Case Study Parkinson's Disease UNFOLDING Reasoning, Lillian "Lilly" Marie Jones, 76 years old (Latest Update) | Download To Score An A.

Parkinson's Disease UNFOLDING Reasoning Lillian "Lilly" Marie Jones, 76 years old Primary Concept Nutrition Interrelated Concepts (In order of emphasis) • Collaboration • Patient Education • Communication • Clinical Judgment NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment Management of Care 17-23%  Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12%  Psychosocial Integrity 6-12%  Physiological Integrity Basic Care and Comfort 6-12%  Pharmacological and Parenteral Therapies 12-18%  Reduction of Risk Potential 9-15%  Physiological Adaptation 11-17%  Copyright © 2019 Keith Rischer, d/b/a KeithRN. All Rights reserved. History of Present Problem: Lillian "Lilly" Jones is a 76-year-old female with a history of hypertension, gastro esophageal reflux disease (GERD) and Parkinson's disease. Ms. Jones was hospitalized three months ago due to a urinary tract infection and dehydration. She is now a resident of Sunnyside Health Care Center, a local long-term care facility because her Parkinson's disease has progressed and her son, Jack, is no longer able to care for her at home. Lilly has lost ten pounds (4.5 kg) in the past month. She is 5 feet-6 inches (167.6 cm) weighs 110 pounds (49.9 kg) and has a BMI of 17.8. After one week of residing at Sunnyside, Jack visits and is saddened when he finds his mother in her room alone. Jack approaches the nursing station and states, "My mother is so thin and losing weight and sits just staring into space. I thought having her here was going to help her get better!” Personal/Social History: Lilly was married to John for 54 years before he passed away two years ago. She has one son, Jack, who lives 30 minutes away. Jack has a medical power of attorney for Lilly's healthcare decisions. Lilly was a homemaker and an active participant in her community. Her hobbies include knitting, playing the piano and reading. Lilly reluctantly has agreed to go to Sunnyside Health Care Center after her son accepted a job that required him to travel. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: 76-year-old female Hx of hypertension, Hx of gastro esophageal reflux disease (GERD) Parkinson's disease Lost ten pounds in the last month, 5 fett-6inches weighs 110 lbs. and BMI of 17.8 Son found his mother in her room alone staring into space Physiological changes occur with aging in all organ systems. Hypertension increases the risk of heart disease, stroke, and other cardiovascular disease GERD is a highly prevalent disease caused by the exposure of the esophagus to refluxed gastric contents, PPIs are the mainstay of current treatment The cardinal symptoms of Parkinson's disease are shaking, stiffness, and slowness and poverty of movement. The condition leads to physical signs including tremor at rest, rigidity on passive movement, slowness of movement (bradykinesia), and poverty of movement (hypokinesia). In patients with low body weight, the brain becomes starved and they can develop symptoms that meet the criteria for depression. A BMI of 20-25 is ideal; 25-30 is overweight and over 30 is obese. If the patient’s BMI is under 18.5, they considered underweight Chronic loneliness can have a significant impact on the overall health, including the mental health of the patient. Loneliness can increase the patient’s risk for depression RELEVANT Data from Social History: Clinical Significance: Husband, John, passed away two years ago Medical power of attorney, the son Jack, lives 30 minutes away Was a homemaker, an active participant in her community, and had many hobbies. She reluctantly agreed to go to Sunnyside Health Care Center after her son accepted a job that required him to travel. Coping with the death of a significant other isn’t easy. Grief can affect our body, mind, emotions, and spirit. A medical power of attorney is a legal document that names one person the health care agent of another person. The agent has the ability to make health care decisions and the responsibility to make sure doctors and other medical personnel provide necessary and appropriate care according to the patient's wishes. Due to the son living 30 mins away and at a new job it may be harder to get a hold of him or take longer for him to get to the facility to make medical decisions for his mother. Knowing this can help show just how differently Lilly is acting now that she is at Sunnyside Health Care Center. These changes in her behavior can be a sign of depression. Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 98.4 F/36.9 C (oral) Provoking/Palliative: "Better when walking a while." P: 90 (regular) Quality: "ache" R: 14 (regular) Region/Radiation: "Knees" BP: 112/70 Severity: "3/10" O2 sat: 98% room air Timing: "When I wake up." What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: Pain: aching knee pain 3/10 after waking, better when walking a while Pain is part of the body's defense system, producing a reflexive retraction from the painful stimulus, and tendencies to protect the affected body part while it heals, and avoid that harmful situation in the future. Joint pain is common with aging and can be difficult to differentiate from conditions like Arthritis and Parkinson's. Current Assessment: GENERAL SURVEY: Alert, flat affect and slow to respond to questions in a soft tone (hypophonia). Oriented and in no acute distress, dress appropriate for the season, hygiene and grooming normal for age and gender. Sitting with a forward leaning posture. NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4); muscle strength 4/5 in both upper and lower extremities bilaterally. Tremors noted at rest in hands. HEENT: Head normocephalic with the symmetry of all facial features, but tremor noted. