Comprehensive Gerontological Assessment
Age selection: Must be at least 60 years or older.
Introduce yourself to the older adult and explain the purpose of the interview/assessment and that you will share the information anonymously with your teacher only. You will only use initials for identification of the "patient".
Do not list client identifiers or location of residence. Instead Use for example: JG is a X year old, white female who lives in a coastal town of North Carolina.
Follow the template,
Include additional assessments where warranted. Examples can be found: Textbook, ConsultgeriRN, or reliable internet sources.
Example: if patient has had falls, add a fall assessment to your assessment, If they do not sleep well or are tired in the afternoon, add a sleep assessment (see textbook for recommendations).
Collect Subjective Data: Review of Systems (What the older adult says about each system.) Remember this is subjective. Using quotations is ok here or the statement Patient reports or denies......or ROS positive for symptoms present and /or negative for (If not present). Examples of what to ask: REVIEW OF SYSTEMS CHECKLIST.docx
Collect information- Instrumental ADLS (IADLS) Performing a geriatric review of systems: assessing ADLs, mobility, mood, and more.
Collect an Environment/Safety Assessment ( home injury is common in older adult population. Assessment the home living environment is important.)
Objective Data: Health interview (brief health (medications, illness, diseases, surgeries, vaccinations) history, nutritional, functional, social, spiritual, and mental status assessments, other risk assessments (identified through the screening, initial assessments).
Discuss the tools used here and include rationale and evidence to support its use. Include the assessment tools as appendices.
Assessment:
Based on the assessment findings Prioritize two nursing diagnoses for the older adult and include a SMART (short-term) goal with an evaluative statement. for each diagnosis. Do a Nursing Care plan in the document after addressing completing the assessment.
Include this is narrative form or table form is also ok if desired. Avoid medical diagnoses and use nursing priorities that relate to health problems. This does not have to be in the form of NANDA nursing diagnoses, but these will be acceptable.
Example: your patient is underweight and BMI. You can use Nutrition less than body requirements or state this as inadequate nutrition to maintain an appropriate weight and essential nutrients. Be sure your interventions are specific and individualized for this patient.
Plan:
List at least 5 interventions for each nursing diagnosis and include evidence-based rationale to support the interventions. Discuss education provided to the patient and timeline for re-evaluating the plan.
Optional: You may submit your final draft to the Preliminary Plagiarism Check to assess for APA errors and plagiarism issues. This is for your benefit and is not a graded site. You will get a Turn-it in report to help you see any errors you may have in the APA citing to avoid plagiarism. Once you get a report and make any needed changes, you will need to submit your final paper for grading.
Please submit paper in a Word .doc or .docx file by calendar
Format submission using APA 7th ed format by due date and provide APA reference page at end of submission for any references cited
Comprehensive Gerontological Assessment Template
Your Name
NSG 321 Gerontological Nursing and End of Life Care
Instructor
Due Date
Comprehensive Gerontological Assessment
This is where you make a brief introduction about the content and purpose of the paper.
Client Profile/Biographic Data
This is where you write about the client/age/lives in small town, large city, etc.
Family Profile
Who they live with. Is there family nearby? Family members able to be involved with care needs? Power of attorney?
Living Environment
Do they live in a house, apartment? Any concerns regarding house design? Maintenance issues? Repairs? Is home safe for them? Is there a safe area for walking or riding a bike (sidewalks)? Think what should be in the home for their safety. Consider content from the content Identifying and prevention in older adults.
Recreation/Leisure Activities
Talk about what they like to do for recreation or leisure time.
Resources/Support Systems Used
What resources or support systems they have or are using now. Retired? Working? Financially stable? Don’t need numbers here. Any assistance at home? Consider support groups or church. Do they receive any health or governmental services? Is insurance adequate to cover needs?
Description of Typical Day (include usual bedtime ritual)
Describe usual daily routine.
Present Health Status
What is their present health status? Preventative Care? Immunizations dates and up to date per CDC guidelines? See recommended screenings in content Identifying and prevention of risks for older adults(Chapter 8)
Past Health Status
Medical History? Hospitalizations, surgeries, etc. Smoker? alcohol use?
