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By msiples Feb 24, 2014 3743 Words
Geriatric Health History Documentation
Student Name___________________________
Focal Points of Geriatric Assessment/Grading Rubric:

1. Biographic Information (2pts) (date of visit, initials of client, race, language spoken, Advance directives, Insurance: primary, secondary)

2. Informant and reliability(3pts): (facility chart, client, family member, staff, etc.) Chief Complaint or client’s request for care
Present Illness: Present Illness or present health status OLD CART (Onset, Location, Duration, Characteristics, Associated factors, Response to treatments tried) Progression of disease/Illness:

Chronological order of events
Specific s/s
Duration, characteristics, location
Abrupt/gradual, related activity
Aggravating/alleviating factors: medication
Treatment
Pertinent negative data

3. Past Medical History(5pts) :
Allergies
Immunizations (childhood, influenza, pneumonia, shingles- provide dates if known) Past Illness:
Illness (including childhood) with/without hospitalization, injuries, poisonings Illnesses with hospitalization: (when and where)
Past surgical history:
Operations (hip, gallbladder, etc. and year)
Transfusions, if any
Falls: # in past year and treatment required, if any

4. Development Data (5pts)
Occupation (former and current), volunteer activities, hobbies Adult Developmental Stage (must include theory and supporting statement) Mental Status (Mini-Mental Health Exam, Geriatric Depression Scale)

5. Social History (5pts): Habits/current issues:
Environment (type, cleanliness, safety)
Driving (night/day, barriers to driving)
Sleep (bedtime, wake-up, quality of sleep, medication taken for sleep, naps - #, duration) Elimination (bowel – constipation, diarrhea, how often and characteristic of stool, dietary prunes/juice; bladder – nocturia, incontinence, dribbling) Exercise (description of any specific exercise program, aerobic, strengthening: barriers to exercise) Nutrition (use nutritional screening tool, Gerontologic Nursing, p. 180, list score and risk status) Use of tobacco, coffee, tea, cola, alcohol, laxatives (amounts and how often) Sexuality (if client is comfortable addressing topic)

6. Family Health History (5pts)
Marital status, children
Place of birth, health status of siblings, parents, if living; If dead, what was cause and age at death Family Personal/Social History
Church affiliations, social groups and support

7. ROS: Review of systems (NOT your assessment but the client’s perception of his/her health) (10pts) General: Unusual weight changes, fatigue, skin color/ texture changes, temperature, chills, sensitivity, mentality, changes in behavior HEENT: Headaches, diplopia, blurred vision, red eyes, painful eyes, cataracts, glaucoma, loss of visual field, oral cavity ulcers or growths, sore throat, hoarseness, glasses, contacts, dentures, or hearing aids? Respiratory: cough, sputum, hemoptysis, dyspnea, pleuritic chest pain, wheezing, asthma, recurrent infections – pneumonia or bronchitis, occupational exposures (asbestos, pneumoconiosis), last Chest x-ray, TB, DVT or PE, sleep pattern. Cardiac: Chest pain or pressure, palpitation, orthopnea, SOB, pedal edema, Hx of rheumatic fever, heart murmur, HTN, hyperlipidemia, Mitral valve prolapse Gastrointestinal: weight gain/loss, change in appetite or diet pattern, nausea, vomiting, diarrhea, constipation, date of last flex. Sig/ colonoscopy, hematemesis, melena, change in stool, hemorrhoids hepatitis, PUD, Gall bladder disease, dysphagia, GERD, belching, flatus, jaundice, abdominal pain. Genitourinary: dysuria)a, frequency, polyuria, pyuria, hematuria (dark urine/ cola colored, character of stream, decrease force of urination, nocturia, hesitancy, incontinence, nephrolithiasis, hx of UTIs, currently sexually active?

Female: Menarche, menopause, postmenopausal bleeding, vaginal discharge, STDs, endometriosis, birth control methods, hormone replacement therapy, #of pregnancies, #live births, #lost pregnancies, hysterectomy, dyspareunia, last pap, breast lumps, nipple discharge, last mammogram, SBE, mastectomy.

