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Complete the

Comprehensive Older Person Evaluation

and the

Home Safety Checklist

on one non-family member over the age of 75 for this assignment.

Write a 3 – 4 page paper, using APA format to:

analyze and draw conclusions the findings of each section of the Comprehensive Older person evaluation and home safety checklist.

discuss at least five evidence-based health promotion teaching opportunities that you base on your findings.

Attach the

Comprehensive Older Person Evaluation and Home Safety Checklist

as an appendix to your paper following references. The 3 to 4 page range does not include

Older Person Evaluation and Home Safety Checklist

, title page, and reference page. You must use two or more scholarly references for your evidence-based teaching plan.

Competency

9 points

6 points

3 points

0 points

Points Earned

Preliminary Cognition Questionnaire

Draws conclusions from the Preliminary Cognition Questionnaire.

Summarizes results of Preliminary Cognition Questionnaire.

Describes results of the Preliminary Cognition Questionnaire.

Does not describe results of the Preliminary Cognition Questionnaire.

/9

Social Support data

Draws conclusions from the Social Support data.

Summarizes results of the Social Support data.

Describes results of the Social Support data.

Does not describe results of the Social Support data.

/9

Financial and Demographic Data

Draws conclusions from the Financial and Demographic data

Summarizes results of the Financial and Demographic data

Describes results of the Financial and Demographic data

Does not describe results of the Financial and Demographic data

/9

Psychological Health Data

Draws conclusions from the Psychological Health data.

Summarizes results of the Psychological Health data.

Describes results of the Psychological Health data.

Does not describe results of the Psychological Health data.

/9

Physical Health Data

Draws conclusions from the Physical Health data.

Summarizes results from the Physical Health data.

Describes results from the Physical Health data.

Does not describe results from the Physical Health data.

/9

Activities of Daily Living Data

Draws conclusions from the Activities of Daily Living data.

Summarizes results from the Activities of Daily Living data.

Describes results from the Activities of Daily Living data.

Does not describe results from the Activities of Daily Living data.

/9

Home Safety List Data

Draws conclusions from the Home Safety List data.

Summarizes results from the Home Safety List data.

Describes results from the Home Safety List data.

Does not describe results from the Home Safety List data.

/9

Competency

15 points

10 points

5 points

0 points

Points Earned

health promotion teaching opportunities

Proposes (or develops) at least five evidence based health promotion teaching opportunities based on findings related to deficits or other issues identified in the interviews.

Lists five evidence based health promotion teaching opportunities based on findings related to deficits or other issues identified in the interviews.

Lists less than five health promotion, without evidence based support, teaching opportunities based on findings related to deficits or other issues identified in the interviews.

Does not include health promotion teaching opportunities identified in the interviews.

/15

Competency

5 points

3 points

1 point

0 point

Points Earned

Organization

Organization excellent, ideas clear and arranged logically, transitions smooth, no flaws in logic.

Organization good; ideas usually clear and arranged in acceptable sequence; transitions usually smooth, good support

Organization minimally effective; problems in approach, sequence, support and transitions

Organization does not meet requirements

/5

Grammar

Grammar, punctuation, mechanics, and usage correct and idiomatic, consistent with Standard American English

Grammar, punctuation, mechanics, and usage good mostly consistent with Standard American English; errors do not interfere with meaning or understanding

Grammar, punctuation, mechanics and usage distracting and often interfere with meaning or understanding

Grammar, punctuation, mechanics, and usage interfere with understanding

/5

References

References are relevant, authoritative and contemporary

Adequate references

Minimal use of appropriate references

Poor use and/or selection of references not relevant

/5

Competency

7 points

5 points

2 points

0 point

Points Earned

APA Format

Demonstrates competent use of mechanics and APA.

Minimal APA errors.

Many APA errors.

Complete lack of understanding.

