Western Mindanao State University

College of Nursing

In Partial Fulfillment of the Requirements in NCM 114

(Care of the Older Adults)

Submitted to:
Emilie Tan, RN, DNS
NCM 114 Instructor

Submitted by:
Duran, Fatima Medriza B.
BSN – 3B

S.Y. 2020 2021

 Client’s Profile

Name: Client N

Age: 62

Date of Birth: April 30, 1958

Weight: 75 kg

Height: 5’ 0”

Address: Mango Drive Tumaga,

Zamboanga City

Sex: Female

Civil Status: Married

Occupation: Housewife

Educational attainment: College

Graduate

Ethnic Group: Tausug

Dialect/Language Spoken: Tagalog,

Tausug, English, Arabic

Religion: Islam
 Health Assessment
A. General Health habits
- Mrs. Duran believes that her general health habits is the reason as to why
all of this time, she is still able to do some things that other people of her
age cannot. Mrs. Nurhaida includes lots of vegetables and steamed meals
into her diet. Her meals are mostly comprised of fish, rice, vegetables
such as cauliflower, carrots and celery. She does not have any problem
with food, however, she does not eat food that are oily and unhealthy.
Also food that is haram as it goes against her religion. She also fasts twice
a week, on Mondays and Thursdays. She does this not only because of
her religious beliefs, but because she stated that it helps her stay fit and
helps her regulate her food intake. Mrs. Nurhaida drinks a lot of water in
day. She says it helps her void regularly. Included in her general health
habits is her regular exercise. Mrs. Duran exercises for 1- 2 hours a day,
she believes that exercising helps her regain and maintain energy. She
utilizes walking exercises and zumba sometimes. The client rests when
she’s tired and has no problems with her sleep. She takes a nap in the
afternoon if she feels tired. She sleeps for approximately 7-8 hours a day.
She sleeps at 10 pm and then wakes up at 4:30 AM to pray. The client
does not smoke nor drink alcohol. She wears her corrective glasses
because of her vision difficulty. She is not using crutches or supportive
devices. The client is able to perform her ADL without help, however, she
gets tired depending on the activity done. The client is still able to use her
cognition and make decisions for herself.
B. Current Health
- The client states that she feels healthy overall. The client is currently
diagnosed with Hypertension. Mrs. Nurhaida has difficulty in reading or
watching without her glasses. She has maintained her weight from the
previous year as she has been exercising and complying with her diet. The
client stated that she feels pain on her knees, back. She tends to feel
dizzy and lightheaded and also complains of headaches sometimes. Client
does not experience any swelling. She tends to have shortness of breath
quickly when doing strenuous activities such as exercising. Client is not
taking any vitamins.

C. Past Health
- The client was fully immunized when she was young. However, the client
stated that she would go to the Barangay Health Center to get herself
immunized with Anti- Pneumonia. She was a nurse in Saudi Arabia back
then, so she was also vaccinated that time. When the client was young,
she had measles, smallpox but she was fairly health, as stated by the
client. As an adult, she never really had any complications with her
health, other than the fact that she was diagnosed with hypertension
when she was pregnant with her last-born son.

D. Family Health history

- Mrs. Duran’s father died of lung cancer, which was then followed by her
mother’s death that was also caused by cancer. Her family mostly
consists of diseases like diabetes, hypertension and cancer.

E. Medication
- For her hypertension she takes Nifedipine and Telmisartan Micardis.
 Physiological/ Physical
a. Integumentary System

– Upon palpation, Mrs. Duran’s skin appeared to dry and sagging. Loss of elasticity is
visible. There were no lesions, masses and wounds, or any skin injury. No loss of
sensation was observed. Client stated that she had no skin problems, except that her
wounds tend to heal slowly. The client uses lotion and other skin moisturizing products
to help maintain skin moisture.

