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Trinity Valley Community College

Associate Degree Nursing Program

Level I – Geriatric Assessment Rubric

Your Name:

Date:

Resident’s Initials:

Name of Clinical Instructor:

Name of Facility:

Total Points (earned/possible): /26

Area

Complete 2 Points

Partial 1 Points

Insufficient 0 Points

Weight

Points

Section 1: Assessment (Clinical Judgment)

1a. Assessment:

Demographic Data

Fills in all blanks with appropriate data

[4 or fewer inappropriate or missing;

Highlights abnormal data except 4 or fewer instances of highlighting normal data or not highlighting abnormal data

Fills in blanks with appropriate data except 5-6 inappropriate or missing;

Highlights abnormal data except 5-6 instances of highlighting normal data or not highlighting abnormal data

Fills in blanks with appropriate data except

more than 7 inappropriate or missing;

Highlights abnormal data except more than 7 instances of highlighting normal data or not highlighting abnormal data

[X1]

Total Possible: 2

Earned:

1b. Assessment:

Subjective Data


Except 4 or fewer inappropriate or missing;




Fills in blanks with appropriate data except more than 7 inappropriate or missing;


[X2.5]

Total Possible: 5

Earned:

1c. Assessment

Objective Data


Except 4 or fewer inappropriate or missing;




Fills in blanks with appropriate data except more than 7 inappropriate or missing;


[X2.5]

Total Possible: 5

Earned:

Section 2. Resident’s Problems (Clinical Judgment)

2a. Formulate Three Problems

(Clinical Judgment)

3 Patient Problems with its supportive data AND etiology

3 Patient Problems with its supportive data AND etiology except missing 1 patient problem and supportive data AND/OR etiology

3 Patient Problems with and its supportive data AND etiology except missing >1 patient problem and supportive data AND/OR etiology

[X2]

Total Possible: 4

Earned:

2b. Resident Problems

Prioritized (PCC)

3 Patient Problems Labeled & Prioritized by Maslow’s Hierarchy

2 Patient Problems Labeled & Prioritized by Maslow’s Hierarchy

One Patient Problems Labeled & Prioritized by Maslow’s Hierarchy

[X1]

Total Possible: 2

Earned:

Section 3. Environment (Safety)

Environment

(Safety)

List of identified hazards AND corresponding recommendations. If environment is hazard-free, then writes one paragraph describing the environment

List of identified hazards AND corresponding recommendations, except missing 1 hazard/recommendation OR 1 inappropriate recommendation OR If environment is hazard free and environmental descriptive paragraph is two to four sentences.

List of identified hazards AND corresponding recommendations

Missing ≥2 hazard AND/OR incorrect recommendation OR if environment is hazard-free and descriptive paragraph is less than two sentences.

[X1]

Total Possible: 2

Earned:

Section 4. Nutrition (Critical Thinking)

Nutrition

(Critical Thinking)

Lists two or more nutrition recommendations

Lists one nutrition recommendation

Missing nutrition recommendations

[X1]

Total Possible: 2

Earned:

Section 5. Team work & Collaboration (Critical Thinking)

Team work & Collaboration (Critical Thinking)

Identifies 5 or more resources already available that is used or not used by the client.

Identifies 3 or 4 resources already available that is used or not used by the client.

Identifies 2 or fewer resources already available that is used or not used by the client or omits paragraph.

[X1]

Total Possible: 2

Earned:

Section 6. APA References

APA References

All references alphabetized with APA format: Author, year, title, and journal.

All references alphabetized with APA format except one or two kinds of errors made of author, year, title, journal

All references not alphabetized and/or with APA format except three or more kinds of errors made of author, year, title, journal

[X1]

Total Possible: 2

Earned:

N:\ADN Syllabus\CBC\Curriculum\Level 1 - Fall 2014\Geriatric Assessment Rubric

298

Trinity Valley Community College

Associate Degree Nursing Program

Level I – Geriatric Assessment

Directions: For this entire document, do the following: 1.) Fill ALL answer blanks. Use “N/A” for “not applicable”, if it does not apply. You may also use “UTA” for “unable to assess” but be certain that you are only using this because you truly cannot assess. For check boxes, click in the box to make an “X” to mark that box; click the box again if you need to remove the “x”. Note: A paragraph includes at least five complete sentences.

