Nursing Case Study Parkinson's Disease

Thomas Aitken

1) Introduction

The following discussion shall be about Parkinson’s disease with an emphasis on the disease’s association with John Magill. In Australia, deaths because of Parkinson’s disease comprised 19. 8% of deaths from nervous system disease in 2010 (Australian Bureau of Statistics [ABS], (2012). The aetiology and risk factors associated with the disease shall be discussed, in addition to its clinical presentation and the required essential physical assessments. Furthermore, the medical management of the disease shall be developed before concluding the discussion.

John’s vital signs appear unremarkable although his respirations are slightly elevated which is most likely due to anxiety-worrying about medications. He has a sick wife suffering from multiple myeloma. This is a form of cancer that would reduce her ability to care for John. John may also be suffering from depression, as evidenced by his teary manner.

It was also noted that there was a skin tear to his right hip and that he started to cough when given a drink of water. There could be a risk of infection with the skin tear and the risk of aspiration due to dysphagia. He had a fall, suffered bruising, has tremor’s and moves slowly.

2) Possible causes / risk factors related to the health condition.

There is no known definitive cause as to why people contract Parkinson’s Disease, although there are several theories regarding the condition. One hypothesis is that it may be due to genetic and environmental components (Schapira, 2010). However, this has not been fully substantiated. It may also involve a combination of factors ranging from environmental influence to viral infections. (Foltynie, Lewis, Barker,2003,).

More males seem to acquire the condition than females and age seems to be connected with the condition most people are diagnosed at about 60-65. Although younger people have also been effected it’s less common. The condition develops slowly and takes about ten to twenty years for the full impact of the condition to be felt. John Magill is about mid-way in terms of this disease and will need careful management. These factors together may result in the death of the dopamine-containing nerve cells. Because, there could be a variety of causes of the condition this could explain why Parkinson’s has different effects on people. The main theories as to why Dopamine cells die, difficulty clearing toxins, inflammation, accelerated aging process, neuron’s inability to clear protein, and genetic factors. (Grimes,2004,)

In the early stages the risks are minimal, but as medication loses its effect risks to sufferers increase. The mains risks are, falls, depression, swallowing, memory, impaired verbal communication, imbalanced nutrition. John has a number of these issues.

3) Discuss clinical manifestations of Parkinson’s disease and key physical assessment.

The patient is best diagnosed by a neurologist or an expert with this condition, the physical signs are noted and observed over time, the most obvious being the tremor. This is the best way to diagnose Parkinson’s. The disease may present with both non-motor and motor symptoms, sometimes the non -motor precedes the motor symptoms. John has the classic resting tremor in his arm and his movements are getting slower.

John also suffers from secondary motor symptoms, like difficulty in swallowing which can be very serious resulting in weight loss, choking and pneumonia. (Theodoras & Ramig, 2011) Other problems to look for would be speech, gait freezing which can increase a person’s chance of falling. The patients face tends to be less expressive and they have a fixed stare.

There are also the Non-Motor Symptoms, like Depression, anxiety, which are two conditions that have been noted in John Magill. Apathy and hallucinations sleeping fatigue and dementia. Nonmotor symptoms may even occur prior to other symptoms and can be even more debilitating than other aspects.

Physical assessment for John would include the four main clinical features of the disease resting tremor, rigidity, postural instability and bradykinesia. Resting tremor can be assessed with the patient resting and in a relaxed sitting position with arms placed on lap (Hauser, 2016).

4) Discuss medical management including medications.

John would require a team of health professionals to help manage his condition. They would include the following, nurse, physiotherapist, occupational therapist, speech therapist, social worker, psychologist, neurologist, GP and carer. The condition will get progressively worse over time and as John gets older it becomes more difficult to deal with. However, by slowing the progression of the disease and reducing its impact just maybe a cure could be found in the future.

John is already on the best available drugs to control his condition. Levodopa (also called L-dopa) is the most commonly prescribed and effective drug used. (Boelen, 2009) The drug reaches the brains nerve cells that produce dopamine which can help as a neurotransmitter. Carbidopa in addition to Madopar are significant in increasing the bioavailability of levodopa in the brain through the inhibition of decarboxylation and consequent inactivation of levodopa Management of John’s non-motor symptoms is also essential, in particular depression, he has been prescribed Citalopram. With these medications, the correct dosage and the timing of the dosage is critical in achieving their full effect.

5) Develop a holistic nursing care plan using NANDA in order of priority.

The Nursing Process

A) three nursing diagnosis–

1) Risk of aspiration due to impaired swallowing reflex

2) Impaired skin integrity due to trauma resulting from a skin tear (right hip)

3) Impaired physical mobility related to his fall and body tremor.

b) Goal for each

1) Patient will not aspirate when drinking fluids.

2) Patient skin integrity will heal and remain intact.

3) Patient will maintain optimum mobility and balance to avoid falls.

c) Three nursing interventions for each

1) a) Ensure medications are administered as directed at correct time’s) Ensure patient is sitting upright (greater than 45 degrees) c) Encourage patient to double swallow. Thickened fluids may be required.

2) a) Where able ensure the skin edges are approximated. b) Ensure that the wound is protected from potential contaminates. C) Ensure that a wound assessment and chart is commenced.

3) a) John shall be assessed for mobility skills. b) John shall be tested for balance. c) John can be taught the correct walking technique to avoid falls.

d) Three rationales for each

1) a) Administering Parkinson’s medication at the appropriate time will assist with the swallow reflex. b) By sitting upright there will be less chance of fluid going into lungs. c) Double swallow and thickened fluids will reduce coughing reflex. Use of a straw to help build oral strength (Theodoras & Ramig).

2) a) By ensuring skin edges on wound are approximated wound will heal better and more quickly. b) Good protection of the wound will help prevent infection. .c) The chart will help monitor the progress of the wound and when to change dressing.

3) a) Physiotherapist will assess John’s mobility skills he may need an aid like a walking frame. b) John will be tested for balance can he walk a straight line. c) John will be helped to improve walking technique by demonstrating small steps, and turning techniques.

Evaluation

Diagnosis 1) Patient demonstrates improved swallowing with no coughing

2) Wound appears to have healed or is on the improve with no infection.

3) John has not had any falls for a set time and is using walking frame..

6) Discharge Plan

A discharge plan starts from the moment a patient enters a hospital environment.

Before John can be released from hospital it is very important that a number of things are put in place in order to reduce the chances of John returning to emergency suffering from another fall which may be more damaging to his health. Patient education is significant in order for John to understand and cope with his condition. (Myeres & Gulanick, 2013).

Ideally, John’s family should be included regarding discharge particularly in regards to making adjustments at home so that falls are prevented. John may need to wear hip protectors, rugs on floor may need removing and safety rails installed.

In general, a basic discharge plan will include the following,

Evaluation/, with patient by qualified personnel/ Discussion, with patient/Planning, transfer from hospital to home. / Determining if care at home is sufficient or support may be required/ Referrals, to support agency. Arranging follow up appointments.

7) Conclusion

Parkinson’s disease is a chronic and debilitating condition that effects over 70,000 Australians. There is no cure and this can be a very difficult concept to accept.

John Magill will be faced with many challenges going forward and he will require a dedicated team of health professionals to assist him coping with the rigours of life.

Because John’s wife is not well he will most certainly need home nurse visits if he is to live independently, which is what most people aspire to do. Keeping John as healthy as possible will be the goal of health care providers. The day may come when John must go into full time care. However, it really depends on John maintaining a positive attitude with a strong desire to enjoy life for as long as possible.,

Word Count 1522 within in 10% of Max 1400

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