Mindanao State University-Iligan Institute of Technology

COLLEGE OF NURSING
Andres Bonifacio Avenue, Brgy. Tibanga, Iligan City, 9200, Lanao del Norte

NSG 131.1 CARE OF OLDER PERSON DUTY

CASE STUDY AND ELDERLY FILIPINO WEEK CELEBRATION NARRATIVE

REPORT

Submitted by:
Sammy Jr V. Familar
November 2022
 Older Adult Case Study: 81-Year-Old Senior Citizen in Barangay Sta. Elena
I. Abstract
This case study is made to know if the client/patient of our choice has a present health
problem that needs a serious medical attention or immediate interventions. As for my
client/patient, I have chosen my grandmother. She does not have any current health problems
or any diagnosed health concerns. She does take any maintenance medicine, but she only takes
some vitamins. She likes to sew; this is her source of income and her hobby. Her MMSE and
GDS results was good because she was not depressed, and she does not have any cognitive
impairment. She is risk for aspiration for the reason of experiencing choking because of food
and water, so many times. She is also risk for fall because you can observe that she is taking
time in walking and even in taking a sit, you can also see that she is shaking when lifting a pen
or when she drinks water from a bottle. All in all, my client is healthy physically and mentally,
but she needs someone to look out for her because she is at a high risk of aspiration and because
of her old age and muscle weakness she is risk for fall. She still needs to be monitored and not
left alone even if she is healthy.
 II. Client Characteristics
Demographic information
Patient Name: Patient E
Age: 81
Birthday: September 12, 1941
Gender: Female
Address: Block 7, Lot 10 Sta. Elena, Iligan City
Place of birth: Samar, Leyte
Marital Status: Married
Religion: Roman Catholic
Education: High School Graduate
Patient E reported that she has no current health problems and any maintenance meds
taken. She only takes vitamins every morning after eating breakfast. She also reported that she
experiences cough and colds last week and it only lasts for 3 days after taking a medicine. She
also reported that the last time that she was being check-up was when she was getting her
vaccine for covid-19. She is fully vaccinated and has a booster of the vaccine; AstraZeneca and
she has not experienced any side effects. She has no hereditary diseases, but her son and
daughter are both hypertensive. She also reported that her hobby is sewing, and she makes
money from it. At the moment, she does not experience any health problems and she does not
have any complains about her health. She has no previous medical history.
Nursing diagnosis
• Risk for aspiration r/t decrease swallowing function as evidence by patient reports
choking several times because of food and drinks
• Risk for fall related to decrease muscle function

Co-morbidities
• Dry mouth
• Bad breath
• Decrease swallowing function
• Muscle weakness
• Muscle tingling
 III. Examination Findings
MMSE
• My patient’s/client’s score in the MMSE is 28. This score means that my patient/client
is in a normal state, and she does not have any cognitive impairment. Although she has
a high score on the MMSE, I can observe that she does take some time to answer the
question and while drawing the object and writing the sentence I can see that she does
not have steady hands and it is shaking though she was not nervous or anxious. But
overall, the result of the examination and based on my observation, my patient/client is
normal and does not have any cognitive impairment.
GDS
• My patient’s/client’s score on the GDS or Geriatric Depression Scale is 3. This means
that my client/patient is not depressed, and she is looks and acts fine. Based on my
observation, my client/patient have answered the questions genuinely, and she is very
energetic and bubbly. I do not see any signs or her being depressed. To conclude, based
on her score on the GDS and base on her actions she is not experiencing depression
now.

