OLDER ADULT INTERVIEW FORM NUR 101 Student Name: Click or tap here

OLDER ADULT INTERVIEW FORM NUR 101

Student Name: Click or tap here to enter text. Date: Click or tap to enter a date.
Length of time talking with client Choose an item. Client Age
Client Initials Client Gender Click or tap here to enter text.
Relationship to student Click or tap here to enter text. Interview Location Click or tap here to enter text. Client Allergies: Click or tap here to enter text.

FUNCTIONAL STATUS ASSESSMENT

FUNCTIONAL STATUS ASSESSMENT

Cognitive status: (choose all that apply)

Alert ☐ Oriented ☐ Confused☐ Forgetful ☐ Depressed Choose an item. MME Score Meaning of scoreChoose an item. Geriatric Depression Scale Score: Click or tap here to enter text. Meaning of GDS score: Choose an item.

Ambulation status: Choose an item. Independent Choose an item. Assistive deviceChoose an item.

Sensory Ability: Hearing: Choose an item. Hearing aid Choose an item.

Vision: Choose an item. Vision aid Choose an item.

Speech: Choose an item. Primary Language Click or tap here to enter text.

Language barrier: Choose an item.

Activities of Daily Living (ADL): Completely independent Choose an item. Katz score: Choose an item.

Needs assistance with: (choose all that apply) or N/A☐

Bathing☐ Dressing☐ Eating☐Transferring☐ Toileting☐ Walking ☐

Needs help with instrumental activities: (choose all that apply) or N/A☐

Shopping☐ Driving☐ Using public transportation ☐ Using the phone☐

Meal preparation☐ Housework☐ Home repair ☐ Laundry☐ Taking Medication ☐ Handling finances☐

Sufficient energy to complete activities: Choose an item.

Activity level: Choose an item. Examples of activities during the week Click or tap here to enter text.

Pain: Choose an item. Location of pain: Click or tap here to enter text. Pain on scale 0-10:

Difficulty getting to sleep: Choose an item. What helps client to sleep?: Click or tap here to enter text. Well rested and ready to start day? Choose an item. Naps: Choose an item.

Determinants of Health

Determinant

YES

NO

1. Able to get medical care when you need it

2. Able to get medication when you need it

3. Visit the dentist at least once a year

4. Has good communication with health care provider

5. Health Care Provider explains things clearly

6. Has health insurance

7. Has dental insurance

8. Has prescription drug insurance

9. Has access to transportation

10. Able to access food without difficulty

11. Has financial security

12. Feels comfortable and safe in house

13. Feels safe in their community

14. Exposed to unhealthy air or water

15. Has friends or family to talk to about their health

TOTAL “NO”

Click or tap here to enter text.

Review of Systems

Review of Systems

Does client have problems in any of the following areas?

Breathing: Choose an item. Describe: Click or tap here to enter text. Wears oxygen: Choose an item. Wears CPAP at night: Choose an item. Respiratory meds: Click or tap here to enter text.

Heart issues: Choose an item. Describe: Click or tap here to enter text. High Blood Pressure Choose an item. Swelling in the extremities: Choose an item. Cardiac meds: Click or tap here to enter text.

Gastrointestinal : Chewing: Choose an item. Swallowing: Choose an item. Describe: Click or tap here to enter text. Dentures: Choose an item. Dry mouth : Choose an item. Appetite: Choose an item. Describe diet: Click or tap here to enter text.

Unexplained weight loss: Choose an item. Describe: Click or tap here to enter text.

Intake of oral water each day: Click or tap here to enter text. Indigestion: Choose an item. Constipation: Choose an item. Diarrhea: Choose an item. Other problems: Click or tap here to enter text. GI meds: Click or tap here to enter text.

Urinary: Urinates more than every 2-4 hours Choose an item. Urinates less than every 2-4 hours Choose an item. Urinates more than once a night Choose an item. Urine is: Choose an item. Empties bladder fully: Choose an item. Other: Click or tap here to enter text. Urinary Meds: Click or tap here to enter text.

Skin: Change in hair or nails: Choose an item. Describe: Click or tap here to enter text.

Dry skin: Choose an item. Non-healing wound: Choose an item. Change in moles or skin pigmentation : Choose an item. Describe: Click or tap here to enter text. Medications for skin:Click or tap here to enter text.