/7

Total

/100

Home Safety
Checklist
Use this checklist as you walk through each room in your home and check for
hazards. You should check off each item in this list (when applicable to your home). If
you are unable to check off an item, be sure to fix it within an appropriate time frame.
Kitchen
 Have a sturdy step stool with handrails, or a utility ladder to reach high
cabinets or shelves
 Hazardous products (household cleaners, disinfectants and insecticides)
are stored in their original labeled containers separate from food
 Knives are kept in a special rack or compartment
 Oven mitts, pot holders and towels are stored away from the stove
 Pot handles are always turned away from the front of the stove
 The pressure gauge on a fire extinguisher is checked monthly – if the
needle is in green it is still good, if the needle is anywhere else, replace
 Fire extinguisher is mounted on a bracket on the wall near an exit
 Broiler, oven and ventilation ducts are free from grease
Bathroom
 Have a slip-resistant surface in the shower or tub
 Grab bars are installed in bathrooms or shower stalls
 Electrical appliances are unplugged when not in use
 Slip-resistant rugs are in place on bathroom floors
Living Room
 Have a safety screen in place in front of fireplace
 Slip-resistant floor coverings and rugs on floor
 Walkways are clear of obstacles (toys, papers, shoes)
 Stairs, hallways and passageways are well lit
 Sturdy handrails installed on all steps and stairways
 Carpeting, stairway treads and risers are in good condition
 Electrical cords are secured
 TVs are properly secured to walls or in or on a sturdy cabinet
Page 1 of 2
© 2014 National Safety Council
Bedrooms
 Phone and flashlight are located near beds
 Lamp or light switch is within reach of bed
 Bed frame is against wall without gaps
 Smoke detectors and carbon monoxide detectors are outside of sleeping
area, with working battery
 Walkway and all exit routes are clear of clutter
Basement or utility room
 Working smoke detector located in basement and every other floor
Smoke detectors
 Gas and water lines are tagged (so you can turn them off in an
emergency)
Every month:
Test them
 Location of main electrical switch is known
 It is known how to light the pilot on your gas furnace and water heater
 Washer and dryer are electrically grounded
Every year:
Change the
batteries
 Tools are properly stored and out of reach of children
 Have an emergency kit in case of hazardous weather
Garage and driveway
Every 10 years:
Replace the
entire unit
 Power tools and hazardous chemicals are locked away in cabinets
 Flammable materials (gasoline or oil-soaked rags) are stored in
appropriate safety containers
 It is known to never turn on your vehicle or other gas-powered equipment
with the garage door closed
 Garage and driveway are well maintained and free of slip and trip
hazards, such as cracks or uneven surfaces
Outside the house
 Lighting in place around steps, walkways, patios and driveways
 Children’s play equipment, (slides, swing set) are securely anchored
 If you have a pool, it is covered or surrounded by a high fence
 Trees and shrubs around your home are maintained by trimming
overhanging branches and removing leaves from gutters
 Heavy snow is removed from the roof with a roof rake
Page 2 of 2
© 2014 National Safety Council
Home Safety
Checklist
Use this checklist as you walk through each room in your home and check for
hazards. You should check off each item in this list (when applicable to your home). If
you are unable to check off an item, be sure to fix it within an appropriate time frame.
Kitchen
 Have a sturdy step stool with handrails, or a utility ladder to reach high
cabinets or shelves
 Hazardous products (household cleaners, disinfectants and insecticides)
are stored in their original labeled containers separate from food
 Knives are kept in a special rack or compartment
 Oven mitts, pot holders and towels are stored away from the stove
 Pot handles are always turned away from the front of the stove
 The pressure gauge on a fire extinguisher is checked monthly – if the
needle is in green it is still good, if the needle is anywhere else, replace
 Fire extinguisher is mounted on a bracket on the wall near an exit
 Broiler, oven and ventilation ducts are free from grease
Bathroom
 Have a slip-resistant surface in the shower or tub
 Grab bars are installed in bathrooms or shower stalls