b. Musculoskeletal System

– Mrs. Duran complains of pain in the joints, and knees. She does not have any problems
with posture, and stance. The client complains of stiffness sometimes. Mrs. Duran also
has osteoarthritis. She has never gone through any accidents. Mrs. Duran is not using
any assistive device but she uses memory foam sometimes to help cushion her knees
whenever she prays.

c. Respiratory System

– The client does not have much problems with her respiratory functions. Mrs. Duran
does not smoke and is not exposed to environment pollutants. There were also no signs
of difficulty in breathing observed, unless there was exertion. Tactile fremitous is
normal.

d. Cardiovascular System

– Going back to the client’s family history, many of her relatives and even her parents
were diagnosed with hypertension. In 1995, Mrs. Duran was diagnosed with the same
disease. According to her, she was diagnosed with it after her pregnancy. The client
stated that she takes Nifedipine and Telmisartan to maintain her blood pressure in its
normal levels. Mrs. Duran restricts her diet to more steamed food, vegetables, fruits and
water. She also exercises regularly, approximately 1-2 hours a day. Her sources of stress
are either her children or financial issues. The client complies with her maintainance,
however, she tends to forget to take it sometimes. So whenever she forgets, she
complains of pain in the chest, lightheadedness and dizziness.

e. Hematopoietic & Lymphatic System

– The client’s skin looks pale and is cold to touch. Capillary refill is approximately 2
seconds. Client stated that she was never diagnosed with anemia. For her
immunizations, she has completed her vaccinations as a kid, however, client stated that
she was going to have herself vaccinated with anti-pneumonia. Mrs. Duran has not
experience any infections recently.

f. Gastrointestinal System

– The client stated that there were no unusual changes in her diet as she was already used
to eating the right food ever since she was diagnosed with hypertension. Mrs. Duran’s
meals mostly consisted of iron and zinc rich food like fish and fruits. She prefers to have
it steamed rather than fried to avoid the oil. Mrs. Duran fasts twice a week, on Mondays
and Thursdays, from 4: 30 AM to 6 PM approximately. She also exercises, she stated
that it helps her regulate her energy. She wears dentures and sometimes complains of
hyperacidity but other than that, no other gastrointestinal problems were noted.
g. Urinary System

– The client complains of irregular urination if she didn’t drink much water. Mrs. Duran
drinks coffee, tea and water. Urine color ranges from light yellow to clear. She is not
using any assistive devices or laxatives to aid her difficulties in urination. The client
stated that her last urinalysis showed high levels of uric acid.

h. Nervous System

– The client has aunts who have had stroke before. There is a delay in the movement of
the client’s left face. Mrs. Duran does not experience any sleeping disturbances and is
not taking any medication for her neurological function. The client has poor short term
memory and tends to forget some things quickly, depending on its relevance. Client is
still able to speak clearly, from concise thoughts and solve analytical problems. Mrs.
Duran has good balance and shows the right expressions when asked to. She also stated
that there she felt no changes of sensation. There were no sleep disturbances, tremors
and seizures noted.

i. Special senses

– Mrs. Duran uses corrective glasses to help her read, watch tv , and assist in seeing
clearly. She cannot read clearly without her glasses unless it is written in large fonts. The
client does not have any difficulty in hearing and is not using any hearing aid devices.
The client can still smell and taste accurately. The client showed no changes in
sensations.

j. Endocrine System

– Mrs. Duran has stated that there was history of diabetes in her family. There were no
changes in her weight and appetite. The client complains of easy fatigability and
increased thirst and fluid intake. The client also complains of vision problems and slow
wound healing. She does not get headache often. There are not much problems with
her gastrointestinal function, except complains of oral problems and hyperacidity. There
were no nodules on the neck upon palpation.

k. Reproductive/genitourinary System

– The client is married and has 4 children. The client does not use any medications for her
sexual function. Client has four children, two daughters and two sons. She had no
history of miscarriage and has no history of stillbirth or premature birth. She had her
menstruation started when she was 15 years old and menopause at the age of 49.
 Functional Health Pattern Assessment
1. Health Perception - Health Management Pattern