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and tacky dry. RESPIRATORY: Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort on room air. CARDIAC: Pink, warm & dry, no edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2, noted over A-P-E-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. ABDOMEN: Abdomen round, soft, and nontender. BS hypoactive in all four quadrants. GU: Urinary Incontinent episode x1, urine yellow INTEGUMENTARY: Skin oily but warm with normal color for ethnicity. No clubbing of nails, cap refill <3 seconds, Hair soft, distribution normal for age and gender. Skin integrity intact, skin turgor elastic, tenting present. What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: General: Alert, flat affect and slow to respond to questions. Sitting with a forward leaning posture. Neuro: Tremors noted at rest in hands. HEENT: tremor noted. Lips, tongue, and oral mucosa pink and tacky dry. Abdomen: BS hypoactive in all four quadrants. The patient’s slow response to questions and postural instability can be a clinical manifestation of her Parkinson Disease. Flat affect is a severe reduction in emotional expressiveness which can be a sign of depression, which can also be a nonmotor clinical manifestation of her Parkinson Disease The patient’s tremor is most likely a motor clinical manifestation of her Parkinson Disease The patient s lips, tongue, and oral mucosa is tacky dry. This can be caused by not drinking enough fluids, sleeping with mouth open, dry hot weather, eating dry foods, or medication side effects. Hypoactive, or reduced, bowel sounds often indicate that intestinal activity has slowed down. Hypoactive bowel sounds are normal during sleep, after the use of certain medicines, and after abdominal surgery. Decreased or absent bowel sounds GU: Urinary Incontinent episode x1, urine yellow Integumentary: tenting present often indicate constipation. The patient has had an incontinent episode, if this happens more often it will place the patient at a higher risk for skin breakdown and impaired skin integrity Tenting of the skin can indicate severe dehydration that needs quick treatment. The patient may have reduced skin turgor and may unable to increase their intake of fluids due to nausea and vomiting Lab Results-On Admission: Complete Blood Count (CBC) WBC HGB PLTs % Neuts Bands Current: 8.5 10.8 154 65 0 Last Month: 6.4 12.8 208 55 0 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: WBC: 8.5 Always relevant based on its correlation to the presence of inflammation or infection. Will usually be increased if infection is present, though it may be decreased in the elderly or peds <3 months Stable Worsening Stable, but going down, keep a close eye on this Stable Stable, but low Hgb: 10.8 ALWAYS RELEVANT to determine anemia or acute/chronic blood loss. PLTs: 154 Relevant whenever there is a concern for anemia or blood loss, or if a patient is on heparin. If platelets are low, it will obviously be significant and must be noted. Any patient on heparin products must also have this noted because of the clinical possibility of heparin-induced thrombocytopenia (HIT), which develops when the immune system forms antibodies against heparin and causes small clots and lower platelet levels. Neuts: 65% ALWAYS RELEVANT for same reason as WBCs. They are the most common leukocyte and their role is as a FIRST RESPONDER to any bacterial infection within several hours or when the inflammatory response is activated. Bands: 0 Essential for fighting disease – low count puts the patient at an increased risk for infections-- might be tied to patient’s anemia or breast cancer Basic Metabolic Panel (BMP) Na K Gluc. Creat. BUN Current: 142 3.7 88 1.4 38 Last Month: 135 3.4 90 1.0 22 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Na: 142 It helps maintain normal blood pressure, supports the work of Stable nerves and muscles, and regulates fluid balance. If your sodium blood levels are too high or too low, it may mean that there is problem with the kidneys, dehydration, or another medical condition. K: 3.7 ALWAYS relevant and must be noted by the nurse even though normal. Essential to normal cardiac electrical conduction, as is Mg+. If too high or low, it can predispose to rhythm changes that can be life threatening Stable Gluc.: 88 High-Normal Fasting Blood Sugar Above 87 mg/dL Could Signal Diabetes Risk. Men and women with fasting plasma glucose levels in the high-normal range of 87 to 99 mg/dL should be counseled with regard to weight and lifestyle, and assessing their lipid profiles Stable Creat.: 1.4 GOLD STANDARD for kidney function and adequacy of renal perfusion. The functioning of the renal system impacts every body system; therefore, it is ALWAYS relevant. The creatinine is slightly elevated and the nurse needs to note the last level and trend. The patient may have chronic renal insufficiency secondary to diabetes and HTN. This is not an imminent concern, but the nurse will need to closely monitor and assess urine output Worsening BUN: 38 High BUN can mean a kidney injury or disease is present --- Can also be caused by low blood flow to the kidneys caused by dehydration or heart failure Worsening Liver Panel Albumin Total Bili Alk. Phos. ALT AST Current: 3.0 1.1 70 12 20 Last Month: 3.6 1.0 68 14 20 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Albumin: 3.0 Albumin carries substances such as hormones, medicines, and enzymes throughout