- Physical needs – what is their health status? Health history?
- Disease Management – do they have multiple chronic diseases?
- Medication compliance – are they taking their medication correctly?
- Risk of rehospitalization – can that risk be reduced by chronic disease management?
- Physician appointments – is there follow-up with all their doctors? Are appointments kept?
- Nutritional status – are they eating and drinking fluids? is the diet and fluid intake appropriate for their needs and disease process? Teeth and mouth are healthy? Appetite?
- Signs of abuse or neglect – could be physical or financial abuse, self neglect, emotional abuse.
- Pain assessment – if they have pain, is it managed?
- Elimination – any incontinence?
- Infection control – frequent urinary infections? Pneumonia? Flu?
- Cognitive assessment – are they confused, disorientated, memory deficits?
- Psychiatric assessment – are they depressed, paranoid, or aggressive? Coping skills?
- Vision and hearing – any deficits? Do they have hearing aids and glasses?
- Accidents – history of falls?
- Advanced Directives – do they have a living will?
- Mobility assessment – how are they walking, any balance issues, weakness?
- Assistive devices – using a cane or walker? Are they using the device recommended?
- Risk of falls – are they safe alone? Do they have a way to call for help – like personal response button or pendant to call for help?
- Would they benefit from physical or occupational therapy?
Emotional and Social Assessment:
- Support system – do they have friends and social events planned? Activities at a Senior Center?
- Advocate – do they have a trustworthy person to advocate for them in an emergency or hospitalization? Do they have someone that they can trust to call for help?
- Mood – are they happy, depressed, talkative, withdrawn?
- Fears – what are they afraid of?
- Wishes – what do they want in the future? What is most important to them?
- Safety – is the environment where they live safe? If living alone – are they safe?
- Risk for falls and injuries – such as throw rugs, poor lighting, using step stools and ladders.
- Bathroom – is the bathroom and shower safe? Grab bars? Shower seat? Need for supervision?
- Emergency – fire and personal safety – are they able to call for help? Get out of the house safely on their own? Smoke detector? Does Fire and rescue know that they have special needs?
- Disaster – do they have food, water, flashlights, extra medication in case of emergency.
- Driving – any accidents? Episodes of getting lost?
- Are they in the right living situation? Consider move to retirement community or Assisted Living Facility? Do they need a higher level of care, support and supervision? More socialization?
- Safety awareness – are they at risk for scams, telemarketers, allowing strangers access to the home?
Spiritual and Cultural Needs:
- Do they have a support system for spiritual needs?
- Are they able to get to services they want to attend?
- Do they have a desire for spiritual support that they are not getting?
- Do they need information in another language?
- Social support – need for a senior group that meets their cultural needs?
Assessment of Additional Care Needs:
- Are they adequately bathing, dressing, walking and toileting on their own?
- Home – is their area clean and free of clutter?
- Transportation – do they have access to transportation?
- Are they able to prepare meals, get to doctor appointments, use the telephone, shopping, manage finances, housekeeping, laundry, take their medicines correctly?
- Caregiver – would they benefit from having additional help in the home?
- Appearance – assess are they clean, hair shampooed, clean clothes?
- Nutrition – is there fresh food in the refrigerator? Expired food? What did they eat today?
- Pets – are they able to care for pets adequately?
- Feedback – does the family think they need additional care?
- Planning for long term care needs – assessment of future needs. Moving from one care setting to another. Advance Directives, end of life wishes and Do Not Resuscitate.