Musculoskeletal: Back pain: Choose an item. Describe: Click or tap here to enter text. Joint pain: Choose an item. Describe: Click or tap here to enter text. Muscle weakness: Choose an item. Describe: Click or tap here to enter text. Meds for Musculoskeletal problems: Click or tap here to enter text.

Neurological: History of: TIA: Choose an item. Stroke: Choose an item. Seizures: Choose an item. Headaches: Choose an item. Numbness or tingling: Choose an item. Describe any neuro condition further: Click or tap here to enter text. Neurological meds: Click or tap here to enter text.

Endocrine: History of: Thyroid problems: Choose an item. Diabetes: Choose an item.

Describe further: Click or tap here to enter text. Other endocrine problems: Endocrine meds: Click or tap here to enter text.

Sexuality: Satisfied with sexual activity: Choose an item. If no, what would make it better? Click or tap here to enter text. Women: Has regular mammogram: Choose an item. Men: Has regular prostate screening: Choose an item.

KATZ INDEX OF INDEPENDENCE IN ACTIVITIES OF DAILY LIVING

ACTIVITIES

POINTS (1 OR 0)

INDEPENDENCE:

(1 POINT) NO supervision, direction or personal assistance

DEPENDENCE: (0 POINTS) WITH supervision, direction, personal assistance or total care

BATHING

POINTS:

(1 POINT) Bathes self completely or needs help bathing only a single part of the body such as the back, genital area or disabled extremity.

(0 POINTS) Needs help with bathing more than one part of the body, getting in or out of the tub or shower. Requires total bathing.

DRESSING

POINTS:

(1 POINT) Gets clothes from closets and drawers and puts on clothes and outer garments complete with fasteners. May have help tying shoes.

(0 POINTS) Needs help with dressing self or needs to be completely dressed.

TOILETING

POINTS:

(1 POINT) Goes to toilet, gets on and off, arranges clothes, cleans genital area without help

(0 POINTS) Needs help transferring to toilet, cleaning self or uses bedpan or commode.

TRANSFERRING

POINTS:

(1 POINT) Moves in and out of bed or chair unassisted. Mechanical transferring aids are acceptable

(0 POINTS) Needs help in moving from bed to chair or requires a complete transfer.

CONTINENCE

POINTS:

(1 POINT) Exercises complete self-control over urination and defecation.

(0 POINTS) Needs partial or total help with feeding or requires parenteral feeding.

FEEDING

POINTS:

(1 POINT) Gets food from plate into mouth without help. Preparation of food may be done by another person.

(0 POINTS) Needs partial or total help with feeding or requires parenteral feeding.

TOTAL POINTS = 6 = High (patient independent) 0 = Low (patient very dependent) (Include score on page 1 of assessment)

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.

Orientation to Time (possible total – 5 points)

Question

Result

What is today’s date?

Correct ☐ Incorrect ☐

What is the month?

Correct ☐ Incorrect ☐

What is the year?

Correct ☐ Incorrect ☐

What is the day of the week?

Correct ☐ Incorrect ☐

What season is it?

Correct ☐ Incorrect ☐

Total:

Orientation to Place (possible total – 5 points)

Question

Result

Whose home is this?

Correct ☐ Incorrect ☐

What room is this?

Correct ☐ Incorrect ☐

What city are we in?

Correct ☐ Incorrect ☐

What state are we in?

Correct ☐ Incorrect ☐

What country are we in?

Correct ☐ Incorrect ☐

Total:

Immediate Recall (possible total – 3 points)

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):

Word

Result

Ball

Correct ☐ Incorrect ☐

Flag

Correct ☐ Incorrect ☐

Tree

Correct ☐ Incorrect ☐

Total:

Attention (Complete EITHER A or B (not both); possible total – 5 points)

Ask the individual to begin with 100 and count backwards by 7. Stop after 5 subtractions. Score the correct subtractions.

Subtraction Interval

Result

93

Correct ☐ Incorrect ☐

86

Correct ☐ Incorrect ☐

79

Correct ☐ Incorrect ☐

72

Correct ☐ Incorrect ☐

65

Correct ☐ Incorrect ☐

Total:

Ask the individual to spell the word “WORLD” backwards. The score is the number of letters in correct position. (only fill out if client could not count backwards by 7)

Letter

Result

D

Correct ☐ Incorrect ☐

L

Correct ☐ Incorrect ☐

R

Correct ☐ Incorrect ☐

O

Correct ☐ Incorrect ☐

W

Correct ☐ Incorrect ☐

Total:

Delayed Verbal Recall (possible total – 3 points)
Ask the individual to recall the 3 words you previously asked him/her to remember.