The client’s general health has improved. Her knee pains have lessened due to the fact
that she exercises every day. For the client’s past health history, she went to see a doctor
because of severe pain at the back of her head and is feeling dizzy for a couple of days. Later,
the physician diagnosed her with hypertension so the physician prescribed her antihypertensive
drug, nifedipine and telmisartan, to maintain her blood pressure. The client takes her
medication regularly and felt fine when taking it every 9 o’ clock in the morning. Just last
month, the client experienced weakness of her knees which she did not have checked. She
drinks UVA Herbal. An herbal tea, its main purpose is to boost her immune system. And
somehow taking this herbal tea regularly makes her condition a bit better. The following
medications mentioned above are effective in maintaining her blood pressure in normal levels.
To keep herself healthy, the client exercises for 2 hours a day as she has gotten used to
exercising already. The client has completed her immunization status when she was still
working in Saudi Arabia the last few years. And as for the family health status, her husband also
complains of knee pains, one of her children has asthma while the other 3 have no deviations in
their health. The same goes for her grandchildren.

2. Nutritional - Metabolic Pattern

Client usually eat three times a day wherein her meals were composed of half cup of
rice with either vegetables or fish, she also eats chicken meat sometimes, and a piece of banana
when it is available in the market in their community. She does not take any food supplements.
She prefers to eat vegetables, spicy food, flour-rich food such as instant noodles, and fruits. As
for her fluid intake, she drinks green tea in the morning and drinks plenty of water throughout
the day. The client does not eat pork as it is forbidden in the Islamic laws. Client cannot eat
hard food as she is using dentures and has decaying teeth that is painful when she tries to eat
hard food. The client does not have any allergies or allergic reactions to food. The client fasts
sometimes due to her religious beliefs. She fasts on Mondays and Thursdays, from 4:30 am to 6
pm. The client’s ability to heal is a little bit poor because it takes time for her wound to heal.

3. Elimination Pattern

Client eliminates soft to hard bowel for two times every two days and does not have any
bowel elimination discomfort. If she had a hard time eliminating bowel, she does not use any
devices and laxatives to aid it. She will just drink plenty of water and wait for her bowel to move
out completely. She has problems in urinating, even if she drinks lots of water throughout the
day. Client experiences excessive perspiration especially when doing activities and does not
have odour problems. She has no wounds because she avoids it due to the fact that her wounds
heal a little longer than the normal.

4. Activity - Exercise Pattern

Client has sufficient energy to accomplish things that she wants to do but with adequate
rest periods because her back aches when she is bending forward for a couple of minutes and
doing tasks for a long time. She exercises for 1- 2 hours every day, she verbalized “Baka sumakit
paa ko pag di ako nag exercise.”. She stated that her knees start to hurt when she does not
exercise. The client easily gets tired and pants even just walking a short distance but continue
to walk after resting for a while. As for her spare time activities, she likes to spend time with her
grandchildren, gardening, and reading the quran. Client is able to perform activities of daily
living.

5. Sleep - Rest Pattern

The client sleeps for approximately 7 hours a day. She is generally well rested and ready
for the day after sleeping. She sleeps at 10:00 P.M. and wakes up at 4:00 A.M. or 4:30 A.M.in
the morning to pray. During daytime, she does not take naps but spends her time worshipping
instead. She does not have sleep onset problems.

6. Cognitive - Perceptual Pattern

Client does not have any hearing difficulties. The client uses her corrective glasses to
help her see better. Client has become a bit forgetful, that she cannot recall some things. Her
back aches often and when it is just mild, she will just ask her children to apply some liniment
on her back to relief the pain and take a rest.

