Geriatric Assessment Tools and Focused Nursing Assessment

Why Standardized Geriatric Assessment Matters

Older adults often present with subtle, overlapping changes that can be mistaken for normal aging. Standardized assessment tools give the LPN a reproducible, objective way to detect problems early, communicate findings clearly, and track changes over time. As an LPN, you do not diagnose, but you are frequently the first clinician to notice a decline. Accurate tool administration and documentation directly support patient safety and guide the care team's response.

The Mini-Cog

The Mini-Cog screens for cognitive impairment in about three minutes. It has two parts: a three-item word recall and a clock-drawing test (CDT).

Administration steps:

1. Tell the resident you are going to say three unrelated words and ask them to remember the words. State the words clearly (e.g., banana, sunrise, chair).

2. Ask the resident to draw a clock face showing a specific time (commonly 11:10). Provide a blank piece of paper.

3. After the clock is drawn, ask the resident to recall the three words.

Scoring: Each recalled word = 1 point (0–3). The CDT is scored as normal (2 points) or abnormal (0 points). Total score ranges from 0–5. A score of 0–2 is considered a positive screen for cognitive impairment; 3–5 is a negative screen. A normal CDT with at least one recalled word generally indicates lower risk. Any positive screen must be reported to the RN immediately, as it affects safety planning, medication management, and fall risk.

Katz Index of Independence in Activities of Daily Living (ADLs)

The Katz Index measures functional status by rating independence in six basic ADLs: Bathing, Dressing, Toileting, Transferring, Continence, and Feeding (remembered easily as B-D-T-T-C-F).

Scoring: Each activity is scored 1 (independent) or 0 (dependent/needs assistance). The maximum score is 6, indicating full independence. A score of 4 or below signals significant functional dependence requiring care planning adjustments. Document the specific activities where dependence is noted—this directs your care plan more than the total number alone. Observe actual performance rather than asking the resident what they can do; self-report and observed ability often differ in older adults.

Braden Scale for Predicting Pressure Injury Risk

The Braden Scale assesses risk for pressure injuries using six subscales: Sensory Perception, Moisture, Activity, Mobility, Nutrition, and Friction/Shear.

Scoring: Five subscales are scored 1–4; the Friction/Shear subscale is scored 1–3. Total scores range from 6 to 23. Lower scores indicate higher risk.

| Score | Risk Level |

|-------|------------|

| 15–18 | Mild risk |

| 13–14 | Moderate risk |

| 10–12 | High risk |

| ≤ 9 | Very high risk |

Assess the patient's skin during this tool administration. If any redness, blistering, or open areas are found, report immediately—do not wait for a scheduled assessment. Reposition high-risk patients at minimum every two hours; document that repositioning occurred.

Morse Fall Scale

The Morse Fall Scale (MFS) predicts fall risk based on six items: history of falling within the past three months, secondary diagnosis, ambulatory aid used, IV/heparin lock present, gait/transferring ability, and mental status.

Scoring guide (approximate ranges):

• History of falling: No = 0, Yes = 25
• Secondary diagnosis: No = 0, Yes = 15
• Ambulatory aid: None/bed rest/nurse assist = 0; Crutches/cane/walker = 15; Furniture = 30
• IV/heparin lock: No = 0, Yes = 20
• Gait: Normal/bed rest/immobile = 0; Weak = 10; Impaired = 20
• Mental status: Oriented to own ability = 0; Overestimates/forgets limitations = 15

Total scores commonly interpreted as: low risk < 25, moderate risk 25–44, high risk ≥ 45. Always verify the cutoff values used at your facility, as protocols may vary. Patients scoring at moderate or high risk require documented fall-prevention interventions: bed alarm, non-slip footwear, call light within reach, and hourly rounding at minimum.

Safety and Scope of Practice Reminders

• Report abnormal findings to the charge RN promptly. An LPN does not determine the plan of care independently but must communicate concerns using a structured format such as SBAR (Situation, Background, Assessment, Recommendation).
• Never skip items on a scoring tool to save time. Incomplete tools produce inaccurate scores and may miss critical risks.
• Use calm, respectful language. Cognitive screening can be distressing; explain each step simply and maintain the resident's dignity.
• Reassess whenever there is a change in condition—not only on admission or on a scheduled cycle.
• Document the time, date, your name, credential, and exact scores. Vague entries such as "patient appears confused" do not replace a scored, documented assessment.

Putting It All Together

These four tools together give a rapid but comprehensive snapshot: cognitive status (Mini-Cog), functional ability (Katz), skin integrity risk (Braden), and fall risk (Morse). Administering them in a systematic order reduces the chance of missing a subscale. After scoring, enter results in the EHR or paper form, flag abnormals, and write your SBAR note. The charge RN uses your documented findings to initiate or revise the care plan.