SECTION 1: ASSESSMENT

Directions: For the “Assessment” sections, use yellow to highlight any abnormal data.

Section 1a: Demographic Data

Demographics Assessment: Healthcare Concept – Diversity

Age:

Gender:

Race:

Ethnicity:

Religion:

Do your spiritual beliefs apply to your health?

☐ Yes

☐ No

If Yes explain:

☐ Affects treatment decisions

☐ End-of-life care

☐ Special dietary needs

☐ Use of Faith/Folk healer

☐ Other:

Years of Education completed / Degrees Conferred:

Past Employment (Career):

Section 1b: Subjective Data

Social Support Assessment: Healthcare Concept - Coping

Emotional support available:

Support System(s), Especially when there are problems:

☐ Yes

☐ No

☐ Case worker

☐ Children

☐ Family

☐ Friend

☐ Guardian

☐ Pet

☐ Religious leader

☐ Sibling

☐ Spouse

☐ Support group

☐ Therapist

☐ Other:

Health History

Medical History:

Surgical History:

Accidents or Injuries: Describe and Year Occurred

How do you define health?

How do you view your own health now?

What are your concerns?

What are your health goals?

Self and Family History

(only highlight abnormal data in “Self” column)

Self and Family History

Self

Mother

Father

Heart Disease

High Blood Pressure

Stroke

Diabetes

Blood Disorders

Cancer

Sickle Cell Anemia

Arthritis

Obesity

Kidney Disease

Tuberculosis

Mental Illness

Seizures

Table 1: Self and Family History of Diseases

Allergies: Healthcare Concept – Immunity

Allergies

Drug Name

(example below)

Food Name

Adverse Reaction(s)

generic, Brand

n/a

macular rash on arm and chest

Table 2: Drug and Food Allergies

Childhood Illnesses

& Immunizations:

☐ Shingles vaccine / Date received:

☐ Influenza (flu) vaccine /Date received:

☐ Pneumococcal vaccine / Date received:

☐ Tetanus, diphtheria, pertussis (Tdap) vaccine / Date received:

Current Medications

Medication Name

(Example below)

Medication Reason

Dosage

Frequency

Side Effects

Adverse Reaction

generic, Brand

high blood sugar

Xmg

once in AM

nausea

anaphylaxis

Table 3: Current Medications

Able to verbalize all home medications:

☐ Accurately

☐ Inaccurately

Manages medication administration:

☐ Independently

☐ Effectively with assistance or dependent

Nutritional Screen: Healthcare Concept – Nutrition

Usual Weight:

Appetite:

☐ Good

☐ Fair

☐ Poor

☐ Other:

Unintentional weight change greater than 10 lbs. in the last 6 months:

☐ Yes

☐ No

Weight gain:

☐ Yes

☐ No

Weight loss:

☐ Yes

☐ No

Diet:

☐ NPO

☐ Regular

☐ Bland

☐ Diabetic

☐ Dysphagia

☐ Ground

☐ Low cholesterol

☐ Kosher

☐ Low fat

☐ Low sodium

☐ Mechanical soft

☐ No added salt

☐ Pureed

☐ Renal

☐ Vegetarian

Eating difficulties:

☐ Chewing

☐ Loose teeth

☐ No teeth

☐ Dysphagia

☐ Dentures (poor fitting)

If eating difficulties present, describe the problem:

Nutritional Risk Factors:

If present, ask and describe history of problem.

Constipation

Eating Disorder

Enteral Feedings

Impaired Nutritional Intake

Fluid intake < 50% of normal in last three days

Nausea/Vomiting/Diarrhea

History of Skin Breakdown/Decubitus Ulcers

Meal

Time

Type of diet and contents of food served

% of meal consumed

Breakfast

Lunch

Afternoon snack

Dinner

HS snack

Functional Assessment: Healthcare Concept – Functional Ability

Functional Assessment

Independent (2)

Requires assistance (1)

Dependent (0)

Comment

Bathing

Dressing

Toileting

Transferring

Continence

Feeding

ADL Index Score

12 = Total independence

6 = Moderate independence

0 = Maximum dependence

Total

Table 5: Functional Assessment

Fall Risk Assessment #1

Directions: Give one point for each “Core Element” that is true for the individual. Total the points at the bottom.