the body. This test can help diagnose, evaluate, and watch kidney and liver conditions. When the kidneys start to fail, albumin starts to leak into urine. Worsening Total Bili: 1.1 Bilirubin is measured to: Help diagnose and/or monitor diseases of the liver and bile duct (e.g., cirrhosis, hepatitis, or gallstones) Stable Alk Phos: 20 Alkaline phosphatase (ALP) is an enzyme in a person's blood that helps break down proteins. The body uses ALP for a wide range of processes, and it plays a particularly important role in liver function and bone development. Stable ALT: 12 Proteins called enzymes help the liver break down other proteins so your body can absorb them more easily. ALT is one of these enzymes. It plays a crucial role in metabolism, the process that turns food into energy. ALT is normally found inside liver cells. ALT is Stable AST: 20 commonly used as a way of screening for liver problems. AST is commonly measured clinically as a part of diagnostic liver function tests, to determine liver health. Stable Urinalysis + UA Micro: Clean Catch Specimen Color: Clarity: Sp. Gr. Protein Glucose Ketones Nitrite LET RBCs WBCs Bacteria Epi. Current: yellow dark 1.030 Neg Neg Neg Neg Neg 0 0 none none Last Month: yellow clear 1.015 Neg Neg Neg Neg Neg 0 0 none none What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Color: yellow Urine naturally has some yellow pigments called urobilin or urochrome. Stable Clarity: dark The darker urine is, the more concentrated it tends to be. Dark urine is most commonly due to dehydration. However, it may be an indicator that excess, unusual, or potentially dangerous waste products are circulating in the body. Worsening Sp. Gr.: 1.030 A urine specific gravity test compares the density of urine to the density of water. This quick test can help determine how well your kidneys are diluting your urine. Urine that's too concentrated could mean that your kidneys aren't functioning properly or that you aren't drinking enough water. Improve Protein: Neg The presence of an increased amount of protein in a urine specimen is often the first indicator of renal disease. Proteinuria may signal severe kidney damage, be a warning of impending kidney involvement, or be transient and unrelated to the renal system. Stable Glucose: Neg The presence of significant amounts of glucose in the urine is called glycosuria. The main reason for glycosuria is hyperglycemia. Diabetes mellitus is the most common cause of hyperglycemia. Stable Ketones: Neg The presence of ketones in the urine probably indicates that the body is using fats rather than carbohydrates for energy. High levels of ketones may be present in the urine of individuals with uncontrolled diabetes because the body's ability to metabolize carbohydrates is defective. Stable Nitrite: Neg The presence of nitrites in urine most commonly means there's a bacterial infection in the urinary tract. Stable LET: Neg Leukocyte esterase is a screening test used to detect a substance that suggests there are white blood cells in the urine. This may mean you have a urinary tract infection. If this test is positive, the urine should be examined under a microscope for white blood cells and other signs that point to an infection. Stable RBCs: 0 A high count of red blood cells in the urine can indicate infection, trauma, tumors, or kidney stones. If red blood cells seen under microscopy look distorted, they suggest kidney as the possible source and may arise due to glomerulonephritis. Stable WBCs: 0 When this test is positive and/or the WBC count in urine is high, it may indicate that there is inflammation in the urinary tract or Stable Bacteria: none Epi.: none kidneys. The most common cause for leukocyturia is a bacterial UTI, such as a bladder or kidney infection. Urine is normally sterile, which means that it contains no bacteria. A small number of bacteria may be found in the urine of many healthy people. This is usually considered to be harmless. However, a certain level of bacteria can mean that the bladder, urethra, or kidneys are infected. It's normal to have one to five squamous epithelial cells per high power field (HPF) in your urine. Having a moderate number or many cells may indicate: a yeast or urinary tract infection (UTI) kidney or liver disease. Stable Stable Lab Planning: Creating a Plan of Care with a PRIORITY Lab: (Reduction of Risk Potential/Physiologic Adaptation) Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: Albumin Value: 3.0 g/dL 3.4 to 5.4 g/dL Critical Value: <2.0 g/dL, >5.4 g/dL Low albumin level, can indicate malnutrition. It can also mean that the patient has liver disease or an inflammatory disease. High albumin levels may be caused by acute infections, burns, and stress from surgery or a heart attack • If the patient’s low albumin levels is due to improper nutrition, the nurse should encourage the patient to eat high- protein foods. • If patient’s hypoalbuminemia is due to liver dysfunction, the patient may be placed on fluid restriction, and a special diet. • Assess I&O closely Clinical Reasoning Begins… 1. Interpreting relevant clinical data, what is the primary problem? What primary health-related concepts does this primary problem represent? (Management of Care/Physiologic Adaptation) Problem: Pathophysiology of Problem in OWN Words: Primary Concept: Dehydration, malnutrition, and depression Adequate nutrition is essential to meet the body’s demands. Dehydration results from decreased intake, increased output, or fluid shift. The decrease in total body water causes reductions in both the intracellular and extracellular fluid volumes. Clinical