7. Self-perception - Self-concept Pattern

“ The client believes and described herself to be a hardworking person and also a pious
one. According to the client, there aren’t any changes in her mood but sometimes she gets
angry when her children do not listen to her. She sometimes feels incapable of providing for her
family, as her family is struggling to make ends meet. She feels strange about the things that
she cannot do anymore or still can do but with accordance to her health condition. The client,
however, is still trying to adapt herself to these changes so that she can be comfortable with it.
Client is happy, however, she wishes that she could provide more for her children and
grandchildren.

8. Role - Relationship Pattern

The client has an extended family structure. The family consists of her, her husband, and
their four children and three grandchildren. Her family member has a good relationship and
communication towards each member. The client’s family uses Tagalog and Tausug in speaking
inside the house. When her family faces problem, they talk it out so that it will be solved right
away and prevent further misunderstandings. The bread winner of the family is her eldest son
and daughter who are currently working abroad. The family’s income is not enough to sustain
the basic needs of the family. Regarding the client’s illness, the family members help the client
to do what she needs to do in order for her to feel well despite being diagnosed with
hypertension. The family allows her to take rests and not work too much even at home.

9. Sexuality - Reproductive Pattern

Client has four children, two daughters and two sons. She had no history of miscarriage
and has no history of stillbirth or premature birth. She had her menstruation started when she
was 15 years old and menopause at the age of 49.

10. Coping - Stress Tolerance Pattern

In times of crisis, the client gathers her children and talk about the problem to find some
solution and client also prays to Allah (S.W.T.) as she believes that He does not give problems to
us that we cannot solve. But most of the time, client tries to solve the problem with herself
because she does not want her children to have a hard time. When patient encounters a big
problem, she talks to her granddaughter sometimes and it sometimes helps her solve the
problem. According to the client, the big changes in her life are the ones pertaining to her
health and her financial state, also her faith in Allah.

11. Value - Belief Pattern

According to the client, the most important thing in life is family because family gives us
strength to live and do everything in life. Religion is also important in life. Having faith in Allah
(S.W.T) is also one of the most valuable things in a person’s life along with the capability to
forgive those who wrong you and choosing to always be good to people. She also said that
praying is the most important thing to do as long as we’re alive.
 Psychological Assessment

MINI - MENTAL STATUS EXAMINATION

Orientation of Time
Correct Incorrect
What is today's date? 1
What is the month? 1
What is the year? 1
What is the day of the 1
week today?
What season is it? 1
Total: 5
Orientation to Place
Correct Incorrect
Whose home is this? 1
What room is this? 1
What city are we in? 1
1
What county are we in?
What state are we in? 1
Total: 5

Immediate Recall

Say "ball", "flag", "tree" clearly and slowly,

about 1 second for each. After you have said Correct Incorrect
all 3 words, ask him/her to repeat them
Ball 1
Flag 1
Tree 1
Total: 3

Attention
Ask the individual to begin with 100 and
count backwards by 7. Stop after 5 Correct Incorrect
subtractions.
93 1

86 1

79 1
 72 1

65 1

TOTAL: 5

Repetition
Ask the individual to repeat the following:
CORRECT INCORRECT

"No if ands or buts “ 1

TOTAL: 1

Delayed Verbal Recall

Ask the individual to recall the 3 words

you previously asked him/her to remember. Correct Incorrect

Ball 1
Flag 1
Tree 1

Total: 3

Naming

Show the individual a wristwatch and ask

him/her what it is. Repeat for pencil. Correct Incorrect

Watch 1

Pencil 1

Repetition 1

Total: 3
 3-Stage Command

Give the individual a plain piece of paper and

say, “Take the paper in your hand, fold it in CORRECT INCORRECT
half, and put it on the floor. “
Takes 1

Folds 1

Puts 1

TOTAL: 3

Reading
CORRECT INCORRECT
Hold up the card reading: "Close your eyes"
so the individual can see it clearly.
1
Ask him/her to read it and do what it says

Writing

CORRECT INCORRECT

Give the individual a 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. 1
 Copying

CORRECT INCORRECT
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.
1
Theories of Aging