UNIVERSITY OF SAN CARLOS

COLLEGE OF NURSING
CEBU CITY
ASSESSMENT TOOL FOR THE ELDERLY CLIENT
Name of Patient: ____________________________________________________________
Sex: _______________ Age: _________________ Date of Birth: _____________________
Religion: ___________________________________________________________________
Address: ___________________________________________________________________
PROFILE OF FAMILY
Spouse:

Children:

Living: ___________________________ Deceased: _______________________

Health Status: _____________________ Year deceased: ___________________
Age: ____________________________ Cause of Death: ___________________
Occupation: ______________________
Living: ___________________________ Deceased: _______________________
Names and Addresses:
Year deceased:

_____ Allergies
Food:
Drug:
Others:
_____ Diabetes
_____ Hypertension

_____ Hospitalizations:
_____ Surgery:
_____ Fractures:
_____ Major Health Problems:

CURRENT HEALTH STATUS

Knowledge and understanding of health problems:
Limitations of function or performance of ADL:
Management of limitations:
PHYSICAL STATUS

T __________
P __________
R __________

Height _________
Weight _________
BP ____________

CURRENT MEDICATIONS
NAME
1.
2.
3.
4.

DOSAGE

FREQUENCY

SKIN CONDITION
______ Intact

______ Rash

______ Wounds

______ Dry

______ Discoloration

______ Pruritus

______ Abnormal Findings

Hair condition __________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________
Nail condition
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________
Mobility
______ Ambulatory
______ Non-ambulatory
______ Ambulatory with assistance

______ Able to rise from chair to toilet

______ Able to climb stairs
______ Able to transfer

Extremity Function
Location

Discription
of Limitation

Assistive /
Relief

Measures
1.
2.
3.
4.
5.
6.

Contracture
Arthritis
Painful Movement
Paralysis
Spasm
Amputation

_________________
_________________
_________________
_________________
_________________
_________________

________________
________________
________________
________________
________________
________________

_________________
_________________
_________________
_________________
_________________
_________________

BLADDER
______ Nocturia
______ Frequency

______ Burning
______ Urgency

______ Incontinence

Voiding pattern:
Urine Characteristics:

BOWEL
______ Hemorrhoids
constipation
______ Straining
diarrhea
______ Ostomy

______ Pain during movement

______ Recent change in pattern

______ Chronic
______ Chronic

STOOL
Bowel movement pattern:
Characteristics:

SENSORY STATUS
Discription of Limitation

Assistive/ Relief

Measures
Hearing
All sounds

___________________________ ____________________________
___________________________ ____________________________

High frequency

___________________________ ____________________________
___________________________ ____________________________

Full vision

___________________________ ____________________________
___________________________ ____________________________

Night vision

___________________________ ____________________________
___________________________ ____________________________

Vision

Peripheral vision ___________________________ ____________________________

___________________________ ____________________________
Reading

__________________________ _____________________________
__________________________ _____________________________

Color discrimination_________________________ _____________________________

__________________________ _____________________________
Taste:

Smell:

Touch
Feels pressure and pain_______________________ ___________________________
__________________________ ___________________________
Differentiates temp. _____________________
Pain
_______________________
Other sensory data:
______ Hearing aid
_____________
______ Contact lenses

______ Eye glasses

________________________
________________________
Date of last ear exam:

RESPIRATION
Precipitating

Description

Assistive/
Factors

of Limitation

Relief Measures

Orthopnea

____________________ ____________________ _____________________

____________________ ____________________ _____________________

Dyspnea

____________________ ____________________ _____________________

____________________ ____________________ _____________________

Shortness
of breath
Wheezing
Asthma

____________________ ____________________ _____________________

____________________ ____________________ _____________________
____________________ ____________________ _____________________
____________________ _____________________ _____________________
____________________ ____________________ ______________________
____________________ ____________________ ______________________

Coughing

____________________ ____________________ ______________________

Sputum characteristics:
Smoking history:
Tracheostomy:

CIRCULATION
Precipitating

Description

Assistive/
Factors

of Limitation

Relief Measures

Chest pain

___________________ ___________________ _____________________

___________________ ___________________ _____________________

Tachycardia

___________________ ___________________ _____________________

___________________ ___________________ _____________________

Edema

___________________ ___________________ _____________________

___________________ ___________________ ______________________

Cramping in
extremities ___________________ ___________________ _____________________
___________________ ___________________ _____________________
NUTRITION
Teeth:

Dentures:

Chewing problems:

Status:

Partial/Complete:

Swallowing problems:

Date of last dental exam:

Indigestion
Constipation
Diarrhea
Usual meal pattern:

Precipitating Factors
_________________________
_________________________
_________________________

Assistive/ Relief Measures

___________________________
___________________________
___________________________

Fluid intake:

Alcohol use:

REST AND SLEEP

______ Insomnia
______ Night restlessness
______ Night confusion

Medicines and alcohol used to induce sleep:

Factors interfering with rest:
Usual sleep and rest pattern:

MENTAL STATUS
______
______
______
______
______
______

Alert
Rapid response to verbal stimuli
Slow response to verbal stimuli
Confused
Stuporous
Comatose

Orientation:
______ Person
______ Place
______ Time

Memory of present events:

Memory of past events:

EMOTIONAL STATUS
______
______
______
______

Anxious
Fearful
Depressed
Hostile

______ Hyperactive
______ Hypoactive
______ Suspicious
______ Euphoric

______ Disinterest in life

______ Emotionally labile
______ Suicidal
______ Others (describe)

SELF-CONCEPT
_____________________________________________________________________________________
_____________________________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________

CURRENT STRESS SITUATION AND ITS FACTORS

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________
ATTITUDE AND CONCERNS ABOUT DEATH
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________