manifestations of dehydration are most closely related to intravascular volume depletion and the physiologic compensation attempts that takes place. As dehydration progresses, hypovolemic shock ultimately ensues, resulting in end organ failure and death. Malnutrition results from the imbalance of nutrients and energy provided to the body (too low), relative to its needs (too high). These needs increase dramatically with illness. Depression is a disorder characterized by a sad or despondent mood or loss of interest in usual activities. Depression can manifest as loss of interest or pleasure in activities, sadness, crying, and substantial changes in weight or appetite over a short period of time Manifestations of Parkinson Disease Collaborative Care: Medical Management (Pharmacologic and Parenteral Therapies) Care Provider Orders: Rationale: Expected Outcome: Referral to a speech-language pathologist (SLP) Speech-language pathologists can help people with Parkinson's disease maintain as many communication skills as possible. They also teach techniques that conserve energy, including non- verbal communication skills. The patient’s communication skills are maintained or improved. Referral to an occupational therapist (OT) Occupational therapy can help people with Parkinson's disease stay active in daily life. By improving the patient’s skills, showing them different ways to complete tasks, or introducing them to handy equipment, an occupational therapist can help the patient perform everyday activities with greater ease and satisfaction. The patient is able to stay active in daily life. Referral to physical therapy (PT) Physical therapy can help the patient compensate for the changes brought about by their condition. These compensatory treatments, include learning about new movement techniques, strategies, and equipment. The goal of physical therapy is to improve the patient’s independence and quality of life by improving movement and function and relieving pain. The patient will have improved posture and less knee pain. Weekly weights The patient lost 10 lbs. over a month, her BMI is 17.8, she is underweight and it is important that she gains weight so that the body can properly function. The patient will see an improvement in her weight. Registered Dietician consult (RD) A consult with an RD, can help guide the patient’s care for gaining back weight in a health manner The patient will follow a healthy diet that facilitates healthy weight gain MVI po daily MVI is a combination of vitamins indicated for the prevention of vitamin deficiency in adults and pediatric patients aged 11 and older receiving parenteral nutrition. The patient will not development clinical signs of vitamin deficiency Ranitidine 150 mg po BID prn Ranitidine is used to treat ulcers of the stomach and intestines and prevent them from coming back after they have healed. This medication is being used to treat Lilly’s GERD. The patient will remain free of stomach and intestinal ulcers. Carbidopa-Levodopa 20-100 mg po TID Carbidopa is in a class of medications called decarboxylase inhibitors. It works by preventing levodopa from being broken down before it reaches the brain. This allows for a lower dose of levodopa, which causes less nausea and vomiting. This The patient’s dopamine levels in the brain will be restored medication is used for Lilly’s Parkinson’s Basic metabolic panel (BMP) The BMP gives the healthcare provider important information about the current status of the patient’s body metabolism. The BMP provides information on the patient’s glucose level, the balance of electrolytes and fluids, and the health of their kidneys. The patient’s lab values will be within normal ranges. Complete blood count (CBC) This is important for being able to watch the changes in the patient’s RBC and WBC. To detect anemia, leukopenia, and thrombocytopenia and can be used to see how medications, medical conditions, or treatments are affecting the patient’s blood. Most relevant labs in this panel are WBC, neutrophils, and bands to gauge severity/degree of physiologic response to infection if present. The patient’s lab values will be within normal ranges. PRIORITY Setting: Which Orders Do You Implement First and Why? (Management of Care) Care Provider Orders: Order of Priority: Rationale: • Referral to a speech pathologist • Referral to an occupational therapy • Referral to physical therapy • Weekly weights • Dietary consult • MVI po daily • Ranitidine 150mg po BID prn • Carbidopa-Levodopa 20- 100mg po TID • BMP, CBC 1) BMP, CBC 2) Dietary consult 3) Referral to a speech pathologist 4) MVI po daily 5) Ranitidine 150mg po BID prn 6) Carbidopa-Levodopa 20- 100mg po TID 7) Referral to an occupational therapy 8) Referral to physical therapy 9) Weekly weights 1) Both of these tests give the HCP important information about the current status of the patient 2) The patient has a malnutrition problem so it is important to have a consult with the RD before starting meds 3) The patient should be referred to a speech pathologist before given medications to assess their swallowing capabilities 4) Since the patient is malnourished it is very important to prevent vitamin deficiency 5) Ranitidine is used to treat the patients GERD, by decreasing the amount of acid the stomach makes. It relieves symptoms such as stomach pain, heartburn, and difficulty swallowing, which in turn can help improve the patient’s appetite. 6) Carbidopa/levodopa remains the most effective drug to treat PD. Carbidopa can helping prevent nausea caused by levodopa, which in turn can help improve the patient’s appetite. 