Male: hernia, testicular masses or pain, penile discharge, penile sores, prostatitis, hx prostate cancer BPH, sexual dysfunction, STDs, Prior PSAs Musculoskeletal: Weakness, clumsiness, ataxia, lack of coordination, unusual movements, back or joint stiffness, muscle or joint pains, cramp, deformities, fractures, swelling, muscle weakness or wasting, limitation of movement, gout, Lyme disease, arthritis. Neurologic: Seizures, temors, dizziness, tingling, sensory changes, or paresthesias, loss of feeling, loss of memory, general affect, speech problems, changes in gait or coordination Vascular: Phlebitis, varicose veins, claudication, cramping, Raynaud’s, PAD (PVD), neck vein distention Endocrine: Excessive thirst or appetite, cold-heat intolerance, DM, Osteoporosis Hematologic: Anemia, pallor, lymph node swelling, bleeding, bruising, blood transfusions, toxic drugs, irradiation, chemotherapy, night sweats Dermatologic: Rashes, moles (recent changes), birthmarks, pigmentation-color changes, jaundice, cyanosis, pallor, lumps, changes in body hair, nails Psychological: depression, agitation, panic-anxiety, memory disturbance, personality changes, hallucinations.

8. Functional Assessment (10pts)
ADLs (feeding, bathing, dressing, toileting, grooming)
IADLs (Instrumental activities of daily living) shopping, doing laundry, housekeeping chores, using phone, opening and answering mail, ability to drive

9. Current Medication (5pts)
List all meds, prescribed and over the counter, what they are, why taken, dosages and times

10. Physical Assessment (20pts)
(Refer to Perry & Potter, Clinical Nursing Skills & Techniques, chapters 3-6) (5) VS, (P, R, BP, Temp, ht, wt, BMI)
Senses: Vision, Hearing (glasses, hearing aids)
(5) General: Well/Ill
Skin: color, texture, turgor, lesions, pigmentation, ecchymosis, trauma, hair, nail condition HEENT: Pulses, symmetry, temporal arteries
Head: Symmetry, scalp, face
Ears: Hearing, cerumen
Eyes: Strabismus/nystagmus, vision, EOMs/cover-uncover, inflammation Nose: Nares, turbinates, hearing, aids,
Mouth/Throat: Teeth, gums, ducts, palate, tongue, pharynx, lesions Neck: ROM, suppleness, thyroid, trachea, JVD
Lymph: Adenopathy, tenderness
(5)Chest:
Thorax; structures, breasts
Lungs: rate, effort, sounds (A&P)
Heart: rate, murmurs, pulses, bruits
Abdomen: Liver, spleen kidneys, masses, tenderness, bowels sounds GI/GU: Optional
(5) Musculoskeletal: symmetry, ROM, muscle strength, digits, feet, spinal alignment
Extremities: edema, temp, clubbing, color, ulceration
Neurological: Motor, sensory, coordination, balance, fall potential, reflexes
Cranial Nerves (integrated)

11. SOAP (5pts) (refer to Potter & Perry, Fundamentals of Nursing, p. 391) Subjective data (what the client states or complains of)
Objective data (assessment findings; significant findings from lab, v/s, physical assessment, etc.)
Assessment (pull your information together both subjective and objective; formulate nursing diagnosis)
Plan (treatments, meds, etc. as well as teaching/education, recommendations, and follow up)

12. Nursing Care Plan and Nursing Diagnoses (20pts) with outcomes (goals) & interventions with rationale. (Use SMART acronym as reminder)

13. References (5pts) (Use APA format; you should be using your fundamentals book, gerontology text book, nursing diagnosis book, and possibly your drug book, lab/diagnostics reference book, med-surg book, etc.)

