The client is a 70 year old, Caucasian male who is a retired siding salesman from Riverside, IA, who has an extensive history with Paralysis agitans (Parkinson’s disease). The client was first admitted to the long term care facility in December 2012. The client explained that he came to be at this facility after “already being in two places like this”. He was removed/discharged from the last long-term care facility for being what he called “disruptive”. The client described the staff at the last facility as not very kind to the residents.
There was an incident where the drugs that were prescribed to the client made him hallucinate and he became unruly with the staff and was restrained and taken to the hospital for evaluation. He was then transferred to this long term care facility. Wanting to gather the client’s health history, an interview was scheduled.
In starting the interview with the client, he was asked if he would be comfortable with being asked some questions and was informed that he did not have to answer any questions that he was uncomfortable with.
Due to the client’s paralysis agitans and his muscle weakness he is primarily in a wheelchair. The client was asked if there was anything that he needed before starting and if he would prefer the door be closed or the curtain be drawn for privacy, he stated that wasn’t necessary. It was observed that the client had tremors in his right hand and arm. A few minutes after sitting down, the client asked for help moving his hand that was resting on the bed to the arm of his wheelchair; in doing this it seemed to help calm the tremors.
When speaking with the client, he is of sound mind and has a sense of humor.
This indicates that the client’s paralysis agitans has not affected the area in the right hemisphere of the brain that controls personality. The client noted that he was in respectable physical health until 1996. He then explained that in the spring of 1996, while he was running he suffered from a TIA (Transient Ischemic Attack). The client sought out professional answers from 5 specialists and was diagnosed with Paralysis agitans. The client conveyed this was a concern he had because his father also had Paralysis agitans. The client describes that the Paralysis agitans has progressively become worse over the past 18 years. It was observed that his speech was slow and monotonous. The client spoke in a low and discreet volume. A lack of facial expressions was also noticed. The client can walk with the assistance of a walker but is generally in a wheelchair.
Name of Drug
200 mg tablet
50 mg tablet
In the afternoon
He is prescribed 3 tablets to be taken orally 3 times a day Carbidopa-Levodopa 25-100 (25 mg of Carbidopa and 100 mg of Levodopa) for paralysis agitans. He is also prescribed 200 mg of Comtan to be taken orally 3 times a day for paralysis agitans. These drugs raise the level of dopamine in the brain. A side effect of having elevated levels of dopamine in the brain is psychosis. The client is also given 50 mg of Seroquel XR orally in the afternoon to alleviate his nonorganic psychosis. It is documented in the client’s chart that there are symptoms of sleep apnea. When asked, the client stated that he was unaware of having that condition. The client does not use a continuous positive airway pressure (CPAP) machine while sleeping at night.
When talking more in depth about sleep patterns and concerns the client stated that he gets approximately 8 hours a sleep a night, this is without any help from sleep aids. When speaking of his bedtime rituals he said that he does have two beers, back to back, at night right before bedtime, while watching television. He does not have difficulty falling asleep but did claim that he sometimes has a hard time staying asleep at night. When questioned about taking occasional naps throughout the day he stated “depends on if I’ve been up all night”. The client then explained that it is the noise level at the long term care facility that keeps him awake.
When inquiring about the client’s family he stated that he has been married for 48 years and has two children, a son who is 44 years old and a daughter that is 39 years old. The client also has seven grandchildren. When asked what he likes to do in his spare time he replied that he loves spending time with his wife and children. He stated that before coming to this long term care facility he enjoyed playing card and gambling. He now plays computer games for fun, when his wife is there to help him. The client explained that he has a “little bit” of high blood pressure and it was noted in his chart that he is given an 81MG Aspirin daily for atrial fibrillation.
Every 6 hour
He has no history of heart surgeries or surgeries of any kind. The client reported that he has never had rheumatic fever. When asked about blood clots, the client responded that he believes that his TIA in 1996 was a result of arterial emboli. The client claims that sometimes he has numbness in his legs and his hamstrings tighten up and it can be painful. He stated that he will ask for his prescribed 650 MG of acetaminophen for the pain.
When speaking about everyday stresses with the client, he stated that he doesn’t have a lot of stress but gets irritated when that staff turn on the lights every morning at 6:30 am. When asked if there was anything that he does when he notices that he is stressed, the client mentioned that when he was younger he would travel to Vedic City in Iowa and practice with the Maharishi meditating. He says that meditating has been very helpful in his adult life. The client also mentioned that he liked to follow the Maharishi lifestyle and eat only organic foods but it is not possible to follow that when residing at a long term care facility. Other things that he does to distress are look at his pictures that he has on his shelf in his room. The one that helps him the most is a black and white picture of him in a small airplane with his flight instructor standing on the wing. The client use to pilot planes when he was younger.
When the client was asked if he was religious and he explained that he is Methodist but hasn’t been to church in about 5 years. He did state that he does pray occasionally. The client stated that is not afraid of dying but he is afraid of falling. He then joked that maybe it’s not so much the falling but maybe it’s the landing. When assessing the client’s vitals it was noted that he has slightly elevated blood pressure of 129/84 and could be cause for concern of pre-hypertension.
