - showing no facial expression regardless
high school undergraduate or graduate, college of circumstances
masteral, doctorate etc. and the past and present d) Inappropriate - displaying a facial expression that is
occupation and indicate where does the person work incongruent with mood or situation; often silly or
(location of work) giddy
e) Restricted - displaying one type of expression
General Appearance usually serious or somber
• Assess client's overall appearance including dress, Client's mood may be described as: Happy. Sad
hygiene and grooming Depressed…Euphoric. Anxious Angry
• Is the client appropriately dressed for his/her age and
weather? Labile (unpredictable and rapid mood swings from depressed
• Does the client appear to be his or her stated age? and crying to euphoria with no apparent stimuli)
• Observe the client's posture, eye contact, facial You may also ask your patient to cate his wood from a scale
expression, and any unusual tics or tremors of 1 to 10
Document specific observations and examples of behaviors 8. Orientation (oriented, disoriented) - Oriented to
to avoid personal judgement or misinterpretation Time, Place, Person and Event
"Di ko matandaan kung paano ako na bunggo sa jeep."
 9. Memory individual & you may also identify the
a) Immediate (You recite alphabets or factors that may influence the elimination
number or words and you ask him/her to pattern)
follow after you) c) Color - yellow-amber, dark-amber; pale;
b) Recent (Ask patient to recall events a week straw-colored; ten-colored, with bright red
ago or few days ago) blood, bright orange; red (dietary)
Anong sasakyan po ang ginamit niyo d) Odor - usually aromatic when newly voided
pagpunia niyo dito sa hospital? ammonia odor, sweet-fruity odor due to
c) Remote (Recall events 5 years ago or 10 acetone or acetoacetic acid as the bi-
years ago) product of incomplete fat metabolism seen
10. Speech - Staggering, stuttering, stammering, with patients with DM or no starvation.
slurred, unclear, with structural deficits of the oral Unusually foul odor due to presence of
and nasal cavities, removal of larynx, with extreme bacteria or offensive
dyspnea could impair speech patterns; e) Clarity - turbid; hazy, clear transparent;
understandable; moderately paced and shows cloud or foamy, with mucus plugs, viscid,
association with thoughts; rapid or slow; normal tone thick
and volume with clear inflection f) Specific gravity (1.010-1.025) - low means
11. Nonverbal Behavior - Pay particular to facial diluted, high means concentrated
expressions (facial grimace, furrowed forehead, g) Lab analysis - presence of pus, WBC;
gestures [thumbs up or thumbs down, or waving of protein, with RBC; glucose, bacteria, blood
hand] body movements; affect, tone of voice, posture or occult blood
[erect or slouchy] and with eye contact, avoid eye h) Presence of urinary diversions if
contact; body movements like purposeful moves and applicable (describe the urine form the
involuntary [like tremors or twitching] the gait ostomy)
[coordinated walking, arms freely swinging at the i) With difficulty or with pain upon
side with head and body leading, stamping of feet, urination
etc.)
The defining characteristics are:
ELIMINATION
• Abnormal breath sounds like the presence of
1. Stool crackles or wheezes
a) Frequency - number of times per shift or • Change in respiratory rate and depth
per 24 hours • Tachypnea or dyspnea
b) Pattern - everyday, twice a day, 3x a week, • With cyanosis (describe location- circumoral
once a week - usually at night time or in the periorbital, peripheral, facial)
morning • With cough (productive or unproductive)
c) Consistency and shape - watery; soft, Describe the nose - are there any presence of
well-formed; hard constipated, ribbon-like; secretion, tumor or mass, polyps, deformity on the
raisin-like nasal septum; presence of inflammation, redness or
d) Amount - minimal, moderate: "explosive" presence of foreign body; faring or ale nasae;
and excessive deviation of septum, bleeding discharges or
e) Presence of unusually foul odor secretions then any foul odor noted, describe the
f) Color - mucoid, clay-colored; black-tarry, turbinate’s if inflamed or reddish
greenish; yellow to brown, blood streaked Describe the mouth- presence of mass in the
g) Presence of parasites or undigested throat, inflamed tonsils that could obstruct the
food pharynx, presence of rashes that could result to
h) Presence of bowel diversions (describe increased secretion of suppuration, presence of
the discharge coming out from the lesions, tongue reddish or strawberry like in color,
ostomies) of this is applicable with cracks
2. Urine 3. Respirations
a) Quantity per voiding within 8 hours or 24
hours (normal is 1,200 ml to 1,500 ml within Ineffective breathing pattern- the state in which one's
24 hours; with anuria, oliguria, polyuria inhalation and or exhalation pattern does not allow normal and
(excessive output of urine, diuresis adequate pulmonary inflation of deflation (or chest expansion)
(increased urine formation])
b) Pattern - (voiding pattern) usually carly in
the morning upon arising; 3-5 per day
(extremely variable from individual to
Defining characteristics; 7. Peripheral Pulse

• With changes in respiratory depth (take the R Radial. temporal carotid. brachial femoral. popliteal.