100 points total

Geriatric Assessment Form

History
1) Biographical Data
Date of visit______02/07/14 02/14/14_______________________________

Client’s Name (Initials only) _______________________________Age___92__ DOB _06/06/22__________Sex___M___

Race__India_____________ Language: Spoken_English, Hendi_____ Understood _______yes_____________

Advance Directives: (Living Will, DPOA, DPOA-HCD, etc.) __living will- son____________________________

Insurance:
Primary: _____Medicare___________________________________________
Secondary: ____Bluecross blueshield__________________________________________

2) Source of Information (informant and reliability):

Chief Complaint/ Present Illness or present health status: (use old cart) O became blind about 5 years ago
L eyes-blind
D permanent
C fall risk
A cannot see, uses walker, wife assist with ADL’s
R T eye drops help with eye dryness

3) Past Medical History:
Allergies: morphine, hydrocodone, cipro, sulfa, penicillin

Immunizations: influenza shot and pneumonia shot

Illnesses: glaucoma, htn

Past surgical history: cholecystectomy, appendectomy, hip replacement, hernia surgery, eye surgery

Transfusions: no transfusions

Falls: 01/2012

4) Developmental Data:
Occupation: business man, owned a liquor store in India, owned a sandwich shop in America Volunteer activities and hobbies handyman- likes to make furniture Adult Developmental Stage & supporting statement: Integrity- he feels like he had a successful life Mini-Mental Health Exam/Geriatric Depression Scale results: (see last section for exam) 19/30 5) Social History/Habit/Current Issues

Environment: safe and clean
Driving: cannot drive
Sleep: sleeps most of night, wakes x2 BR
Elimination: normal BM
Exercise: daily exercise activity, walks the halls with wife Nutrition (use nutritional screening tool, Gerontologic Nursing, p. 180, list score and risk status): 13- normal nutritional status Use of tobacco, coffee, tea, cola, laxatives no tobacco or alcohol use. Drinks hot tea HS Sexuality: married

6) Family Health History:
Married, divorced, widowed: married, wife
Children: 2 sons
Place of birth: Bomboi, India
Health status of living parents or siblings: both parents and all siblings have passed Cause of death for parents or siblings: old age
Church affiliations: parsee- religion
Social groups or support: one son lives here and 2 granddaughters

7) Review of Systems (This is what you ask the client; review pp.60-62, Gerontologic Nursing) General (what is client’s perception of his/her health)
HEENT:
Neck/Lymph: pt has full ROM in neck. Pt stated no pain in neck area

Respiratory: pt states SOB on exertion

Cardiovascular: no c/o chest pain. Pt states he has high BP

GI/GU: pt states he takes fiber daily for constipation

Musculoskeletal: pt denies any muscular pain or pain on ambulation

Neurological: pt states no memory or concentration problems

Endocrine: pt states he is not diabetic

Hematologic: pt states no blood disorders

Dermatologic: pt states no skin cancer or present acne

Psychological: pt states somewhat depressed but happy to be alive

8) Functional Assessment
Activities of Daily Living
Feeding with guidance
Bathing needs assistance
Dressing needs assistance
Toileting needs assistance
Grooming needs assistance
Instrumental activities of Daily Living
Preparing meals facility prepares meals, son will sometimes bring culture food items Shopping son will shop for them
Managing money son manages money
Performing laundry tasks son takes laundry home
Housekeeping chores wife helps with cleaning, facility does weekly housekeeping Communication such as using phone, opening mail, responding to mail, ability to drive Uses home phone with assistance, son manages mail, can no longer drive 9) CURRENT MEDICATIONS (should list what, how much/when, and why) Prescriptions & OTC

Medication
Dosage & Frequency
Indication (taking for ?)
Additional Information
lasix
20 mg qd
edema

asprin
81 mg qd
CVA prevention

finasteride
5 mg qd
BPH

metoprolol
50 mg qd
htn

Muro 128 opth
5% one gtt qd
glaucoma
Right eye
norvasc
5 mg HS
htn

fluorometholone
0.1% one gtt
Chronic eye inflammation
QID
flomax
0.4mg HS
BPH

travatan
0.004% one gtt
glaucoma
Both eyes
Artificial tears
QID
Dty eyes

10) Physical Assessment (your assessment, observations, etc.) Vital Signs: BP: 119/55 HR: 53 Resp.Rate: 18 T:95.9 Ht/Wt:62 in /141lbs BMI:22 Senses: hearing, vision totally blind, hearing aides both ears General perception (well/ill appearing) looked well but tired Skin moist, warm, no lesions, no rashes