 Electrical appliances are unplugged when not in use
 Slip-resistant rugs are in place on bathroom floors
Living Room
 Have a safety screen in place in front of fireplace
 Slip-resistant floor coverings and rugs on floor
 Walkways are clear of obstacles (toys, papers, shoes)
 Stairs, hallways and passageways are well lit
 Sturdy handrails installed on all steps and stairways
 Carpeting, stairway treads and risers are in good condition
 Electrical cords are secured
 TVs are properly secured to walls or in or on a sturdy cabinet
Page 1 of 2
© 2014 National Safety Council
Bedrooms
 Phone and flashlight are located near beds
 Lamp or light switch is within reach of bed
 Bed frame is against wall without gaps
 Smoke detectors and carbon monoxide detectors are outside of sleeping
area, with working battery
 Walkway and all exit routes are clear of clutter
Basement or utility room
 Working smoke detector located in basement and every other floor
Smoke detectors
 Gas and water lines are tagged (so you can turn them off in an
emergency)
Every month:
Test them
 Location of main electrical switch is known
 It is known how to light the pilot on your gas furnace and water heater
 Washer and dryer are electrically grounded
Every year:
Change the
batteries
 Tools are properly stored and out of reach of children
 Have an emergency kit in case of hazardous weather
Garage and driveway
Every 10 years:
Replace the
entire unit
 Power tools and hazardous chemicals are locked away in cabinets
 Flammable materials (gasoline or oil-soaked rags) are stored in
appropriate safety containers
 It is known to never turn on your vehicle or other gas-powered equipment
with the garage door closed
 Garage and driveway are well maintained and free of slip and trip
hazards, such as cracks or uneven surfaces
Outside the house
 Lighting in place around steps, walkways, patios and driveways
 Children’s play equipment, (slides, swing set) are securely anchored
 If you have a pool, it is covered or surrounded by a high fence
 Trees and shrubs around your home are maintained by trimming
overhanging branches and removing leaves from gutters
 Heavy snow is removed from the roof with a roof rake
Page 2 of 2
© 2014 National Safety Council
Comprehensive Older Person’s Evaluation
Name (print): ______________________________________________________________________
Date of Visit:
_________________________
Chief complaint:
____________________________________________________________________________________________________________
Today I will ask you about your overall health and function and will be using a questionnaire to help me obtain this information. The first few
questions are to check your memory.
Preliminary Cognition Questionnaire: Record if answer is correct with ( ); if answer is incorrect, with ( ). Record total number of errors.
( , )
1) What is the date today?
______
2) What day of the week is it?
______
3) What is the name of this place?
______
4) What is your telephone number or room number? (record answer: _______)
______
If subject does not have phone, ask:
What is your street address?
5) How old are you? (record answer: _______)
______
6) When were you born? (record answer from records if patient cannot answer: _______)
______
7) Who is the president of the United States now?
______
8) Who was the president just before him?
______
9) What was your mother’s maiden name?
______
10) Subtract 3 from 20 and keep subtracting from each new number you get, all the way down.
Total errors
______
______
If more than 4 errors, ask #11. If more than 6 errors, complete questionnaire from informant.
11) Do you think you would benefit from a legal guardian, someone who would be responsible for your legal and financial matters?
Do you have a living will? Would you like one?
a)
No
b)
Has functioning legal guardian for sole purpose of managing money
(describe: ______________________________________________________________________)
c)
Has legal guardian
d)
Yes
Demographic Section
1) Patient’s race or ethnic background (record: _______________)
2) Patient’s gender (circle) Male Female
3) How far did you go in school?
a)
Postgraduate education
b)
Four-year degree
c)
College or technical school
d)
High school complete
e)
High school incomplete
f)
0-8 years
Social Support Section: Now there are a few questions about your family and friends.