Core Element

Definitions

POINTS

Age 65+

Advancing age increases the risk of a person falling.

Resident history of falls within 3 months

Fall definition, “An unintentional change in position resulting in coming to rest on the ground or at the lower level”

Incontinence

Inability to make it to the bathroom or commode in a timely manner. Includes frequency, urgency, and / or nocturia

Visual Impairment

Includes macular degeneration, diabetic retinopathies, visual field loss, age related changes, decline in visual acuity, accommodation, glare tolerance, depth perception & night vision or not wearing prescribed glasses or having the correct prescription

Impaired functional mobility

May include residents who need help with ADLS or IADLS or have gait or transfer problems, arthritis, pain, fear of falling, foot problems, impaired sensation, impaired coordination or improper user of assistive devices

Environmental Hazards

May include poor illumination, equipment tubing, inappropriate footwear, pets, hard to reach items, floor surfaces that are uneven or cluttered, or outdoor entry and exits

Poly Pharmacy

(4 or more prescriptions)

Drugs highly associated with fall risk include but not limited to, sedatives, antidepressants, tranquillizers, narcotics, antihypertensive, cardiac medications, corticosteroids, anti-anxiety drugs, anticholinergic drugs and hypoglycemic drugs

Pain Affecting

Function

Pain often affects an individual’s desire or ability to move or pain can be a factor in depression or compliance with safety recommendations

Cognitive Impairment

Could include residents with dementia, Alzheimer’s or stroke residents, or residents who are confused, use poor judgment, have decreased comprehension, impulsivity, memory deficits. Consider residents ability to adhere to the plan of care

Total Points------------------

Table 6: Falls Risk Assessment #1

****A Score of 4 or More is Considered at Risk for Falling****

If your resident scored a 4 or greater, then your resident MUST RECEIVE safety teaching. Write a paragraph below and explain the safety teaching you provided to your resident:

Sleep Assessment: Healthcare Concept – Sleep

Average hours of sleep

Usual bedtime:

Usual awake time:

Do you feel rested after you sleep?

☐ Yes

☐ No

Quality of sleep:

☐ Poor

☐ Fair

☐ Good

☐ Poor

Sleep problems:

☐ Difficulty falling asleep

☐ Difficulty remaining asleep

☐ Night awakenings

☐ Nightmares

Pain Assessment: Healthcare Concept – Comfort (Pain)

Pain History:

Location: Where is your pain?

Quality: Tell me what your discomfort feels like

Intensity: On a scale of 0-10 with “0” representing no pain and “10” representing the worst possible pain, how would you rate your

pain?

Pattern: When did or does the pain start?

How long have you had the pain, or how long does it last?

Do you have pain free periods? When? For how long?

Precipitating factors: What triggers the pain or makes it worse?

Alleviating factors: What measures or methods have you found helpful in lessening or relieving the pain?

Effect of pain on:

None

Very mild

Mild

Moderate

Severe

Very Severe

Daily life

Sleep

Appetite

Relationships

Emotions

Concentration

Table 7: Pain Affects

Section 1c: Objective Data

Mental Status Assessment: Health Care Concept – Cognition

General Appearance of the Resident

Grooming Appearance:

☐ Well

☐ Fair

☐ Poor

☐ Disheveled

Hygiene Appearance:

☐ Well

☐ Fair

☐ Poor

Posture Appearance:

☐ Normal

☐ Relaxed

Behavior

☐ Stiff

of the

☐ Slumped

Resident

Speech

☐ Clear

☐ Disorganized

☐Dysarthria

☐ Expressive aphasia

☐ Loud

☐ Monotone

☐ Rapid

☐ Slow

☐ Soft

Affect:

☐ Anxious

☐ Depressed

☐ Elated

☐ Happy

☐ Irritable

☐ Labile

☐ Sad

☐ Other:

Cognition of the Resident

Screening Tool: The Mini-Mental State Examination (MMSE)

Maximum

Score

5

Orientation

· What is the (year) (season) (date) (day) (month)?