HEENT:
Head: head round and of proportion, no lesions, no headaches Ears: symmetrical, hearing aides
Eyes: blind
Nose: no obstruction
Mouth/throat: upper and lower dentures
Neck & Lymph: no jvd, trachea midline
Chest:
Thorax: atropohic, symmetric
Lungs: lung sounds clear bilaterally
Heart: s1, s2 regular heart sounds
Abdomen: hypoactive bowel sounds
GI/GU (optional)
Musculoskeletal: gait steady, uses walker
Extremities: skin warm and moist, palpable bilateral pedal pulses Neurological: alert oriented x4
Cranial nerves: pt blind and cannot follow movement
11) Evaluation: SOAP note (Potter & Perry, Fundamentals of Nursing, p. 391;SOAP note instructions at the end of this document following Reference page): S: c/o blindness, not able to care all for himself O: observed pt wife assisting client with bathroom assistance and other ASL’s A: depression r/t self care deficit

P: social interactions/activities Conclusion: When asked, “Is there any additional information that we have not talked about that would be important for me to know?” the client/family responded: “No, I’m ready to nap.” Care plan: As listed in your syllabus:

12) Nursing Care Plan

The Nursing Care Plan links theory to clinical practice via a written table. Care Plans facilitate organization of data and application of theory to developing plans of care for individual clients. The following format is to be used to develop a client care plan:

ITT Technical Institute
Associate of Science in Nursing
Nursing Care Plan
Client initials: _RF______Client age: _92_____ Support system: __wife, son_____________________________ Admitting diagnosis: hip fracture__________________________________________________________ Secondary diagnoses: blindness__________________________________________________________

Preclinical Data Assessment and Development of Plan of Care Revision Notes

Admission (summarize events leading up to point of admission): He fell in 2010 caused him to have a fractured hip.
He was admitted because of blindness and hip fracture

Summary of current visit history (summarize client course since admission): He does not really like to be here but he tries to be happy for his wife. They walk around and talk to people and engage in activities together. His wife helps a lot with taking care of him.

Client social/cultural/spiritual/developmental/support system/environmental factors: Does engage in facility activities. Does not usually leave the facility due to blindness. Religion is parsee, they have a temple in India but here in America they do not celebrate their religion.

Current treatments and medications (list any treatments; list meds if any other than previous list): He gets several eye frops for his dry eyes and glaucoma.

Pertinent lab/X-ray/diagnostic procedure results (abnormal values only): 1/27/2010 left hip hemiarthroplasty

Significant assessment findings:
Overall in great health
He does seem to feel helpless and powerless
Because he is blind and needs so much help with ADL’s

Nursing Care Plan
Priority nursing diagnoses (3 diagnoses) and one goal/outcome for each (timed & measurable)

Nursing diagnosis a).self care deficit r/t blindness
Goal: pt will identify what is useful in optimizing the autonomy and independence of the pt by the end of shift today.

Nursing diagnosis b). fall risk r/t blindness
Goal: pt will remain free of any falls today.

Nursing diagnosis c). ineffective coping r/t loss of vision
Goal: pt will remain free of destructive behavior toward self or others on today’s shift.

Use your Nursing Diagnosis book:
Priority nursing interventions (interventions/implementation): 7 interventions (with rationale) for each diagnosis, timed and measurable, where applicable.