including the depth) posterior-tibia dorsalis pedis
• With pursed-lip breathing and with prolonged
• Assess for the rhythm or pattern of beats
expiratory phase
(arrhythmias, dysrhythmin..etc)
• With dyspnea, with shortness of breath (note for the
• Assess for the pulse volume or the strength using
position assumed to ease respiration) with
these description: Absent, not discernible Thready or
orthopnea, two- pillow orthopnea, 3-pillow
weak, difficult to feel Normal, detected readily,
orthopnea, or prefers to sot and lean of a chair, etc.
obliterated by strong pressure Bounding, difficulty to
• Use accessory muscles when breathing (intercostal
obliterate
muscles or sternocleidomastoid muscles, or the
• Assess for elasticity of the arterial wall
abdominal muscles)
Straight, smooth, soft und pliable,
• With tachypnea
inelastic, tortuous and irregular upon
• With cyanosis
palpation There should be bilateral
• Abnormal ABG reading (with acidosis or alkalosis) equal pulses
• Altered chest excursion 8. Apical Pulse
• Increased anteroposterior diameter • Indicated for newborns and adult clients
who have irregular peripheral pulses
4. Lung sounds • Note for the rate rhythm., volume. It should
• Presence of crackles or rales, wheezes, be loudest at the apex of the heart
rhonchi or gurgles 9. Blood Pressure
• Normal vocal fremiti
• Normal breath sounds or with obstructing Site.
sounds upon entry of air
• Upper arm=uses brachial artery.
5. Color
• Forearm=uses radial artery.
• Color of skin (mucous membranes; the
• Lower leg =uses dorsalis pedis
conjunctiva), nailbeds, lips; palms and
• Thigh B/P= uses the popliteal artery
soles of feet
• Color of skin (cyanotic or flushed or B/P reading at the lower extremities usually is higher than the
jaundice color, greenish color, bluish color; B/P taken at the upper extremities, by 20-30 mmig
ictero-hemorrhagical or orange in color
usually at the eyes or red or black) Sign of Hypertension
6. Capillary refill • Headache
• Normal- it should be prompt (1-2 seconds • Ringing in the ear
is acceptable) beyond 2 seconds is • Flushing of face
considered sluggish capillary refill
• Nosebleeds
• Pulse oximetry- noninvasive procedure
• Fatigue, weakness, low energy
that measures a client's (Arterial Blood
• Bounding peripheral pulses
Oxygen Saturation) by means of a sensor
attached to the client's finger, toe, earlobe Sings of Hypotension
or forehead (foot or hand of a neonate)
Normal Sa02 is 95% Sa02 below 70% is life • Tachycardia
threatening • Weak and thread pulse
• Dizziness
• Mental Confusion
• Restlessness
• Cold clammy skin. May be pale or cyanotic
 10. Edema • ABG Arterial Blood Gases = take
the pH, PaC02, HCO3 and identify
Assess for the:
if compensated or
Location or the area uncompensated. May indicate
acidosis or alkalosis.
