MDJ 4382

Gerontology Nursing
Practicum
Case Study of Madam P From
Bilik Perempuan,RSK
Group Member:
1. Laurita Estiny anak Recky 36604
2. Rosyatimah binti Tamrin 38528
3. Siti Aishah binti Zainal 38714
 Presentation Outline
• Introduction
– Client’s profile
– 11 Gordon’s Pattern
– Pathophysiology of Hypertension & Osteoarthritis
– Pharmacology treatment
• Nursing assessment
– Head to toe examination
– Functional Assessment
– Psychosocial Assessment
• Health Education
– Diet, Exercise & Lifestyle
• Nursing Diagnosis
• References
 Introduction
This case study was taken from Rumah Seri
Kenangan (RSK) specifically a resident from Bilik
Perempuan. We did our interview, assessment
and observation from the 21st of December until
the 23rd of December. But, we continue to do
follow-up throughout the subsequent week by
asking regarding our client’s condition from our
batch mates who are posted in RSK.
 Client’s Profile
Madam Voluntary
P Admission

87 Years 9th October

old (1928) 1998 Present

Widowed
Java (2001)

No child,
adopted one
Islam child
 Medical History
• Diagnosed with pneumonia in 2011
• In 2013, she was officially diagnosed of Knee
Osteoarthritis
 Surgical history
• 2 surgeries in 2000
– Cataract removal at both eyes
– Intraocular lens
 11 Gordon’s Patterns
Health Perception and Health Management
 No use of tobacco, alcohol or drugs
Nutrition/Metabolic Pattern
 Normal appetite. No nausea and vomiting.
Elimination Pattern
 Normal habit.
 Pass urine 4 to 5 times a day and bowel open once in two day.
Activity/Exercise Pattern
 Ability to walk without assistant has been decreasing
 Able to do activity daily living
 She moves by using the wheelchair to those places and able to
transfer her own body to bed, toilet bowl and chair.
 11 Gordon’s Patterns cont…
Sleep/Rest Pattern
 Good sleep pattern.
Cognitive-Perceptual Pattern
 Alert on what happened to her surroundings.
 Oriented to time, date and place.
 Able to produce clear speech and easily understood.
Sensory-Perceptual Pattern
 Good hearing.
 Not used eyeglasses
Coping Stress Tolerance/Self-perception/Self Concept Pattern
 Most concerned about money
 11 Gordon’s Patterns cont…
Role-Relationship Pattern
 Social welfare, which gave her RM10 per month.
 Received Bantuan Rakyat 1 Malaysia (BR1M)
 Some pocket money during certain occasions and celebrations such
as Chinese New Year, Hari Raya and Christmas.
Sexuality/Reproductive Pattern
 She claimed of menopause since long time ago.
Value-Belief Pattern
 Islam
 Learn again how to pray every Wednesday in mosque
Anatomy of the Knee

• Made up of the
lower end of the
femur (thighbone),
the upper end of
the tibia (shinbone),
and the patella
(kneecap).
Anatomy of the Knee
• Ends of the three bones
where they touch are covered
with articular cartilage.
• Cartilage- a smooth, slippery
substance that protects and
cushions the bones.
• Menisci- Two-wedge shaped
pieces of cartilage which are
tough and rubbery act as
“shock absorbers” between
the femur and tibia.
Anatomy of the Knee
• The knee joint is
surrounded by a thin
lining called the
synovial membrane.

