Behavioral Impairment Checklist: (Pre-test)

Select the appropriate number for each of the common behavioral problems in
Dementia as observedin the resident/patient observed.
Rated by: foster parent social worker researcher
Please rate severity: 4 Strongly disagree (not observed); 3 Disagree (noticeable,
but not a significant change); 2 Agree (significant, but not severe); 1 Strongly
agree (very marked or prominent, a severe problem)
BEFORE 4 3 2 1
Strongly Disagre Agre Strongl
disagre e e y agree
e
1. The patient appeared confused.
2. The patient was anxious or uneasy.
3. The patient felt bored.
4. The patient was delusional or believed
things even if proven false.
5. The patient was wandering.
6. The patient was feeling panicky.
7. The patient felt fearful or was worrying
excessively.
8. The patient was unable to be still and calm.
9. The patient was verbally threatening.
10 The patient was physically threatening.
.
11 The patient experienced bouts of amnesia
. or memory loss.
12 The patient was prone to disrobing.
.
13 The patient kept asking repetitive
. questions.
14 The patient displayed poor hygiene.
.
15 The patient was having tantrums.
.
16 The patient was wound up and edgy.
.
17 The patient was restless or feeling tense
.
18 The patient displayed signs of aggression
. such as closed or clenched fists and
muscle tension.
19 The patient experienced feelings of
. helplessness or depression.
20 The patient was indifferent and withdrawn
. from his/her external world.
21 The patient had wandering thoughts.
.
22 The patient was restless and looking for
. alternative activities.
23 The patient was actively trying to escape
. current situation/activity and the people
responsible for it.
24 The patient was irritable or angry.
.
25 The patient was having hallucinations.
.
26 The patient believed he/she had a physical
. defect or medical problem which does not
exist.
27 The patient had difficulty concentrating on a
. task.
28 The patient had an increased heart rate and
. quick breathing.
29 The patient was experiencing shortness of
. breath.
30 The patient was trembling or shaking.
.
Behavioral Impairment Checklist: (Post-test)
Select the appropriate number for each of the common behavioral problems in
Dementia as observed in the resident/patient observed.
Rated by: foster parent social worker researcher
Please rate severity: 4 Strongly disagree (not observed); 3 Disagree (noticeable,
but not a significant change); 2 Agree (significant, but not severe); 1 Strongly
agree (very marked or prominent, a severe problem)
After 4 3 2 1
Strongly Disagre Agre Strongly
disagree e e agree
1. The patient appeared confused.
2. The patient was anxious or uneasy.
3. The patient felt bored.
4. The patient was delusional or believed
things even if proven false.
5. The patient was wandering.
6. The patient was feeling panicky.
7. The patient felt fearful or was worrying
excessively.
8. The patient was unable to be still and
calm.
9. The patient was verbally threatening.
10 The patient was physically threatening.
.
11. The patient experienced bouts of
amnesia or memory loss.
12 The patient was prone to disrobing.
.
13 The patient kept asking repetitive
. questions.
14 The patient displayed poor hygiene.
.
15 The patient was having tantrums.
.
16 The patient was wound up and edgy.
.
17 The patient was restless or feeling tense
.
18 The patient displayed signs of
. aggression such as closed or clenched
fists and muscle tension.
19 The patient experienced feelings of
. helplessness or depression.
20 The patient was indifferent and
. withdrawn from his/her external world.
21 The patient had wandering thoughts.
.
22 The patient was restless and looking for
. alternative activities.
23 The patient was actively trying to
. escape current situation/activity and the
people responsible for it.
24 The patient was irritable or angry.
.
25 The patient was having hallucinations.
.
26 The patient believed he/she had a
. physical defect or medical problem
which does not exist.
27 The patient had difficulty concentrating
. on a task.
28 The patient had an increased heart rate
. and quick breathing.
29 The patient was experiencing shortness
. of breath.
30 The patient was trembling or shaking.
.
 LETTER TO THE RESPONDENTS

DEAR RESPONDENTS,

We are students of Olivarez College in Paranaque City who are currently

conducting a study on The Effects of Social Recreation to the Progression of Dementia
to the Residents of House of Somang This is one of the requirements for the degree of
Bachelors Science in Nursing.

In this regard, we are asking for your full cooperation in answering the attached
survey questionnaire honestly. Your answer would be of great help to us in this study.
Rest assured that your answers will be kept confidential.

Looking forward for your cooperation.

 Thank you.

Sincerely yours, Noted by:

BSN students Paulo Manuel L. Macapagal, PhD, RPm, RPsy
Rosemarie Reyes Thesis adviser
Angelica Sirot
Leah Raymundo

PROFILE OF THE RESPONDENTS

The profile of the respondent in terms of:
Age _________
Gender _________

STATEMENT OF THE PROBLEM

This study strives to discover the effects of social recreational activities to the
progression of dementia in afflicted residents of a nursing home and aims to answer the
following questions:

1. What is the profile of the respondents in terms of:

1.1 Age
1.2 Gender

2. What are the different social recreational programs given by the institution to
patients with dementia?

3. To what extent are the manifested behavioral issues of the client before the
application of social recreational activities as perceived by the health care
providers?

4. To what extent are the manifested behavioral issues of the client after the
application of social recreational activities as perceived by the health care
providers?

5. What is the difference of the results from the pre-test and the post-test?
 6. Based on the findings, what activities from the program are most applicable to
improve the behavior of the client?

I. Demographic Profile

Instruction: Please fill out the following fields

Name: ________________________ Gender: ___________

Age: _____________

II. Recreational Activities

Instructions: Please check the box that corresponds to the recreational activity
conducted for the residents.

Watching television
Board Games(Bingo, Chess, Checkers)
Art Activities (Coloring, Painting, Drawing, Greeting card making)
Puzzle Games
Rosary bead making
Dancing and Singing