• Periorbital (around the eyes)- Localized to an area,
only note Clients with Acid Base Imbalance
• Facial- Bipedal (both feet below ankle, and above
• Impaired Gas exchange- The state in which an
ankle)
individual experiences a decreased in the passage
• General- Ascites ( take the abdominal girth of client of oxygen and/or Carbon dioxide between the
in cms and Inches) alveoli of the lungs and the vascular system,
Color • Defining characteristics Confusion:
[Link]..somnolence,hypoxia...hyp
• Flushed or with redness [Link]
• Dark or Blackish
• Pale or shinny Abdomen - Bowel sounds

Temperature • Hypoactive soft and infrequent it indicated

decreased motility.
• Warm to touch and Cold • Hyperactive increased, high pitch loud sounds
(borborygmi) increased intestinal motility are
Shape/Size
associated with diarrhea, early bowel obstruction.
• Mild. Moderate… Severe • The absence of sound indicates cessation of
• Take the circumference of the affected area if it is at intestinal motility.
the extremities
Contour - observe for umbilical hernia
• Taut
• Firm Palpation- observe for tenderness, size, masses, guarding

Degree of indentation or pitting (when pressed with REST AND ACTIVITY

finger) Scale for describing edema:
1. Current Activity Level
➢ 1+ = barely detectable • Ambulatory….. Wheel chair... Bedridden...
➢ 2+ = indentation of less than 5mm On complete bed-rest. Just at bedside
➢ 3+ = indentation of 5-10mm dangling feet
➢ 4+ = indentation of more than 10mm • Vigorous and active. Sedated (immediate
post-op status)... Immobilized due to cast or
11. Homan's Sign traction
• This pain felt by individual in the calf • Limited activity due to severe pain
muscles with forceful dorsiflexion of the foot 2. ADLs - able or unable to do:
Calves firm and tensed With edema over • Grooming Feeding Toileting Ambulating
the dorsum of the foot Warmth and Pain Communicating
• All of these aspects should be present in a
Lab analysis
normal individual
• RBC's = are examined by their size, shape, 3. Sleep
color, maturation, and content. c/o a) Sleep History (usual bedtime, usual
laboratory. waking time, normal bedtime rituals,
• Hemoglobin = a low level may be an preferred environment for sleeping,
evidence of anemia. bedtime routines)
• Hematocrit = an elevated may indicate b) Duration - (vary among persons of all age
dehydration. groups) just indicate how many hours of
• Platelet count = Normal level. 250,000-400 sleep during the night; and how many hours
000/mcl of blood during the day
Low level may indicate bleeding and c) Quality and characteristics or sleep in
may be hereditary disorders, lack of greater depth (deep sleep, easily
Vit. B12, drug therapy and radiation awakened)
therapy. d) Pattern (time of sleep, how many times the
patient awakens at night, waking time)
 e) Review factors affecting sleep (emotional or 11. Range of Motion
mental status) • Legs - with joint stiffness, swelling, pain,
f) Evaluate the client's response to sleep limited movement and unequal movement,
disturbance can rotate joints normally 180 degrees, 360
g) Explore the client's interventions to improve degrees, can adduct, abduct extremities,
sleep pronation and supination of arms.
4. Body Frame • Arms - the same as above.
• Ectomorph(lean and delicate), endomorph, 12. Pain Relief Measures
mesomorph • Ask the patient his pain relief measures
• Body type: e.g, trim and muscular when he feels pain.
• Obese Excessively thin.…. Weight low for
Example: tries to sleep..do relaxation
height
5. Posture technique(yoga/meditation). ... have body mussage and take
a warm bath take - over the counter medication. consultation
• Upright stance with parallel alignment of the
for acupuncture, acupressure. drink sedatives and many more
hips and shoulders
• Normal sitting posture involves some 13. Mobility and Use of Assistive Devices
degree of rounding of the shoulders • What does the client utilize during transfer
• Abnormal like - slumped, erect, or bent or during the performance of his activities
posture, stooped-bent-forward posture, • With crutches. With walker.. With
with hips and knees flexed and arms bent wheelchair. Cane? Are there other devices
at the elbows, raising the leyels of the arms he uses to assist him in his performance.