Interventions:
1a maintain individuality with hairstyle, jewelry, clothing, everyday with dressing
Rationale: helps define a persons identity and promote self esteem

2a encourage client to help as much as possible with ADL’s everyday
Rationale: performing self care helps maintain independence

3a provide explanation of everything you do every shift
Rationale: this will reduce anxiety

4a include regular exercise and walking program in plan of care BID
Rationale: exercise improves functional abilities

5a provide privacy and preserve dignity every care interval
Rationale: maintains their autonomy

6a teach family members to see dressing as an opportunity to promote independence and better quality of life
Rationale: this is a time to retain independence

7a involve the client in planning of care
Rationale: it is important for the client to be involved with their health plan

Interventions:
1b staff will instruct client to wear proper foot wear and the beginning of the day
Rationale: this will prevent client from slipping and falling

2b keep walker and wheelchair in easy reach at all times throughout the day
Rationale: pt will have less chance of falling if walker is in easy reach

3b encourage resident to use nursing call cord throughout the day
Rationale: so pt will have easy access to help when needed

4b thoroughly orient pt to environment daily
Rationale: this will help guide pt

5b avoid use of restraints every shift
Rationale: there is no increase in falls without a restraint

6b use a high risk sign on door everyday
Rationale: this will alert others

7b keep room free of clutter TID. Keep a clean pathway
Rationale: this will prevent anything in the way of causing a fall

Interventions:
1c when caring for resident everyone should use verbal and nonverbal therapeutic communication approaches including empathy, active listening, encourage client to express emotions.
Rationale: communication skills contribute to the well being of clients and minimizes psychosocial factors

2c encourage client to describe previous stressors and mechanisms used during daily assessment
Rationale: identifying symptoms can decrease depression

3c be supportive of coping behaviors, allow client to relax
Rationale: a supportive relationship has a positive effect on coping

4c encourage use of social support resources every week
Rationale: high levels of social support improves coping

5c actively listen to complaints and concerns every shift
Rationale: quality of care can be improved by active listening

6c engage the client in reminiscence anytime you communicate with the client
Rationale: life reviews as an intervention had a significant effect of lowering depression

7c teach relaxation techniques to be used once a day
Rationale: mindful mediation was found to promote health promotion

Mini-Mental Status Examination

The Mini-Mental Status Examination offers a quick and simple way to quantify cognitive function and screen for cognitive loss. It tests the individual’s orientation, attention, calculation, recall, language and motor skills.

Each section of the test involves a related series of questions or commands. The individual receives one point for each correct answer.

To give the examination, seat the individual in a quiet, well-lit room. Ask him/her to listen carefully and to answer each question as accurately as he/she can.

Don’t time the test but score it right away. To score, add the number of correct responses. The individual can receive a maximum score of 30 points.

A score below 20 usually indicates cognitive impairment.

The Mini-Mental Status Examination

Initials of pt: ____________________________________ DOB: __________________

Years of School: ____________________________ Date of Exam: ___________

Orientation to Time Correct ______ Incorrect ______

What is today’s date? ___________________

What is the month? ___________________

What is the year? ____________________

What is the day of the week today? _________________

What season is it?

Total: ____ /5

Orientation to Place

Whose home is this?

What room is this?

What city are we in?

What county are we in?

What state are we in?

Total: ____ /5

Immediate Recall

Ask if you may test his/her memory. Then say “ball”, “flag”, “tree” clearly and slowly, about 1 second for each. After you have said all 3 words, ask him/her to repeat them – the first repetition determines the score (0-3):

Ball

Flag

Tree

Total: ____ /3

Ask the individual to spell the word ”WORLD” backwards. The score is the number of letters in correct position.

D

L

R

O

W

Total:_____ /5

Delayed Verbal Recall

Ask the individual to recall the 3 words you previously asked him/her to remember.

Ball

Flag

Tree

Total: _____ /3

Naming

Show the individual a wristwatch and ask him/her what it is. Repeat for pencil.

Watch

Pencil

Total:______/2

Repetition

Ask the individual to repeat the following:

“No if, ands, or buts”

Total ____/1

3-Stage Command

Give the individual a plain piece of paper and say, “Take the paper in your hand, fold it in half, and put it on the floor.”

Takes

Folds

Puts

Total ____/3

Reading

Hold up the card reading: “Close your eyes” so the individual can see it clearly. Ask him/her to read it and do what it says. Score correctly only if the individual actually closes his/her eyes.

