Question

Assess an older adult using the Geriatric Assessment Tool . Perform a head to toe physical assessment on the client, document positive findings and current medications (if any indicated for the body system).

For example, vital signs: high blood pressure (Amlodipine 5 mg PO daily, eyes: glaucoma (Xalatan 0.005% one drop both eyes daily).

Answer 1

Mr. XY, aged 70 years :

Head to toe assessment or the physical examination is the examination of the patient's body with the use of such methods as inspection, palpation, percussion and auscultation.

Geriatric Assessment is an evaluation of an older person's physical health, mental health, cognitive abilities and socio- economic and envirommental situations. It is a multidisciplinary and multidimensional assessment aids in diagnosis of a medical condition , effectiveness of a treatment and the planning for the follow up.

Geriatric Assessment: Activities of Daily Living ( ADL)

Bathing : Baths self completely   

Dressing : independent   

Toileting: goes and comes back to toilet without assistance , no continence   

Transferring: moves here and there, wakes up from  bed without assistance

Feeding: self , without assistance .

Head to toe Assessment:

Vital signs:

Temperature: 98 .2 degree Fahrenheit

Pulse : 84 beats / minutes

Respiration : 20

Blood pressure: 140/ 90 , high blood pressure .

Mr . XY is on treatment for Hypertension since 4 years.

General appearance: Neately dressed, moderate body built

Skin : Wrinkling started and skin start to lose the turgor

Head and Neck:

Hair pattern: hair alopecia is present. hair is present at the temples and back of the head

Hair colour: Black and white

Eyes :

Eye lid: wrinkled

Conjunctiva and sclera: No yellowish discoloration, subjective complaints of dryness of eye.

Vision:Hyperopia/ long sightedness is present, use of refractory lens .

Nose:

No abnormal discharge

No septal deviations

Mouth and throat

No dentures , No gingivitis or infection

History of 2 root canal surgery

No enlarged tonsils

Neck: No enlarged lymph nodes

Thorax : symmetrical expansion

Respiratory system: Rate ( 20 breaths/ minutes), depth and rhythm is normal

No abnormal breath sounds such as wheezing

Cardiovascular system:

Heart rate : 85 beats / minutes

Heart sounds: S1 and S2 heard. Systolic Murmurs are present.

Abdomen: No scars are present, no ascitis

Bowel sounds heard

Genitalia, Rectum and Prostrate:

No urinary incontinence or fecal incontinence

No prostate enlargement

No inguinal hernia is present.

Extrimities and back

Range of Motion: limited ROM

No paralysis of extrimities

Back : No Scoliosis or Kyphosis are present ( abnormal spine curvatures)

Positive findings:

Dryness of eye and long sightedness

Blood pressure: 140/ 90 mm of Hg

Heart sounds: Systolic Murmur is present.

Mr. XY is suffering with Hypertension since 4 years. He is presently under treatment with Antihypertensives.

Filodepine 5mg PO Daily

Atenelol 25 mg PO twice a day

Chlorothiazide ( Diuril) 500mg PO Daily.

For Dryness of eyes : Refresh tears Lubrucant eye drops.