It is noted in his chart that the client is given a 25 mg tablet of metoprolol tartrate orally twice a day for hypertension. His respirations were within normal range at 18 respirations per minute. SaO2 was at 86%. The client’s temperature was taken orally and was 97.6 °F. The client is 6 feet and 1 inch tall and weighs 257 lbs. The client has a BMI of 33.9. The client received a vaccination for influenza on 10/16/13. The clients chart states that he requires assistance with many daily activities. He is dependent on help with dressing, and bathing. When asked, the client stated that it is challenging to get dressed and undressed due to the stiffness in his arms and legs.
The client is on a regular diet and states that he doesn’t have any difficulty swallowing foods and doesn’t require help with feeding. When asked about appetite he said that sometimes he doesn’t have much of an appetite but he believes that is due to the medications that he is taking. The client explains that he is not aware of having any food allergies. He also stated that after eating he does not experience sensations of nausea/vomiting, but does encounter heartburn/indigestion occasionally, which he takes 30 ml an antacid suspension. He is also given one multivitamin orally daily for supplement.
Every 6 hours
When the client was asked about dentures he stated that he does not have dentures even though dentures were noted in his chart. He states he needs aid in transferring from bed to a chair and with toileting. When asked about the character of his stools he explained that both consistency and color were normal. The client also stated that he does not need the help of laxatives. Noted in the client’s chart he is given a 100 mg capsule of Docusate sodium orally 2 times a day to help with constipation.
100 mg capsule
The client does not have any history of kidney or bladder disease. He claims that the frequency, amount and color of his urine are normal. He also claims that he does not have any difficulty voiding and there is no pain or burning while urinating. According to the CNA, the client is able to stand, holding the hand rails, while urinating. It is noted in the clients care plan that he is urinary incontinent which is related to impaired mobility and PRN straight catheter needed for intermittent retention secondary to BPH. The client is given one 0.4 mg of Tamsulosin HCL orally a day for BPH (benign prostatic hyperplasia).
The client needs assistance with bathing as well. The client also has a DNR order.
Parkinson’s disease (paralysis agitans) is a progressive disorder of the nervous system that affects ones mobility. According to Hubert and VanMeter, Parkinson’s disease is a “dysfunction of the extrapyramidal motor system that occurs because of progressive degenerative changes in the basal nuclei, principally in the substantia nigra.”(UMMC, 2012) The substantia nigra is the primary area of the brain that is affected by Parkinson’s disease (PD). (UMMC, 2012) The substantia nigra is comprised of a specific set of neurons that send chemical signals, called dopamine.
Dopamine then travels to the striatum, responsible for balance, control of movements, and walking, by means of long fibers called axons. (Okun, 2013) These regular body movements are controlled by the activity of dopamine on these axons. With PD the neurons in the substantia nigra break down and die causing the loss of dopamine, which in turn causes the nerve cells in the striatum to trigger excessively. The excessive firing of neurons makes it impossible for one to control their movements, a sign of Parkinson’s disease. (Okun, 2013) According to the Parkinson’s disease Foundation (2014):
As many as one million Americans live with Parkinson’s disease, which is more than the combined number of people diagnosed with multiple sclerosis, muscular dystrophy and Lou Gehrig’s disease. Also approximately 60,000 Americans are diagnosed with Parkinson’s disease each year, and this number does not reflect the thousands of cases that go undetected. An estimated seven to 10 million people worldwide are living with Parkinson’s disease. Incidence of Parkinson’s increases with age, but an estimated four percent of people with PD are diagnosed before the age of 50 and men are one and a half times more likely to have Parkinson’s than women. (p 1) Since PD is a progressively degenerative disease the signs and symptoms change over time and vary from person to person. A widely used clinical rating scale is the Hoehn and Yahr scale (HY); this helps to identify signs and symptoms in the various stages of Parkinson’s disease. (MGH, 2005)
Early stages, like HY’s stage one, of Parkinson’s disease the symptoms are usually mild and appear unilateral. There may be changes in facial expressions, posture and locomotion; these symptoms are usually untimely and bothersome but not disabling. As the disease progresses, into stage two of the HY scale, it may begin to affect ambulation and be noticeable bilaterally with minimal disability. (MGH, 2005) As symptoms worsen, as in stage three of the HY scale, there is considerable slowing of body movements, early impairment of equilibrium with walking and standing and generalized dysfunction that is moderately severe. The Hoehn and Yahr scale’s stage four explains that signs and symptoms are severe but the person can still walk to a limited extent. (MGH, 2005) Rigidity and bradykinesia become factors in mobility. In stage five the person is unable to walk or stand so is bedridden or confined to a wheelchair. This stage is referred to as the “cachectic stage”. Constant nursing care is required in stage five (Costa and Quelhas, 2009). There are many complications that are associated with PD; one can be difficulty swallowing (dysphagia), likely due to the loss of control of muscles in the throat. (UMMC, 2012)
Drooling can occur since saliva may accrue in the mouth due to dysphagia. Difficulty swallowing can also lead to malnourishment, but also poses a risk for aspiration pneumonia (Leopold and Kagel, 1997). Constipation can be another complication as to the slowing of the digestive tract. Parkinson’s disease can also cause urinary retention and urinary incontinence. Dementia and difficulty thinking comes in later stages of PD. (University of Maryland Medical Center, 2012) Depression is very common in patients with Parkinson’s. The disease process itself causes changes in chemicals in the brain that affect mood and well-being. Anxiety is also very common and may be present along with depression (University of Maryland Medical Center, 2012).