Total __/1

Writing

Give the individual a piece of paper and ask him/her to write a sentence. It is to be written spontaneously. It must contain a subject and verb and be sensible.

Total____/1

Copying

Give the individual a piece of paper and ask him/her to copy a design of two intersecting shapes. One point is awarded for correctly copying the shapes. All angles on both figures must be present, and the figures must have one overlapping angle.

Total ___/1

Total Score:_____ /30

*Your evaluation of this exam: (using your book, state if the client has cognitive impairment or not based on this tool)

Geriatric Depression Scale: Short Form
Choose the best answer for how you have felt over the past week:

1. Are you basically satisfied with your life? YES / NO
2. Have you dropped many of your activities and interests? YES / NO 3. Do you feel that your life is empty? YES / NO
4. Do you often get bored? YES / NO
5. Are you in good spirits most of the time? YES / NO
6. Are you afraid that something bad is going to happen to you? YES / NO 7. Do you feel happy most of the time? YES / NO
8. Do you often feel helpless? YES / NO
9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO 10. Do you feel you have more problems with memory than most? YES / NO 11. Do you think it is wonderful to be alive now? YES / NO

12. Do you feel pretty worthless the way you are now? YES / NO 13. Do you feel full of energy? YES / NO
14. Do you feel that your situation is hopeless? YES / NO
15. Do you think that most people are better off than you are? YES / NO

Answers in bold indicate depression. Score 1 point for each bolded answer. A score > 5 points is suggestive of depression.
A score ≥ 10 points is almost always indicative of depression. A score > 5 points should warrant a follow-up comprehensive assessment. Source: http://www.stanford.edu/~yesavage/GDS.html
*YOUR EVALUATION OF THIS EXAM: (using your book, state if the client has depression or not based on this tool)

13. List books in APA format used in this care plan: Fundamentals, Gerontology text, nursing diagnosis book, drug book, etc.) References

SOAP note instructions
1
Write the "S" or subjective section. This includes everything the client reports. Information in this section usually relates to the client's complaint in his own words and includes any reported symptoms, their severity and their duration. Record the subjective information --- the "S" in SOAP --- to document symptoms and complaints as reported by the client in her own words. Include symptom examples, such as pain, vomiting and diarrhea. Document the frequency, onset, location and duration of symptoms.

2
Write the "O" or objective section. This section details any information you observe while listening to the client's complaints and performing an examination. If you notice ankle swelling as the client reports pain, this is the section where you record it. Take measurements and vitals, such as oxygen saturation, blood pressure and pulse to document objective information. This is the "O" in SOAP. Include measurable signs, such as lab test results, vitals, weight and height, in the objective data section. Perform a head-to-toe clinical exam of the client's body's systems to rule out various diagnoses. Document exam findings in the "O" section. 3

Write the "A" or assessment section. Here, you include your diagnostic nursing assessment, as well as any lab test results you perform. If you are monitoring rather than assessing a client, you note any changes in the client's condition here. Offer a nursing diagnosis in the "A" or assessment section, which includes both subjective and objective information. Confirm and synthesize subjective and objective notes to create assessment data. Record a nursing diagnosis, such as "at risk for a sexually transmitted infection," in this section. Record, for example, "client complains of shortness of breath" in the subjective section. Document "client is wheezing in left and right upper lobes upon auscultation" in the objective section after performing a clinical exam. Record "client is short of breath" in the assessment section as confirmation of data reported in the subjective and objective sections. 4

Write the "P" or plan section. This is the plan for treatment, including what medications or other therapies you will administer or advise. This section should be actionable and thoroughly map out the course of treatment, as well as the intended outcomes and any necessary follow-ups, referrals or additional testing that is needed. Document the "P," which is the "plan" of treatment, last. Record long and short-term treatment actions, such as "antibiotic therapy," "follow-up X-ray in three weeks," "client education about Foley catheter insertion" or "physical therapy consult." Include relief measures or actions that worsen the client's symptoms. Provide an evaluation of the success or failure of treatment interventions.

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