6. Gait - movements should be coordinated, Normally
walks with arms swinging freely at the sides with the SAFE ENVIRONMENT:
face and the head leading the body 1. Allergies/Reaction
7. Coordination - good motor coordination; purposeful a) Medication (penicillin, Cephalosporins,
movements; well-coordinated body movements; no NSAID's etc) The best way to know the
tremors or repetitive movements; with chorea history of your patient is to ask them any
(involuntary purposeless, rapid motions (as flexing or history of allergic reaction.
extending of the fingers, raising or lowering of the b) Food (chicken, eggs, seafoods, canned
shoulders or grimacing) goods due to preservatives, iodine bases
8. Balance - Well-balanced on standing, bending substances)
towards front or back, Bending towards the sides, c) Environment (soot, smoke, dust, pollen,
use the Roomberg's test for assessing balance. No grains, fabric/textile, disinfectants, animal
dizziness, no complaints of room/ceiling "spinning manure of cars, dogs, birds. Aerosol
around" sprays, insect repellants.
9. Muscle 2. Eyes/Vision:
a) Strength (use scale 1-5) - Refer to scales • Glasses: Indicate the grade of glasses or
of muscle strength Kozier page 541. contact lenses used, using magnifying
Abnormal if 25% & below of the normal glass when reading, using of Schnell’s test
strength or visual acuity charts, take note any
b) Tone (atonic, firm, flaccid, muscle wasted) presence of color blindness, test for
c) Size (with atrophy, with hypertrophy) peripheral vision.
d) With contractures or shortening, (Tunnel vision or visual field
malposition of body parts - dorsiflexed, or smaller than normal = is a sign of
with foot drop Glaucoma)
e) Fasciculation or tremors (one-half vision in one or both
f) Movement (flaccid, spastic or smooth) eyes = indicates nerve damage)
g) No involuntary movements like
twitching and spasms and tics Note: Maps, spots, or flashes of lights as claimed double
10. Motor Function vision, blurring of vision
• Gross - can flex and ext
• Pupils: PERRLA, constricted, pinpoint
• end extremities, can bend at the waist, can
constricted, equal responses to light,
bend head on all sides
unequal responses or no response at all.
• Fine - can pick-up small pieces of items on
Assess each pupil's reaction to
the floor with the use of his toes, or can hold
accommodation: Pupils constrict
pens or pencils arid can write legibly
when looking at a near object,
 pupils dilates when looking at a far speaker, turns the head, cups the
object, pupils converge when a ears, or speaks in
near object is moved toward the Assess also by whispering: able to
nose. repeat whispered words; unable to
Assess six ocular movement to repeat whispered words
determine eye alignment and Assess also by using a ticking
coordination (both eyes clock: able to hear ticking on one
coordinated, move in unison and or both ears; unable to hear ticking
with parallel alignment, cross-eye on one or both ears
or with squinting, no voluntary eye Assess using the tuning fork: The
movements. Webber Test (bone conduction) or
The "cardinal position' are six the Rhine test (air conduction)-
positions of gaze which allow these tests will diagnose hearing
comparison of the horizontal, loss due to conduction; a positive
vertical, and diagonal movement Weber test indicates obstruction of
produced by the six extraocular ossicles or nerve or inner ear
muscles, damage. Sound conducted by air
is heard more readily than sound
The 6 cardinal positions:
conducted by bone
Up/right; Up/left: Right 4. Skin
• Assess for cuts, bruises, lacerations,
Left/down: Right/down: Left hematoma, erythema, maculo-papulae,
• In each position of gaze, one muscle of clastered vesicles, grouped, thick silvery,
each eye is the primary mover of that eye scaly plaques, edematous bright red
and is yoked to the primary mover of the erythema, mottled, slightly elevated,
other eye, Below, each of the six cardinal blistered, patches, desquamation, nodular,
positions of gaze is shown, along with petechia and ecchymoses, lentil-like
upward gaze, downward gaze, and papilloma, gangrenous, suppuration and
convergence: necrotic, blanchable, non- blanchable,
 MR= Medial Rectus deep ulcerations, etc.