Family History
Discuss family history (heart disease, cancer, diabetes, etc.)
Medications
Current prescription and over the counter medications/supplements. Make sure to list home remedies/herbal remedies if any. Be sure to include dosage, frequency and indication. Address compliance to regimen.
Allergies
List any and all allergies and reactions.
Review of Systems ( Using Chapter 4 to identify aging changes reported per system)
Review each system for subjective data. Address age related changes, risks for population and any reported abnormals. This is not a physical assessment but what the older adult reports.
· The Review of systems is the subjective part where you ask the patient by system if they have any past or present issues. Jarvis (2012) states that this review of systems serves three purposes:
o (1) to evaluate the past and present health state of each system
o (2) to double check in case any significant data were omitted in the present illness section
o (3) to evaluate health promotion practices
(Jarvis, 2012, p 54)
General
Skin
HEENT (Head, Eyes, Ears, Nose, Throat)
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary
Musculoskeletal
Neurological
Endocrine
Hematologic/Lymphatic
Psychological
Nutrition (pg 667)
What is a typical day intake? Use an assessment tool and 24 hour recall with evaluation of adequacy using good nutritional standards like My Plate and Mini Nutritional Assessment
Any biometric data ( reported ht, wt and state BMI, If diabetic, do they check FSBS and what do they report? Do they know they A1c?) important?
Functional Status Assessment (pp 231-237)
Complete Barthel Index or other assessment of functional ability.
Complete Lawtons’ IADLs tool for independent living skills.
Consider a fall assessment if that is a concern for your older adult
Mental Status Assessment (see pp 249-252)
Level of Cognitive Function – Complete the Mini Cog, OR Montreal Cognitive Assessment or other cognitive function tool – report score and interpretation. Any other mental health concerns?
Social and/or Spiritual Assessment (see pp 254-256 and pg 786)
Complete Family Apgar or other social assessment tool (Lubben Social Network Scale) and FICA Spiritual Assessment tool with results and interpretation.
Plan of Care
The italics below are just helps and guidance. Please delete and put your priorities in the two heading below. Do not duplicate information. But discuss each priority and plan in respective headings.
Priorities of Care – identify the 2 high priority nursing needs. Write 2 nursing diagnoses.
Read carefully the instructions for this part. This is key in grade. We need to see your nursing process clinical reasoning and care needs to be based on evidenced based practice guidelines for older adults. Analyze findings and based on your collection of subjective data, develop a comprehensive nursing care plan that includes:
Analyze findings and based on your collection of subjective data, develop a comprehensive nursing care plan that includes:
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2 nursing diagnoses or priority problems. These do not have to written as NANDA statements but you can use it. Ex. If you find that your client has nutritional needs such as malnutrition as evidenced by low BMI and insufficient intake. You can use NANDA Nutrition less than body needs RT inadequate intake as evidenced by BMI of 16 and daily intake below suggested intake according to My Plate guidelines.
Or you can simply say Poor nutrition for her age as the MNA score indicates malnutrition and BMI 16 underweight.
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1 or 2 goals for each diagnoses Remember to write SMART goals. Consider a short- and long-term goal. Have a goal that you can see achievement in the course timeframe.
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Use evidenced based nursing interventions for each priority that you will carry out (or however many is appropriate) Be sure these are individualized and specific to this patient. Be sure interventions lead to goal achievement. You can write these as bullets or numbered list
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How you will evaluate your goal(s) in part 2?
Priority One:
SMART goal statement:
Interventions/Rationales: (List at least 5 interventions with at least one on teaching education for each nursing diagnosis and include evidence-based rationale.)
Evaluation plan:
Priority Two:
SMART goal statement:
Interventions/Rationales: (List at least 5 interventions with at least one on teaching education for each nursing diagnosis and include evidence-based rationale.)
Evaluation plan:
References
Reference and cite each tool please.
This is the format to use for the Mauk textbook. It is a chapter authored edited book and cited and referenced by chapter authors.
Chapter Author(s). (2023). Chapter title. In K. L. Mauk (Ed.), Gerontological nursing: Competencies for care 5th ed). (pp. 23-41). Jones & Bartlett.