• Synovial membrane
releases synovial
fluid, a fluid that
lubricates the
cartilage and reduces
friction.
Pathophysiology of Knee
Osteoarthritis
• The cartilage in the
knee joint gradually
wears away and
becomes frayed and
rough.
• Protective space
between the bones
decreases
Pathophysiology of Knee
Osteoarthritis
• The bone underneath the
cartilage reacts by
growing thicker and
becoming broader.
• The bone at the edge of
the joint grows outwards,
forming painful bone
spurs called osteophytes.
• The capsule and
ligaments slowly thicken
and contract.
Causes of Knee Osteoarthritis
• Age more than 55 years old
• A woman
• Repetitive stress injuries
- H/O fall in the year 2000
- Previous job as a maid, do a lot of activity
that can stress the joint, such as kneeling,
squatting, or lifting heavy weights (55
pounds or more)
Wear and Tear Theory of Aging
• Wear and tear theories of biological aging
propose that aging in humans and other
animals is simply the result of universal
deteriorative processes that operate in any
organized system.
• Damage accumulates when the body fails
to repair itself (Anti-Aging Today, 2013).
Wear and Tear Theory of Aging
• This aging theory is applicable to our
client whom is having knee osteoarthritis
where the cartilage of her both knee joint
gradually wears out as she grow older.
• Body repairs the damage by letting the
bone under the cartilage grows thicker
and broader whereas tissues in the joint
become active than normal.
Wear and Tear Theory of Aging
• Osteophytes are formed and this cause her
knees to swell and painful.
• Although the body tries to repairs the
damage, it does more harm than good
which is a proof of failed repair thus
automatically support the wear and tear
theory of aging.
PHYSIOLOGY OF
CARDIOVASCULAR
Factors Contributing to Hypertension
• Excessive sodium intake
• Body experience stress
• Genetic alteration
• Obesity and endothelial
• Poor cardiovascular system
Pathophysiology of Hypertension

Medication
LMS cream (Methyl
Salicylate/menthol topical
analgesic cream)
Intra articular Lignocaine
2ml + Prednisolone 3ml
(stat dose on the 13th Aug,
2015)
Pharmacology
Indication Nursing Implication
Temporary relief of minor • Ensure client is not
aches and pains caused by allergic to any ingredient
osteoarthritis. in methyl
salicylate/menthol
cream, including oil of
wintergreen.
• Assess the area where
client need to apply this
cream for any wound or
skin breakdown.
Offer relief of • Note for side effect of
inflammation/symptoms of this medicine after the
knee OA which lasts from first two days of
days to weeks. administration which are
pain and swelling.
 Pharmacology
Medication Indication Nursing Implication

Syrup Expectorant 10ml To treat coughs and • Carefully measure the dose
TDS congestions caused by using a special measuring
common cold, bronchitis, device/spoon in order to
and other breathing decrease the risk of side
illnesses. effects.
• Advise client to drink plenty
of fluids while taking this
medication as fluids will help
to break up mucus and clear
congestion
Acetaminophen Used as a pain reliever. • Supervise client in case she
(Paracetamol) 1g PRN takes other over-the-counter
medications as many
medication contain
acetaminophen/paracetamol
and this may cause client to
 Pharmacology
Medication Indication Nursing Implication

Amlodipine (Calcium To treat hypertension • Administer on empty

Channel Blocker) 5mg stomach.
OD • Monitor BP for effectiveness
of treatment.
• Check for signs and
symptoms of side effect such
as irregular heart beat, SOB
and edema.
 Nursing Assessment
1. Physical Assessment
2. Functional Assessment
3. Psychosocial Assessment
PHYSICAL ASSESSMENT
 Head to Toe Examination
• Respiratory system
– No adventitious breath sounds such as fine
crackle, coarse crackle, sonorous wheeze
(rhonchi), sibilant wheeze, pleural friction rub, and
stridor are heard upon lung auscultation.
• Heart
– No abnormalities
• Neurological assessment
– 12 cranial nerves were normal
 Head to Toe Examination cont…
Passive and active ROM:
Musculoskeletal – Flex knee with calf touching
System thigh.
• Upper limb has no – Extend knee beyond normal
abnormalities point of extension.
– Rotate knee and lower leg
• Lower limb
toward midline.
 Muscle wastage
 Head to Toe Examination cont…

Joint Assessment

• Bunions formation
present at her foot
 Vital Sign
Blood Pressure: 133/87mmhg
Pulse: 72bpm
Respiration: 21/min
Temperature: 36.7°C
FUNCTIONAL ASSESSMENT
 Katz Index of Independence
• Tool for assessing an older adult's baseline
ability to bathe, dress, use the toilet, transfer,
remain continent, and feed herself or himself
(Wallace & Shelkey, 2008).
• The scoring: 6 over 6
• Therefore, it shows our client is highly
independent in doing ADLs.
 Modified Barthel Index
• Covers 10 domains of functioning (activities):
bowel control, bladder control, as well as help
with grooming, toilet use, feeding, transfers,
walking, dressing, climbing stairs, and bathing
(Shah, Vanclay, & Cooper, 1989)

• Asked questions and through direct observation.