 LR= Lateral Rectus • Assess for the skin color too: with pallor,
 SR= Superior Rectus with cyanosis, with jaundice,
 IR- Inferior Rectus hypopigmentation like vitiligo, chloasma,
 SO= Superior Oblique melisma, red-flushed skin
 IQ= Inferior Oblique Note for any discharges and foul odor:
• Assess for external structure: no Hyperhidrosis (excessive
inflammation, no secretions; no redness of perspiration), bromhidrosis (foul-
the conjunctiva and the sclera, has blinking smelling perspiration)
reflex, transparent cornea; opaque and Note presence of edema (swollen,
surface not smooth, symmetrical, non- shinny and taut and tends to blanch the
symmetrical skin color
3. Hearing/hearing aid: 5. Mucous membranes
• with the use of tuning fork Structure: • moist and intact, dry, cracked, parched,
presence of defects, presence of with cuts or bruises or with redness and
cysts or masses, assess for size Swelling, with suppurative secretions
and position; symmetry, inspect  Oral cavity
also for presence of discharges or  Nasal passages
secretions and note the odor.  Rectal canal
 Urethral orifice
• Hearing acuity
 Vaginal canal
Assess for response to normal
6. Temperature - indicate what site: oral, axillary,
voice tone (normal voice tones
through the ear canal, vaginal (36.4-37.4C) 7.
audible or normal voice tones not
7. Laboratory analysis
audible (eg. loud tone of voice)
requests nurse to repeat words or • WBC (leukocytes)
statements, leans toward the • The secondary defense: Approximately
5,000 to 10 000/mm?
 • More than the normal range indicates • Indicate the route the patient had taken in
infection fluids.
• Less than normal range indicates - 3. IVF's
destruction of these cells probably due to • Indicate the site and the solution
radiotherapy or chemotherapy connected.
• Blood transfusions and the type and
OXYGENATION
component.
1. Activity Tolerance • Indicate also if the patient has Total
• Easily fatigued during mild or moderate or Parenteral Nutrition
strenuous activities; • Side-drips with incorporations
• Experience dizziness or weakness during 4. Height and Weight
mile or moderate activity • Determine IBW
• Experience shortness of breath during mild • Determine the Anthropometric
or moderate activity Measurements.
• There is increased respiratory rate during • These are: Determine the IBW…. Midarm
mild or moderate activity muscle circumference.. Skin fold thickness
• Sudden facial pallor after an activity (triceps,- biceps, subscapular, abdominal,
• Heart rate and respiratory rate significantly hip, calf.
exceeds baseline levels 5. Tissue Turgor/skin turgor
• Heart rhythm changed from regular to • Mild moderate severe dehydration
irregular after an activity • Well hydrated if normal
• Weakening of the pulse 6. Ability to:
• Dyspnea, shortness of breath or chest pain • Chew = check for functions of mastication,
upon mild or moderate exertion muscles of chewing, teeth and gums.
• Changes in diastolic pressure of 10mmllg or • Swallow = check gag reflex
more • Tolerate food = with nausea, vomiting,
• Totally dependent when performing ADLS stomach distention, regurgitation, diarrhea,
• Partially dependent when performing ADLs pain after eating.
• Can perform ADLs alone • Feed self- determine if the patient can eat
• Most useful measures in predicting activity and drink alone ( without assistance or
tolerance are Pulse rate, strength and without assistive device)
rhythm; take also the respiratory rate, depth 7. Lab Analysis
and rhythm, and blood pressure - take • Blood Chemistry
these date before the activity, immediately • Na C K Glucose Cholesterol Total
after the activity and 3 minutes after the protein/albumin
activity has stopped and client has rested 8. Blood Glucose Monitoring
2. Airway clearance • If with hypoglycemia or with hyperglycemia.
• Ineffective airway clearance- This is the
state in which one is unable to clear
secretions or obstruction from the
respiratory tract to maintain airway patency
NUTRITION
1. Hospital Diet/Restrictions
• Examples: DAT, Clear, Liquid, General
liquid, BRAT diet, Low salt, Low calorie,
Low fat, Low residue, High protein
2. Fluid intake
• Restrict fluid (less than 1000ml per day)
• Increase fluid intake = to give liberal amount
as tolerated
• Force fluid (more than 3000ml per day)
• Indicate how much the client fluid intake for
a period of time (shift)
• (IVF. Oral, NGT, ostomies or rectal)