7) Although this is an important part of the patient’s care plan the other orders hold a higher priority, OT can help the patient stay active in daily life. 8) Although they are important parts of the patient’s care plan the other orders hold a higher priority, PT can help the patient compensate for the changes brought about by their condition. 9) Although they are important parts of the patient’s care plan the other orders hold a higher priority, this is not something needed immediately Collaborative Care: Nursing 2. What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY: Imbalance of nutrition: less than body requirements PRIORITY Nursing Interventions: Rationale: Expected Outcome: • Check the patient’s exact weight • Maintain proper positioning • Maintain good oral hygiene • Encourage patient to have small, frequent feedings • Have a baseline for the patient’s weight will help determine if the patient’s condition is improving or worsening • It will prevent or lower risk of having aspiration when eating • It enhances good appetite and better taste of the food • It will enhance the appetite and will have better digestion of food intake • The patient will see an improvement in her weight • The patient will not aspirate while eating • The patient’s appetite will improve 3. What body system(s) will you assess most thoroughly based on the primary/priority concern? (Reduction of Risk Potential/Physiologic Adaptation) PRIORITY Body System: PRIORITY Nursing Assessments: • Musculoskeletal system – The body naturally loses muscle and bone as you age; however, malnutrition can accelerate these losses and impact your independence and ability to be active. • Endocrine System- Parkinson’s is caused by an imbalance of dopamine in the brain and endocrine disorders often cause or co-occur with depression. • Nervous System • Assess for symmetry of the joints, muscles, and bones – checking for swelling, redness, and ease of movement • Palpate over the joints – take note of areas of warmth and/or tenderness • Assess ROM—take note of posture, strength, crepitus, and any limitations • A thorough assessment must be completed by the nurse that begins with the ABCs and includes neurological and integumentary evaluation. • Assess the patient for depression and suicidal thoughts 4. What is the worst possible/most likely complication(s) to anticipate based on the primary problem of this patient? (Reduction of Risk Potential/Physiologic Adaptation) Worst Possible/Most Likely Complication to Anticipate: Reduced muscle and tissue mass/ decreased mobility and stamina as a result of muscle wasting Nursing Interventions to PREVENT this Complication: Assessments to Identify Problem EARLY: Nursing Interventions to Rescue: • Active or passive range of motion, positioning, mobilization, leg exercises, the use of sequential compression devices or antiembolism stockings, and the initiation of falls risk prevention measures • Increasing exercise and activity levels, in a safe environment • Maintaining a healthy diet • Provide the patient of rest periods in between activities. Consider energy- saving techniques • Set goals with patient for cooperation in activities or exercise and position changes. • A thorough assessment must be completed by the nurse that begins with the ABCs and includes neurological and integumentary evaluation. • Assess the client for mobility, gait, strength and motor skills • Perform skin assessment and implement measures to maintain skin integrity and prevent skin breakdown • Active or passive range of motion, positioning, mobilization, leg exercises, the use of sequential compression devices or antiembolism stockings, and the initiation of falls risk prevention measures • Maintaining a healthy diet • Maintaining a safe environment 5. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity/Basic Care and Comfort) Psychosocial PRIORITIES: Emotional support, spiritual support, and knowledge and education about what is taking place and the care priorities for the days ahead PRIORITY Nursing Interventions: Rationale: Expected Outcome: CARE/COMFORT: Caring/compassion as a nurse Caring is traditionally viewed as the essence of the nursing practice and one of the most important characteristics of a nurse. Providing comfort for the patient can help to improve their health Patient will feel valued and comforted EMOTIONAL (How to develop a therapeutic relationship): Discuss the following principles needed as conditions essential for a therapeutic relationship: Emotional support can increase longevity, improve psychological function and cause improvement to immune system function. Emotional support involves being present and available to the patient and actively listen to what the patient has to say A therapeutic relationship includes rapport, trust, respect, genuineness, and empathy. Patient will feel valued and destressed SPIRITUAL: • F-Faith or beliefs: • I-Importance and influence • C-Community: • A-Address: Exploring and assessing the patient’s spirituality is an essential component of the nursing practice. The patient can find comfort in talking about their spirituality and can help reduce anxiety. Questions to ask: F- What are your spiritual beliefs? What things do you believe in that give meaning to life? I- Is faith important to you? How has your condition affected your belief practices? C- Are you connected to a faith center in the community? Is there a person/group who assists you in your spirituality? A- What can I do for you? What support can I provide to support you spiritual belief/practices? Faith/beliefs are supported CULTURAL Considerations (IF APPLICABLE) Religious worldviews