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Comprehensive Older Person’s Evaluation
4) Are you married, widowed, separated, divorced, or have you never been married?
a)
Now married
b)
Widowed
c)
Separated
d)
Divorced
e)
Never married
5) Who lives with you? (circle all responses)
a)
Spouse
b)
Other relative or friend (specify: _______________________)
c)
Group living situation (non-health)
d)
Lives alone
e)
Nursing home, number of years
6) Have you talked to any friends or relatives by phone during the last week?
a)
Yes
b)
No
7) Are you satisfied by seeing your relatives and friends as often as you want to, or are you somewhat dissatisfied about how little you see
them?
a)
Satisfied (skip to #8)
b)
No (ask A)
A)
Do you feel you would like to be involved in a Senior Citizens Center for social events, or perhaps meals?
1)
No
2)
Is involved (describe: _________________________)
3)
Yes
8) Is there someone who would take care of you for as long as you needed if you were sick or disabled?
a)
b)
Yes (skip to C)
No (ask A)
A) Is there someone who would take care of you for a short time?
1)
Yes (skip to C)
2)
No (ask B)
B) Is there someone who could help you now and then?
1)
Yes (ask C)
2)
No (ask C)
C) Whom would we call in case of an emergency? (record name and telephone: ______________________
________________________________________________)
Financial Section
9) Do you own, or are you buying, your own home?
a)
Yes (skip to #10)
b)
No (ask A)
A) Do you feel you need assistance with housing?
1)
No
2)
Has subsidized or other housing assistance
3)
Yes (describe: ________________________________)
B) What type of housing did you have prior to coming here?
10) Are you covered by private medical insurance, Medicare, Medicaid, or some disability plan? (circle all that apply)
a)
Private insurance (specify and skip to #11): )
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Comprehensive Older Person’s Evaluation
b)
Medicare
c)
Medicaid
d)
Disability (specify and ask A: _________________________)
e)
None
f)
Other (specify: ______________________________________)
A) Do you feel you need additional assistance with your medical bills?
1)
No
2)
Yes
11) Which of these statements best describes your financial situation?
a)
My bills are no problem to me (skip to #12)
b)
My expenses make it difficult to meet my bills (ask A)
c)
My expenses are so heavy that I cannot meet my bills (ask A)
A) Do you feel that you need financial assistance such as: (circle all that apply)
1)
Food stamps
2)
Social Security or disability payments
3)
Assistance in paying your heating or electrical bills
4)
Other financial assistance (describe: ____________)
Psychological Health Section: The next few questions are about how you feel about your life in general. There are no right or wrong answers,
only what best applies to you. Please answer yes or no to each question.
Yes
No
_____
_____
_____
_____
14) Does it seem that no one understands you?
_____
_____
15) Are you happy most of the time?
_____
_____
16) Do you feel weak all over much of the time?
_____
_____
17) Is your sleep fitful and disturbed?
_____
_____
12) Is your daily life full of things that keep you interested?
13) Have you, at times, very much wanted to leave home?
18) Taking everything into consideration, how would you describe your satisfaction with your life in general at the present time—good, fair, or
poor?
a)
Good
b)
Fair
c)
Poor
19) Do you feel you now need help with your mental health; for example, a counselor or psychiatrist?
a)
No
b)
Has (specify: _______________________________________)
c)
Yes
Physical Health Section: The next few questions are about your health.
20) During the past month (30 days), how many days were you so sick that you couldn’t do your usual activities, such as working around the
house or visiting with friends?
21) Relative to other people your age, how would you rate your overall health at the present time: excellent, good, fair, poor, or very poor?
a)
Excellent (skip to #22)
b)
Very good (skip to #22)
c)
Good (ask A)
d)
Fair (ask A)
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Comprehensive Older Person’s Evaluation
e)
Poor (ask A)
A) Do you feel you need additional medical services such as a doctor, nurse, visiting nurse, or physical therapist? (circle all that
apply)
1)
Doctor
2)
Nurse
3)
Visiting nurse
4)
Physical therapist
5)
None