Word

Result

Ball

Correct ☐ Incorrect ☐

Flag

Correct ☐ Incorrect ☐

Tree

Correct ☐ Incorrect ☐

Total:

Naming (possible total – 2 points)

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

Object

Result

Watch

Correct ☐ Incorrect ☐

Pencil

Correct ☐ Incorrect ☐

Total:

Repeat Phrase (possible total – 1 point)

Ask the individual to repeat the following: “No if, ands, or buts”

Question

Result

Phrase repeated correctly?

Correct ☐ Incorrect ☐

Total:

3-Stage Command (possible total – 3 points)

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.”

Command

Result

Takes paper

Correct ☐ Incorrect ☐

Folds paper

Correct ☐ Incorrect ☐

Places paper

Correct ☐ Incorrect ☐

Total:

Reading (possible total – 1 point)

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.

Command

Result

Closes eyes

Correct ☐ Incorrect ☐

Total:

Writing (possible total – 1 point)
Give the individual 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.

Sentence

Result

Contains subject, verb, and is sensible

Correct ☐ Incorrect ☐

Total:

Copying (possible total – 1 point)

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.

Figure

Result

Figure is correctly copied

Correct ☐ Incorrect ☐

Total:

TOTAL MINI-MENTAL SCORE
(maximum points = 30)

(Include score on page 1 of the assessment)

Geriatric Depression Scale: Short Form

Choose the best answer for how you have felt over the past week:

Are you basically satisfied with your life? YES ☐ / NO ☐

Have you dropped many of your activities and interests? YES ☐/ NO ☐

Do you feel that your life is empty? YES☐ / NO ☐

Do you often get bored? YES☐ / NO ☐

Are you in good spirits most of the time? YES ☐ / NO☐

Are you afraid that something bad is going to happen to you? YES☐ / NO ☐

Do you feel happy most of the time? YES ☐ / NO☐

Do you often feel helpless? YES☐ / NO ☐

Do you prefer to stay at home, rather than going out and doing new things? YES☐/ NO ☐

Do you feel you have more problems with memory than most? YES☐ / NO☐

Do you think it is wonderful to be alive now? YES ☐ / NO☐

Do you feel pretty worthless the way you are now? YES☐ / NO ☐

Do you feel full of energy? YES ☐ / NO☐

Do you feel that your situation is hopeless? YES☐ / NO ☐

Do you think that most people are better off than you are? YES☐ / NO ☐

TOTAL SCORE
(Include score on page 1 of the assessment)

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

Reflection

Please answer and/or document reflection on the following questions. Explain what considerations you made when planning the client’s interview.

How did you decide what client to interview? (please explain your thought process)

How did you decide location of the interview?

What barriers did you need to plan around? (Include barriers we discussed in class that were a factor for this client)

Were there other considerations needed? (describe anything that you will do to plan ahead so the interview goes smoothly)

In reviewing the data that you collected, what are the three highest priority problems your client is experiencing?

What method did you use to prioritize your client’s needs? (e.g. ABCs, Maslow; Please describe how you came to your decision)

Please document an open-ended question along with the client’s response for each of the priority needs listed in question #2.

Open-ended question for priority #1:

Client’s answer to the question:

Open-ended question for priority #2:

Client’s answer to the question:

Open-ended question for priority #3:

Client’s answer to the question:

How effective was your question for each priority need? Did the question encourage the client to give you further data that would be helpful in planning care for this client?

Satisfied with data ☐ Not satisfied with data ☐

If not satisfied with data what could you have done differently?

Satisfied with data ☐ Not satisfied with data ☐

If not satisfied with data what could you have done differently?

Satisfied with data ☐ Not satisfied with data ☐

If not satisfied with data what could you have done differently?

Describe one finding in your client that is an expected finding in an older adult but not a normal finding. Please explain.

Explain how you used the technique of active listening during this interview. (please use information covered in class when answering)

Explain how you used two (2) of the pillars of therapeutic communication during your interview. (Respect, Empathy, Genuineness, Concreteness, Confrontation)

Click or tap here to enter text.

Click or tap here to enter text.

Which developmental stage is your client in based on Erikson’s Ego integrity vs Despair?

Ego integrity ☐ or Despair ☐

What data did you base your assessment on? (please use client quotes to support your answer)

Based on the number of “NO” answers for determinants of health, what concerns do you have regarding your client’s health?