provide a window to the prevailing values and ethnic norms of the patient. Being knowledgeable of the patient’s culture can help when planning care. Cultural beliefs are supported Evaluation: Three weeks later… Current VS: One Week Ago: Current PQRST: T: 98.0 F/36.9 C (oral) T: 98.4 F/36.9 C (oral) Provoking/Palliative: P: 70 (regular) P: 78 (regular) Quality: R: 14 (regular) R: 16 (regular) Region/Radiation: no pain today BP: 120/78 BP: 118/68 Severity: O2 sat: 99% room air O2 sat: 98% room air Timing: Weight: 112 lbs/50.9 kg Weight: 110 lbs/49.9 kg Current Assessment: GENERAL SURVEY: Alert, flat affect, in no acute distress, calm, forward flexion of the trunk while sitting in a chair. NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4); slow to respond to questions. Muscle strength 4/5 in both upper and lower extremities bilaterally. Tremors noted in bilateral hands. Movement slow and rigid. HEENT: Head normocephalic with the symmetry of all facial features but tremor noted of the head. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist. RESPIRATORY: Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort on room air. CARDIAC: Pink, warm & dry, no edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2, noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. ABDOMEN: Abdomen round, soft, and nontender. BS normoactive in all four quadrants GU: Voiding urine clear/yellow. Bedside commode in the room. INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill <3 seconds, Hair soft-distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present. 1. What data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: TREND: Improve/Worsening/Stable: • Weight: 112 lbs. • Pain: 0/10 • One of the goals for this patient was to improve her nutrition to get her to a healthier weight • Pain is part of the body's defense system, producing a reflexive retraction from the painful stimulus, and tendencies to protect the affected body part while it heals, and avoid that harmful situation in the future. Last time the patient was experiencing knee pain at waking --- now the patient is not experiencing knee pain, this is an improvement • Improve • Improve RELEVANT Assessment Data: Clinical Significance: TREND: Improve/Worsening/Stable: General: Alert, flat affect, in no acute distress, calm, forward flexion of the trunk while sitting in a chair. Neuro: slow to respond to questions. Tremors noted in bilateral hands. Movement slow and rigid. HEENT: Lips, tongue, and oral mucosa pink and moist. Integumentary: Skin integrity intact, skin turgor elastic, no tenting present. The patient’s slow response to questions and postural instability can be a clinical manifestation of her Parkinson Disease. Flat affect is a severe reduction in emotional expressiveness which can be a sign of depression, which can also be a nonmotor clinical manifestation of her Parkinson Disease The patient’s tremor is most likely a motor clinical manifestation of her Parkinson Disease. The patient is now experiencing slow ridged movement which can be a sign that the Parkinson Disease is worsening The patient s lips, tongue, and oral mucosa are pink and moist. This can indicate that the patient is properly hydrated. The patient’s skin is intact, elastic, and has no tenting --- This can indicate that the patient is properly hydrated. Worsening Worsening Improve Improve 2. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? (Management of Care, Physiological Adaptation) Evaluation of Current Status: Modifications to Current Plan of Care: Overall, the patient is stable--- her malnutrition and fluid status has improved The patient is experiencing other symptoms and complications due to her Parkinson’s. These symptoms will need to be monitored and interventions may need to be modified to further maintain her safety, prevent infections, and manage her depression. 3. Based on your current evaluation, what are your CURRENT nursing priorities and plan of care? (Management of Care) PRIORITY Nursing Interventions: Rationale: Expected Outcome: Assess for fall risk, may need further PT With the progression of PD, the patient’s gait can further be impaired. Interventions to slow the progression is a must. Patient will maintain proper gait and mobility Assess for speech/ ability to communicate, advise the patient to attend follow-up appointments Speech impairment is a possibility as the patient’s PD progresses. Keeping her appointments with SLP, it going to be important in combating the progression of her PD. The patient will maintain effective communication Assess skin integrity Skin integrity can be compromised due to extended periods of sitting and incontinence, which can lead to skin breakdown and increased the risk for infection The patient’s skin will remain intact and free of pressure ulcers Assess patients nutritional and hydration status The patient’s main problem was malnutrition and dehydration, so it is important for the nurse to continue to assess her nutritional and hydration status as she continues to recover The patient will continue to improve her nutritional and hydration status. The patient will remain adequately hydrated and her skin will remain free of tenting. It is now the end of your shift. Effective and concise handoffs are essential to excellent care and, if not done well, can adversely impact the care of this patient. You have done an excellent job to this point; now finish strong and give the following SBAR report to the nurse who will be caring for this patient: (Management of Care) Situation: Name/age: Lillian "Lilly" Marie Jones, 76 years old BRIEF summary of the primary problem: Lilly has lost ten pounds (4.5 kg) in the past month. Day of admission/post-op #: three weeks Background: Primary problem/diagnosis: Lilly has Parkinson’s Disease. She was dehydrated and malnourished, but she is improving RELEVANT past medical history: hypertension, gastro esophageal reflux disease (GERD) and Parkinson's disease. RELEVANT background data: Lilly was married to John for 54 years before he passed away two years ago. She has one son, Jack, who lives 30 minutes away. Jack has medical power of attorney. Assessment: Most recent vital signs: Height: 5 feet-6 inches (167.6 cm), Weight: 110 pounds (49.9 kg), BMI of 17.8, Temp:98.0 F, HR: 70, RR: 14, BP: 120/78, O2 Sat: 99% room air, Pain: 0/10 RELEVANT body system nursing assessment data: General: Alert, flat affect, in no acute distress, calm, forward flexion of the trunk while sitting in a chair. Neuro: slow to respond to questions. Tremors noted in bilateral hands. Movement slow and rigid. HEENT: Lips, tongue, and oral mucosa pink and moist. Integumentary: Skin integrity intact, skin turgor elastic, no tenting present. RELEVANT lab values: No recent lab values TREND of any abnormal clinical data (stable-increasing/decreasing): How have you advanced the plan of care? Patient has engaged with a dietitian, SLP, OT, and PT. Lilly has started to be receiving MVI, Ranitidine, and Carbidopa-Levodopa. Patient response: Lilly is currently stable and will currently remain in a long-term care facility to receive care since she can not do so on her own due to progression of her Parkinson’s. INTERPRETATION of current clinical status (stable/unstable/worsening): Lilly is stable and improving, but requires ongoing close assessment Recommendation: Suggestions to advance the plan of care: Lilly should be monitored for complications of PD such as dehydration, gait disturbances, dysphagia, and impaired skin integrity. Education Priorities/Discharge Planning What educational/discharge priorities will be needed to develop a teaching plan for this patient and/or family? (Health Promotion and Maintenance) Education PRIORITY: Patient/family teaching on the manifestations of Parkinson’s disease and the importance of adequate nutrition and hydration. PRIORITY Topics to Teach: Rationale: Teach the family about the signs and symptoms of dysphagia Teach the family about the progression on Parkinson’s disease Teach the patient/family about prescribed medications As mentioned before, dysphagia is common in patients with Parkinson’s disease. The patient’s family should watch for food pocketing or remaining food in the oral cavity even after swallowing when they are with her at the care facility. Dysphagia may require further assessment by SLP and call for changes in the patient’s diet to avoid aspiration. It is important to involve the family in the patient care, especially in Lilly’s case since her son has medical power of attorney. Family members should be aware of how the disease affects the patients and be aware of how it can progress. The patient and in this case her son should be taught what medication she is taking and their action. This is important because medication adherence is important for controlling chronic conditions, treating temporary conditions, and overall long-term health and well-being. Caring and the “Art” of Nursing What is the patient likely experiencing/feeling right now in this situation? What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person? (Psychosocial Integrity) What Patient is Experiencing: How to Engage: • The patient is most likely feeling a vast amount of emotion, such as sadness, loneliness, hopelessness, and low self- esteem COVID- 19: the patient might be experiencing fear and anxiety, this will most likely add to her depression • Provide comfort for the patient • Anticipating the patients’ needs • Preserve the patient’s dignity • Informing and explaining what is going on to the patient ----- Knowledge is power from a patient’s perspective, and when the nurse provides this information it can decrease anxiety and fear and make a real difference in her well-being. COVID-19: The nurse should still engage the same way but be more cautious and follow infection control measures. The nurse should also talk about advance care plans, such as the MOST form. Use Reflection to THINK Like a Nurse What did you learn that you can apply to future patients you care for? Reflect on your current strengths and weaknesses this case study identified. What is your plan to make any weakness a future strength? What Did You Learn? What did you do well in this case study? I learned more about the clinical manifestations of Parkinson disease and the care that can be provided for those diagnosed with Parkinson’s. I also was able to learn more about mental health and how it can affect older adults in nursing home facilities. Webinar: The first COVID webinar we participated in I found to be more informative that the webinar that took place today. The clinical experience today gave me an opportunity to use critical thinking skills. I think I did well with the case study and enhanced my thought process. I feel like I was making this case harder than it was meant to be, but I felt like I was able to explain the importance of the patient’s symptoms and the lab test that were performed. What could have been done better? What is your plan to make any weakness a future strength? I struggled with the prioritization of care for the patients in the case study because to me most of the care will happen around the same time. My alternative strategies will include getting assistance from my colleagues and instructors. Since