22) Do you use an aid for walking, such as a wheelchair, walker, cane, or anything else? (circle aid usually used)
a)
Wheelchair
b)
Other (specify: ______________________________________)
c)
Visiting nurse
d)
Walker
e)
None
23) How much do your health troubles stand in the way of your doing things you want to do: not at all, a little, or a great deal?
a)
Not at all (skip to #24)
b)
A little (ask A)
c)
A great deal (ask A)
A) Do you think you need assistance to do your daily activities; for example, do you need a live-in aide or choreworker?
1)
Live-in aide
2)
Choreworker
3)
Has aide, choreworker, or other assistance (describe: ____________________________________)
4)
None needed
24) Have you had, or do you currently have, any of the following health problems? If yes, place an “X” in appropriate box and describe;
medical record information may be used to help complete this section.
HX
CURRENT
DESCRIBE
a) Arthritis or rheumatism?
b) Lung or breathing problem?
c) Hypertension?
d) Heart trouble?
e) Phlebitis or poor circulation problems in arms or legs?
f) Diabetes or low blood sugar?
g) Digestive ulcers?
h) Other digestive problem?
i) Cancer?
j) Anemia?
k) Effects of stroke?
l) Other neurological problem?(specify: ___________)
m) Thyroid or other glandular problem? (specify:
___________)
n) Skin disorders such as pressure sores, leg ulcers,
burns?
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Comprehensive Older Person’s Evaluation
o) Speech problem?
p) Hearing problem?
q) Vision or eye problem?
r) Kidney or bladder problems, or incontinence?
s) A problem of falls?
t) Problem with eating or your weight? (specify:
___________)
u) Problem with depression or your nerves? (specify:
___________)
v) Problem with your behavior (specify: ______
____________________)
w) Problem with your sexual activity?
x) Problem with alcohol?
y) Problem with pain?
z) Other health problems?(specify: ___________)
Immunizations: _____________________________________________
_________________________________________________________
25) What medications are you currently taking, or have been taking, in the last month? (May I see your medication bottles?) (If patient cannot
list, ask categories a-r and note dosage and schedule, or obtain information from medical or pharmacy records and verify accuracy with
the patient.)
Allergies:
Rx (DOSAGE AND SCHEDULE)
a) Arthritis medication
b) Pain medication
c) Blood pressure medication
d) Water pills or pills for fluid
e) Medication for your heart
f) Medication for your lungs
g) Blood thinners
h) Medication for your circulation
i) Insulin or diabetes medication
j) Seizure medication
k) Thyroid pills
l) Steroids
m) Hormones
n) Antibiotics
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Comprehensive Older Person’s Evaluation
o) Medicine for nerves or depression
p) Prescription sleeping pills
q) Other prescription drugs
r) Other nonprescription drugs
26) Many people have problems remembering to take their medications, especially ones they need to take on a regular basis. How often do
you forget to take your medications? Would you say you forget often, sometimes, rarely, or never?
a) Never
c) Sometimes
b) Rarely
d) Often
Activities of Daily Living: The next set of questions asks whether you need help with any of the following activities of daily living.
27) I would like to know whether you can do these activities without any help at all, or if you need assistance to do them. Do you need help
to: (If yes, describe, including patient needs.)
YES
NO
DESCRIBE (INCLUDE
NEEDS)
a) Use the telephone?
b) Get to places out of walking distance (using
transportation)?
c) Shop for clothes and food?
d) Do your housework?
e) Handle your money?
f) Feed yourself?
g) Dress and undress yourself?
h) Take care of your appearance?
i) Get in and out of bed?
j) Take a bath or shower?
k) Prepare your meals?
l) Do you have any problem getting to the bathroom
on time?
28) During the past 6 months, have you had any help with such things as shopping, housework, bathing, dressing, and getting around?
a) Yes (specify: ________________________________________)
b) No
Signature of person completing the form:
Reprinted with permission from Pearlman R: Development of a functional assessment questionnaire for geriatric patients: COPE, J Chronic Dis
40:85S-94S, 1987.
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

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