• The total scoring: 87 over 100
• According to MBI our client can be discharged to
community because she is independent in
transfers and able to use the wheelchair
independently.
 Tinetti Assessment Tool
• The balance portion of the tool evaluates the client's
balance while sitting, standing, and turning in various
circumstances. The gait portion assesses gait initiation,
stepping, trunk sway, stance, and other factors
(Ponce, 2012).
• Balance score: 8
• Gait score: 5
• The total score for Balance & Gait: 13/28
• Therefore, our client’s score is 13 as she is at the high
risk for falling.
PSYCHOSOCIAL
ASSESSMENT
 Mini Mental State Examination
(MMSE)
• The Mini Mental State Examination (MMSE) is the
most commonly used instruments for screening
of cognitive function.
(Boer, Mattace-Raso, Van Der Steen, & Pel, 2014)
• Not suitable for making a diagnosis, but can be
used to indicate the presence of cognitive
impairment, such as in a person with suspected
dementia or following a head injury.
(Sallam & Amr, 2013)

• The total score: 17 out of 30

Element in MMSE

Client’s Drawing
 Geriatric Depression Scale
• A self-report measure of depression in older
adults
(American Psychological Association, 2015)
• These tools which consist of 15 items were
chosen because of their high correlation with
depressive symptoms in previous validation
studies
(Sheikh & Yesavage, 1986)

• The total scoring: 1 over 15,

• Shows that she is not depress
Nursing Diagnosis
Nursing Diagnosis: High risk for fall related to muscle weakness.

Goal: Client will not fall when doing activity of daily livings (ADLs) in Rumah Seri
Kenangan.

Interventions:
1. Observe client while doing the activities such as getting up from a chair,
transfer from wheelchair to bed, raising the foot completely off the floor
and sitting down, which to provide clinical information to identify fall risk
of the client.
2. Rise up the bedrail when client is on the bed to prevent her fall from bed.
3. Assist client while ambulating and transferring to avoid falls.
4. Teach client about how to use the lock system of the wheelchair to
promote independence.
5. Teach client on how to get up from a fall and how to get help so that
immediate interventions could be provided by the social worker.
6. Provide client the emergency plan, such as a put bell near the bed or on
the floor in case client cannot get up and want to get help immediately.

Evaluation: Client does not fall while doing activity daily livings (ADLs) in
Rumah Seri Kenangan.
Nursing Diagnosis: Impaired physical activity related to decrease muscle tone as
evidenced by assessment of musculoskeletal; muscle waste on lower limbs.

Goal: The client will maintain maximum physical mobility and will not develop
complications of immobility such as muscle atrophy and contracture.
Interventions:
1. Assess for the strength and mobility of musculoskeletal system to monitor level of
mobility either maintain or deteriorate. Contact with physicians or physiotherapist
for further management.
2. Instruct client to perform range of motion exercises at least 3 times/ day. Passive
ROM exercises help maintain joint mobility, prevent contracture and improve
circulation.
3. Reinforce instructions, activities and plans recommended by the physio/
occupational therapy to increase client’s participation in exercise.
4. Use walking belts when transferring the client to ensure safety of the client.
5. Place client’s belongings near the bedside and at reachable place to prevent
injuries.
6. Put bed rails up at all time and put bed in the lowest position to avoid fall.
Evaluation: Client maintains maximum physical mobility and does not develop
complications of immobility such as muscle atrophy and contracture.
 Health
Education
 Diet
Limit the intake of
high sodium foods
Obtain a well-
balanced diet while
consuming fewer
calories to avoid
weight gain.
Advised client to eat
more fruits and
vegetables compared
to junk foods.
 Exercise
Seated Hip March
 Sit up straight on a chair

Lightly kick the left foot back a few inches

underneath the chair, keeping toes on the
floor for support.

Lift the right foot of the floor, keeping the

knee bent at 90-degree angle

Repeat 10 times for

each foot
 Social Lifestyle

Advised her not to be

shy asking for helps
from other residents or
even staffs.
Encourage her to
socialise
Encourage spiritual
 Conclusion
As one grows older, a person will have
changes in her/his physical and psychological
aspect.
As a healthcare practitioner, we should notice
the changes in the older adult to plan early
intervention to promote care in the elderly.
Apart from that, we have to really take care of
our parents because their health might reduce
in split of seconds.
 References
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 References
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