5

· Where are we (state) (country) (town) (facility) (unit or hallway)?

3

Registration

· Name 3 objects: 1 second to say each. Then ask the resident all 3 after you have said them. Give 1 point for each correct answer. Then repeat until he/she learns all 3. Count attempts and record Attempts:

5

Attention and Calculation

· Serial 7’s. 1 point for each correct answer. Stop after 5 answers. Alternatively spell, “world” backward.

3

Recall

· Ask for the 3 objects repeated above. Give 1 point for each correct answer.

2

Language

· Name a pencil and watch.

1

· Repeat the following, “No ifs, ands or buts.”

3

· Follow a 3-stage command:

“Take a paper in your hand, fold it in half and put it on the table.”

1

· Read and obey the following: CLOSE YOUR EYES.

1

· Write a sentence

1

· Copy the design shown.

Table 8: MMSE

Assess level of consciousness along a continuum (circle one): ALERT—DROWSY—STUPOR--COMA

Total Score:

(Interpretation of score: 27 is the average expected score; 18-23 suggests dementia and delirium (mild cognitive impairment); 0-7 suggests severe cognitive impairent.)

MMSE adapted from:

“Mini-Mental State.” A Practical Method for Grading the Cognitive State of Patients for the Clinician. Journal of Psychiatric Research, 12(3): 189-198, 1975.

Respiratory Assessment: Health Care Concept – Gas Exchange

Directions: Choose one word below and write it in the lobe you auscultated. Do this for each lobe you auscultated.

· Clear

· Course crackles

· Fine crackles

· Rhonchi

· Stridor

· Wheezes (expiratory)

· Wheezes (inspiratory)

· Wheezes (Insp. & exp.)

Anterior:

RUL:

LUL:

Posterior:

LUL:

RUL:

RML:

LLL:

LLL:

RLL:

RLL:

Table 9: Respiratory Sounds

SPO2: ☐ Room Air or ☐ O2 (if O2, how many L/min = )

Respiratory Effort

☐ dyspnea

☐ DOE (dyspnea on exertion)

☐ Use of accessory muscles

Respiratory Pattern

☐ effortless

☐ deep

☐ gasping

☐ tachypneic

☐ labored

☐ shallow

☐ grunting

☐ bradypneic

Coughing

☐ none

☐ wet productive; color:

☐ wet nonproductive

☐ dry

☐ strong

☐ weak

Oxygen Delivery System

☐ room air

☐ aerosol

☐ nasal cannula L/min:

☐ simple face mask

Cardiovascular Assessment: Health Care Concept -Perfusion

Height (Feet & Inches):

Weight:

(Pounds)

Ideal body weight (range):

Source:

Vital signs:

T:

P:

R:

B/P:

Which arm?

Sitting:

Standing:

Apical Rate:

/min

Rhythm:

☐ Regular

☐ Irregular

☐ S1

☐ S2

Pacemaker:

☐ Yes

☐ No

Jugular Vein Distention:

☐ Yes

☐ No

Capillary refill time (CRT):

Arterial Pulses: (grade on 0-4 scale)

Site

Right

Left

Carotid

(Do NOT do at same time.)

Brachial

Radial

Femoral

Post tibial

Dorsalis pedis

Table 10: Pulses

Gastrointestinal Assessment: Health Care Concept – Elimination

Contour:

☐ Flat

☐ Rounded

Symmetry:

Pigmentation & Color:

Scars

Umbilicus:

Striae:

Respiratory movement:

Masses, nodules:

Pulsations:

Drains, tubes:

Intestinal diversions:

Urinary diversions:

Bowel sounds:

Vascular sounds: (aortic bruit)

Continence:

Tenderness or pain:

Rebound tenderness:

Rectal

Fissures:

Hemorrhoids:

Other:

Comments:

Skin & Extremities Assessment: Healthcare Concept - Tissue Integrity

Skin Color:

☐ Normal for ethnicity

☐ Ashen

☐ Cyanotic

☐ Flushed

☐ Jaundice

☐ Pale

☐ Mottled

☐ Other

Variations in skin color:

☐ Birthmarks

☐ Calluses

☐ Freckles

☐ Moles

☐ Stria

☐ Other

If any variations present, document location:

Skin Temperature:

☐ Warm

☐ Cold

☐ Cool

☐ Hot

☐ Other

Skin Turgor:

☐ Elastic

☐ Tenting

☐ Other:

Nail Description:

☐ Groomed

☐ Bruised

☐ Clubbed

☐ Dirty

☐ Yellow

☐ Ridged

☐ Smooth

☐ Thick

☐ Thin

☐ Brittle

☐ Ingrown

☐ Inflamed

Hair Description:

☐ Absent on extremities

☐ Absent on head

☐ Alopecia

☐ Coarse

☐ Brittle

☐ Dry

☐ Fine

☐ Oily

☐ Shiny

☐ Soft

Braden Skin Assessment

For Predicting Pressure Sore Risk

(Note: Use your textbook to learn how to score the Braden)

Sensory perception

Completely limited = 1

Very limited = 2

Slightly limited = 3

No impairment = 4

Moisture

Constantly moist = 1

Moist = 2

Occasionally moist = 3

Rarely moist = 4

Activity

Bedrest = 1

Chairfast = 2

Walks occasionally = 3

Walks frequently = 4

Mobility

Completely immobile = 1

Very limited = 2

Slightly limited = 3

No limitations = 4

Nutrition

Very poor = 1

Probable inadequate = 2

Adequate = 3

Excellent = 4

Friction and Shear

Problem= 1

Potential problem = 2

No apparent problem = 3

Total

Table 11: Braden Scale

Note: A Braden score of 18 or lower indicates risk for pressure ulcers. If your resident’s Braden score is 18 or less, then write one paragraph below about what protective measures are in place OR need to be in place to help protect the client from developing or worsening pressure ulcers:

Musculoskeletal Assessment: Health Care Concept - Mobility

Gait:

☐ Steady

☐ Asymmetrical

☐ High stepping

☐ Dragging

☐ Jerky

☐ Shuffling

☐ Spastic

☐ Staggering

☐ Stiff

☐ Unsteady

☐ Wide based

☐ Unable to assess

☐ Other:

Evaluation of bilateral muscle strength

Strength

Evaluate hand grip strength

Muscle Tone

Sensation

Range of Motion (ROM)*

LLE

LUE

RUE

RLE

* ROM – Document Full motion active (preferred) or passive, limited motion active or passive, pain with movement, unable to move

Resident follows instructions to release the hand when assessing grip strength: ☐ Yes ☐ No

Muscle size and Symmetry:

☐ Symmetrical

☐ Asymmetrical

☐ Atrophy

☐ Spasms

☐ Smooth, fluid motion

Muscle tenderness:

☐ Yes

☐ No

If yes, document location and severity:

☐ Mild

☐ Moderate

☐ Severe

Joint tenderness:

☐ Yes

☐ No

If yes, document location and severity:

☐ Mild

☐ Moderate

☐ Severe

Spinal Assessment:

☐ Normal

☐ Kyphosis

☐ Lordosis

☐ Scoliosis

Activity limitations

☐ Yes

☐ No

If yes, document location and describe the limitations:

Sensory Function Assessment: Health Care Concept - Sensory Perception

Perform Fingertip-to-nose Touch Test on resident:

☐ WNL

☐ Abnormal

Comment:

Fall Risk Assessment #2: - Healthcare Concept – Safety

Morse Fall Risk Assessment

Yes

No

Response points

Points

History of Falling immediate or in the last three months

Yes response = 25

Presence of secondary diagnosis

Yes response = 15

Use of ambulatory aid

Furniture =30 Crutches, cane, walker = 15

IV/Heparin lock

Yes response =20

Gait/Transferring

Impaired = 20

Weak =10

Mental Status

Forgets limitations = 15

Total Score:

0-44 indicates need for standard environmental safety precautions.

A score of 45 or > will add a problem “At Risk for Falls” to the problem list. Please initiate the Fall Prevention Plan of Care.

Total:

Table 13: Fall Risk Assessment #2 (Morse Fall Risk)

Assessment of Environment for Safety Hazards: Healthcare Concept – Safety

Is there good lighting available?

