Case Study

I.
Client Profile
a. Pesonal Characteristics
Siti is an elderly 65-year-old single Indonesian Women. She is staying at home and live with
her sons family. She still actively participates in religious activity which is held every week
in the area where she lives. Siti complate her senior high school in education. She enjoys
active with her grandchildren, knitting clothes and cooking.
b. Current Health Orientation
Since 5 years ago, she noticed urine loss with exercional activities.
c. Family caracteristics
Sitis husband had died five years ago. She currently lives with her first sons family. She
has two grandchildren aged 5 and 7 years old.
d. Environtmental Characteristics
She currently lives in a nice neighborhood . Sitis house located in urban areas and close to
public facilities. The hospital is only 5 km from her home.
II.

Universal Self-Care Requisities

a. Air
Siti dan all family members do not smoke. She lives in urban area where so much pollution.
b. General Health Habit
1. Siti practices good health habit. She walked around the housing complex every
morning. She visits her physician when appropriate. Her vital sign are all within
normal limits. Siti drink almost one and a half liters of water a day. She also
drink a cup of green tea every morning.
2. Review of system
-

Skin : no rashes, scaling, lesions, growth and tumors

Hair : long stright hair

Nails : denies any changes in appearance

Breast : denies any pain, lumps or nipple discharge. No family with breast
cancer

Respiratory : there is no history of asthama. Lungs are clear to ausculation

and percution

Cardiovascular system: denies palpitation, heart murmur, hypertension.

Integument : no evidence of dehydration. Skin has good turgor.

Urinary system : she noticed urine loss with exercional activities.

c. Food
Denies any special needs for food preparation or dietary modifications. She denies
any change of her weight and does not any problem with digestion.
d. Elimintaion
1.Health habits: bowel movements every day.

Denies use of laxatives or stool

softeners. Complains of urine loss associated with exertional activities without

urgency. Voids 8 times per day.
2.Reviews systems:
-

Bledder: complains of urinary incntinence associated with activities such us

runing and coughing.

Bowel : denies hemorids, diarrhea or constipation

e. Activity and rest

Siti enjoys walking around her house complex every morning. She requires 6-8
hours sleep. Denies using alcohol and smokes.
III. Developmental Self Care Requisities
Siti is functioning normaly for her developmental stage
IV.

Past Health Deviation Self Care Requisities

a. Seeking appropriate medical assistance : siti has regular doctor examinations.
Her recent complaint of UI is upsetting to her
b. Attending to pathological states: Siti need medical intervention to treat her
problem with UI. She wants to adress the problem now to prevent the symtom
from becoming wrose.
c. Carrying out medicaly prescribed measures : siti did kgel exercise as
prescribed by her doctor.
d. Attending to deleterius effects of medical care measures : siti realize her
incontinence symptomatology will increase if she doesnt adress the problem
now
e. Modifying ones self-concept: siti has no complaints or evidence of depression
associated with her complints of UI

f. Learning to live with effects of pathological conditions : realizes incontinence

is not a life threatening condtion. However, she realize that long term effects
of UI may alter her quality of life.
V.

Present Health Deviation Self-Care Requisities

a.

Seeing appropriate medical assistance : siti has set up some appointment to

meet doctor to adress her problem with UI

b. Attending to pathological states : siti desires prevention of her symtoms from

increasing
c. Carrying out medically prescribed measures : has attempted kegel exercise in
the past.
d. Learning with concept to live with the effects of pathological conditions: siti
accepts the diagnosis of UI and reality of addresing the condition before
symtoms get worse. Has cosen not to undego a surgical intervention at this
elderly age

Diagnosis
Nursing Diagnosis :
1. Knowledge deficit related to non surgical treatment of urinary incontinence.
a. Nursing system : supportive educative
b.Self care deficit : elimintation : seeking information related to urinary incontinence.
2. Altered patterns of UI
a. Nursing system : supportive educative
b.Self care deficite : elimination : UI associated with exertional activities
3. Potential for depression with increasing symptomatology asscociated with aging
process
a. Nursing system : supportive educative
b.Self care deficite : normalcy associated with self-concept
Goal
1. Increased knowledge base to the causes and types of UI
2. Increased awareness as to the nonsurgical care of urinary incontinence
3. Increase knowledge as to the use of pelvic floor muscle and other behavioral
interventions to decrease symptomatology.
Plan
Clients Responsibilities
1. Listen to explanations of causes, types

Nursing Responsibilites
Provide comfortable environtment for

and treatment of UI
2. Utilize the information gained to

education proscess
Encourage client to express feelings and

decrease potential for depression.

3. Keep bladder diaries

provide education to improve potential

quality of life issues
Encourege client to complete the diaries by
informing her about the importance of the
document. The nurse should also interpret the

4. Do prescribed pelvic floor excercises at

home and during activities that cause UI
5. Return to office for followup session as
prescribed
Evaluation

diary weekly
Encourege pelvic floor excercises per client.
Monitor weekly sessions, looking for
improvement and changes in status
Set up appointements and followup as needed

1. Within the first week, siti should able to restate the couses, types and treatment of
UI
2. Within 4 weeks adecrease in the syptoms should be noted by increased use of
pelvic floor muscle and increase knowledge of the activities that trigger UI
3. Encourege siti to monitor symptoms and call for appointments to return to office
if any time symptoms return of changes in urogenital