I am still unconfident in my ability to appropriately prioritize care, I can improve upon this skill by working on more NCLEX style questions that involve prioritization. Med Cards Ranitidine (Zantac) • Drug Class: anti-ulcer agents, H2 antagonists • Therapeutic Action: Inhibits the action of histamine at the H2-receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion. Healing and prevention of ulcers. Decreased symptoms of gastroesophageal reflux. Decreased secretion of gastric acid. • Indications: Treatment of gastroesophageal reflux disease (GERD). • Dosages: GERD—150 mg twice daily • Pharmacokinetics: I o Half-life: 2-2.5 hr • Contraindications: o Hypersensitivity o Syrup contains alcohol and should be avoided in patients with known intolerance • Use Cautiously in: o Renal impairment o Hepatic impairment o Acute porphyria o Pregnancy o Geri.: more susceptible to adverse CNS reactions • Adverse Effects: confusion, dizziness, drowsiness, hallucinations, headache, arrythmias, constipation, diarrhea, nausea, erectile dysfunction, anemia, neutropenia, thrombocytopenia, hypersensitivity reactions • Nursing Considerations: Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate. Assess geriatric and debilitated patients routinely for confusion. Give with or immediately after meals. • Relevant labs: o Watch renal panel o May increase serum creatinine, AST, ALT, LDH, alkaline phosphate, and bilirubin o May cause false positives of urine protein • Client Teaching: o Instruct patient to take medication as directed for the full course of therapy, even if feeling better. Take missed doses as soon as remembered but not if almost time for next dose. Do not double doses. o Inform patient that smoking interferes with the action of histamine antagonists. Encourage patient to quit smoking or at least not to smoke after last dose of the day. o Advise patient to avoid alcohol, products containing aspirin or NSAIDs, excessive amounts of caffeine, and foods that may cause an increase in GI irritation. o Advise patient to report onset of black, tarry stools; fever; sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health care professional promptly. Carbidopa-Levodopa • Drug Class: antiparkinson agent, dopamine agonists • Therapeutic Action: Levodopa is converted to dopamine in the CNS, where it serves as a neurotransmitter. Carbidopa, a decarboxylase inhibitor, prevents peripheral destruction of levodopa. Relief of tremor and rigidity in Parkinson's syndrome. • Indications: Parkinson’s disease • Dosages: 25 mg carbidopa/100 mg levodopa 3 times daily; may be increased every 1-2 days until desired effect is achieved (max = 8 tablets of 25 mg carbidopa/100 mg levodopa/day). • Pharmacokinetics: C o Half-life: Levodopa -- 1hr, carbidopa -- 1-2hr • Contraindications: o Hypersensitivity o Angle-closure glaucoma o Nonselective MAO inhibitor therapy o Malignant melanoma o Undiagnosed skin lesions o Some products contain tartrazine, phenylalanine, or aspartame and should be avoided in patients with known hypersensitivity • Adverse Effects: depression, involuntary movements, anxiety, confusion, dizziness, drowsiness, hallucinations, memory loss, psychiatric problems, sudden sleep onset, urges (gambling, sexual), orthostatic hypotension, blurred vision, mydriasis, constipation, nausea, vomiting, anorexia, dry mouth, hemolytic anemia, leukopenia, dyskinesias, neuropathy. • Nursing Considerations: Assess parkinsonian symptoms (akinesia, rigidity, tremors, pill rolling, shuffling gait, mask-like face, twisting motions, and drooling) during therapy. "On-off phenomenon" may cause symptoms to appear or improve suddenly. Assess BP and pulse frequently during period of dose adjustment. Assess for signs of toxicity (involuntary muscle twitching, facial grimacing, spasmodic eye winking, exaggerated protrusion of tongue, behavioral changes). Consult health care professional if symptoms occur. Administer on a regular schedule. • Relevant labs: May cause false-positive test results in Coombs' test. May cause increased serum glucose. Dipstick for urine ketones may reveal false-positive results. Monitor hepatic and renal function and CBC periodically in patients on long-term therapy. May cause increased AST, ALT, bilirubin, alkaline phosphatase, LDH, and serum protein-bound iodine concentrations. May cause decreased hemoglobin, decreased hematocrit, agranulocytosis, hemolytic and nonhemolytic anemia, thrombocytopenia, leukopenia, and increased WBC. • Client Teaching: o Instruct patient to take medication at regular intervals as directed. Do not change dose regimen or take additional antiparkinson drugs, including more carbidopa/levodopa, without consulting health care professional. Take missed doses as soon as remembered, unless next scheduled dose is within 2 hr; do not double doses. o Explain that gastric irritation may be decreased by eating food shortly after taking medications but that high-protein meals may impair levodopa's effects. Dividing daily protein intake among all the meals may help ensure adequate protein intake and drug effectiveness. Do not drastically alter diet during carbidopa/levodopa therapy without consulting health care professional. o Caution patient to change positions slowly to minimize orthostatic hypotension. Health care professional should be notified if orthostatic hypotension occurs. o Advise patient to notify health care professional of any adverse effects. Dose reduction may be required. o Inform patient that sometimes a "wearing-off" effect may occur at end of dosing interval. Notify health care professional if this poses a problem to lifestyle.