IV. Nursing Hypothesis

Risk for aspiration is based on her health history and because of her old age. She is in
a very high risk of aspiration because they have decreased swallowing function. Then, the client
will be having a hard time recovering oxygen which then results to dyspnea and other
complications. This is the reason why she is at a high risk of aspiration.
Risk for fall is based on her age, NA1, and my observations. She has already muscle
weakness and she tends to be left alone at home. This nursing diagnosis is just a precaution to
make sure that she will not be experiencing any accidents.
V. Recommended Intervention
Risk for aspiration r/t decrease swallowing function as evidence by patient reports choking
several times because of food and drinks
Time Intervention Rationale
7:00am – • Assess level of consciousness • The primary risk
7:05am factor of aspiration
12:00pm – is decreased level
12:05pm of consciousness.
7:00pm –
7:05pm
7:05am – • Monitor respiratory rate, depth, and • Signs of aspiration
7:15am effort. Note any signs of aspiration such should be identified
12:05pm – as dyspnea, cough, cyanosis, wheezing, as soon as possible
12:15pm or fever to prevent further
7:05pm – aspiration and to
7:15pm initiate treatment
 that can be life-
saving.
7:15am – • Elevate the client to the highest or best • Adults and children
7:18am possible position for eating and should be upright
12:15pm – drinking. for meals to
12:18am decrease the
7:15pm – likelihood of
7:18pm drainage into the
trachea and to
reduce reflux and
improve gastric
emptying.
7:18am – • Provide foods with consistency that the • Thickened
7:20am patient can swallow. semisolid foods
12:18pm – such as pudding
12:20pm and hot cereal are
7:18pm – most easily
7:20pm swallowed and less
likely to be
aspirated.
7:20am – • Allow the patient to chew thoroughly • Well-masticated
7:25am and eat slowly during meals. food is easier to
12:20pm – swallow, food cut
12:25pm into small pieces
7:20pm – may also be easier
7:25pm to swallow.
8:00am • Provide oral care before and after • Oral care before
1:00pm meals. meals reduces
8:00pm bacterial counts in
the oral cavity. Oral
care after eating
removes residual
food that could be
aspirated at a later
time.
.
Risk for fall related to decrease muscle function
Time Intervention Rationale
8:00am – • Clear environment for hazards. • To prevent injuries.
9:00am
9:00am – • Provide appropriate day or night • To give appropriate
9:10am lighting vision for the client.
9:10am – • Model safe practices during client • To encourage patient,
10:10am interventions. have safe environment.
 10:10am – • Consider hazards in the care • Identifying needs or
10:30am setting and/or home/another deficits provides
environment. opportunities for
intervention and/or
instruction
10:30am – • Ascertain the client’s significand • May reveal a lack of
11:00am other’s level of knowledge to understanding,
safety needs. insufficient resources,
simple disregard for
personal safety, a lack
of appreciation for
effects of current
condition or a lack of
resources to attend to
safety issues in all
settings.

VI. Expected Outcome

Risk for aspiration r/t decrease swallowing function as evidence by patient reports choking
several times because of food and drinks
After 8-72 hours of nursing intervention, the patient/client will:
• The client will experience no aspiration as evidence by clear breath sounds.
Risk for fall related to decrease muscle function
After 8-72 hours of nursing intervention, the patient/client will:
• The client will verbalize understanding of individual’s risk factors that contribute to the
possibility of falls.
• Demonstrates behaviors and lifestyle changes to reduce risk factors and protect from
injury.

VII. Discussion
The client’s/patient’s nursing diagnosis is based on the interview that I have conducted with
her. The risk for aspiration is based on her history of experiencing aspiration many times. Then,
risk for fall is based on her age, on the NA1, and my observation. She does not have any current
health problems and any diagnosed health problems. That is why I have come up some nursing
diagnosis base on her health history and my observations.
Client’s/patient’s score on MMSE and GDS are normal. They both have great results. It shows
that she does not have any cognitive impairment and depression. It is also visible to her that
she can response well and she is very bubbly. She is still doing her hobby and making income
out of it, which is sewing.
Overall, my client/patient is healthy mentally and physically. Though she is now at old age,
she is still very bubbly. Still, she must not be left alone even in home, and especially when she
is going out because she is now weak and has a high risk of aspiration. She needs a guardian
to look out for her so that she will be safe.
VIII. References
F. A. Davis Company (2022) Nurse’s Pocket Guide Diagnosis, Prioritized Interventions, and
Rationale 16th Edition.
Wayne G. (2022) Risk for Aspiration Nursing Care Plan. https://nurseslabs.com/risk-for-
aspiration/#:~:text=The%20primary%20risk%20factor%20of,cyanosis%2C%20wheezing%2
C%20or%20fever.