☐ Yes

☐ No

Is temperature of home within a comfortable range?

☐ Yes

☐ No

Are there loose extension cords, small sliding rugs, and slippery linoleum tiles present?

☐ Yes

☐ No

If yes; describe:

Are the edges of rugs tacked down?

☐ Yes

☐ No

Are electrical cords in good condition?

☐ Yes

☐ No

Is furniture arranged to allow for free movement in heavily traveled areas?

☐ Yes

☐ No

Is furniture sturdy enough to give support?

☐ Yes

☐ No

Is furniture designed to accommodate easy transfers on and off?

☐ Yes

☐ No

Is there a telephone present?

☐ Yes

☐ No

Are smoke detectors present?

☐ Yes

☐ No

Are there grab bars in the bath, in shower, and around the toilet?

☐ Yes

☐ No

Erickson’s Stages: Healthcare Concept - Human Development

Directions: Answer the following:

Erikson’s Stage (Consult your text and be sure to select stage associated with your resident’s age):

Write a paragraph and explain one example of how the resident is meeting the above Erikson’s stage:

SECTION 2 RESIDENT’S PROBLEMS

Section 2a: Formulate Three Resident Problems

Directions: Complete the table below.

Step One: Copy ALL of the abnormal data you highlighted above in section one into the appropriate concept problem boxes in Table 14 below.

EXAMPLE: Step One:

Concept: Elimination

Patient Concept Problem: Impaired Elimination

Abnormal Data: inactivity, constipation, too little fluid intake

Etiology

Step Two: Next, choose any THREE of the Health Concept Problems in Table 14, and for each one, determine one cause (etiology) for the concept problem and write that on the etiology side of the table. Note: You may have many pieces of abnormal data in the Health Concept Problem, but choose only one as a cause for the problem. Note that some of the abnormal data may be a clinical manifestation or a problem. Remember the etiology causes the problem. (See example below.)

EXAMPLE: Step Two

Elimination

Impaired Elimination: constipation

related to

inactivity, constipation, too little fluid intake, “I feel constipated.”

Etiology

inactivity

Table 14: Healthcare Concept Problems

Health Concept

related to

Health Concept Problem

Etiology

Cognition

Impaired Cognition:

Comfort

Pain:

Coping

Maladaptive Coping:

Elimination

Impaired Elimination:

Functional Ability

Impaired Functional Ability:

Gas Exchange

Impaired Gas Exchange:

Human Development

Impaired Human Development:

Immunity

Impaired Immunity:

Mobility

Impaired Mobility:

Nutrition

Malnutrition:

Perfusion

Impaired Perfusion:

Safety

Impaired Safety:

Sensory Perception

Impaired Sensory Perception:

Sleep

Impaired Sleep:

Tissue Integrity

Impaired Tissue Integrity:

Table 14: Health Concept Problems

SECTION 2B: PRIORITIZING RESIDENT’S PROBLEMS

Directions: Place each of your resident problems with etiology (problem statement) in rank order with the first one listed being the most important. Use Maslow’s Hierarchy (consult your textbook) to guide you in ranking your resident’s three problem statements. Include a rationale for the ranking for each problem statement.

Ranking

Resident’s Problem Statement

Rationale for Ranking

First

Second

Third

SECTION 3: ENVIRONMENT

Directions: Provide recommendations for all identified safety, environmental and/or hazardous problems from the “Assessment of Environment for Safety Hazards” in this assessment form. Complete one paragraph describing all hazards identified; if no hazards identified, then write one summary paragraph describing the environment:

SECTION 4: NUTRITION

Directions: Critical Thinking Exercise. Examine the “Food Intake History” in Table 1 in this Geriatric Assessment. Next, write a paragraph below explaining your recommendations for healthy food choices for your resident:

SECTION 5: TEAM WORK AND COLLABORATION

Directions: Critical Thinking Exercise. Because of the increasing number of older adults, identify and list below this paragraph at least five resources that are available to help assist your resident. Note: The resources you choose may or may not be the ones your resident is actually using.

SECTION 6 APA STYLE REFERENCES

trinity valley community college · web viewpain often affects an individual’s desire or ability...

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