Sleep problems and sleeping disorders are also associated with PD, with this comes fatigue. Some patients may experience feeling light headed when standing due to the drop in blood pressure (orthostatic hypotension). Pain can also be another symptom related to Parkinson’s disease (Okun, 2013). There is not yet a cure for Parkinson’s disease but there are treatments that can help alleviate the symptoms. The most commonly used is drug therapy. Medications can help with difficulty with movement, walking and controlling tremors by increasing the brains amount of dopamine. (University of Maryland Medical Center, 2012) The most common and most effective Parkinson’s disease drug is Levodopa. This is a natural chemical that passes into your brain and is converted to dopamine (Okun, 2013). There is also surgical procedures available, deep brain stimulation. With this procedure the surgeon implants electrodes into a specific location in the patient’s brain. A generator is implanted in the patient’s chest, which is attached to the electrodes.
This generator sends electrical impulses to the patient’s brain, which may lessen the symptoms of Parkinson’s disease. (University of Maryland Medical Center, 2012) Other ways that help control the effects of PD is a healthy diet. Constipation is a complication associated with PD, so a diet that is balanced with whole grains, fruits and vegetables helps to manage this complication. Balance, coordination, flexibility and muscle strength deteriorate with PD so, exercise is encouraged. Exercise also helps with decreasing anxiety and depression. The client exhibits many of the discussed signs and symptoms of Parkinson’s disease. The client experiences resting tremors, bradykinesia, mask like face (hypomimic), slowed speech and is in a wheelchair. He scores very poorly according to the Hoehn and Yahr scale. The client is on medications to help diminish the signs and symptoms of Parkinson’s disease. Impaired physical mobility level 3, related to bradykinesia, akinesia, neuromuscular impairment motor weakness, pain and tremors. (Berman & Snyder, 2012)
Evidenced by lack of decisive movement within physical environment, including movement in bed, transfers, and ambulation. Limited range of motion (ROM). Decreased muscle stamina, strength and control. Limitation in independent, purposeful physical movement of the body and impairment unilaterally on the right side. Due to the muscular and neuromuscular weakness related to Parkinson’s disease, evidenced by it being difficult for the patient to ambulate. The client has a defect of extrapyramidal tract, in
the basal ganglia, with loss of the neurotransmitter dopamine. (Berman & Snyder, 2012) Classic triad of symptoms: tremor, rigidity, bradykinesia (Jarvis, 2012). Tremors associated with paralysis agitans make it difficult maneuver. Tremors cease with voluntary movement and during sleep (VanMeter and Hubert, 2014). Immobility is an expected human response to Parkinson’s disease. The client’s immobility puts him at risk for thrombophlebitis, skin breakdown, pneumonia and depression. Immobility impedes circulation and diminishes the supply of nutrients to specific areas. As a result, skin breakdown and formation of pressure (decubitus) ulcer can occur (Berman and Snyder, 2012).
Immobility also promotes clot formation. Self-care deficits related to neuromuscular impairment, immobility, decreased strength, and loss of muscle control and lack of coordination, ridgity and tremors. Self-care deficits, dressing, hygiene and toileting, evidenced by tremors and motor disturbance. The client lacks the ability to cleanse his body, comb his hair, brush his teeth and do skin care. . The client is also unable to dress himself satisfactory. He does not have the capability to fasten his clothes. The patient is assisted with ADL’s. Patient is incapable to bathe, dress or brush teeth without aid. Patient occasionally needs assistance with feeding. Assistance is also required with toileting. Aid is needed with ADL’s because of the lack of coordination and for safety. This nursing diagnosis is important because it ensures hygiene, improves quality of life, and promotes dignity, self-worth, independence and freedom. Risk for falls related to decreased mobility, and unsteady gait secondary to sedentary lifestyle and Parkinson’s disease. Patient uses a wheelchair and ambulates with a walker. Patients gait is impaired due to Parkinson’s disease. Festination, or a propulsive gait (short, shuffled steps with increasing acceleration), occurs as postural reflexes are impaired, leading to falls (VanMeter and Hubert, 2014).
Falls also result in psychological implications for the patient with a decrease in self-confidence and a fear of further falls. This contributes to a decrease in mobility and culminates in a significant reduction in quality of life (Jarvis, 2012). Impaired bowel elimination/constipation related to medication, physical disability and decreased activity. Evidenced by the client not passing stools daily. Medications prescribed to patient for Parkinson’s disease attribute to constipation. The patients experience with immobility is also a contributing factor for constipation. This nursing diagnosis is important because it allows nursing staff to monitor the patient’s bowel movements and avoid fecal impaction. Imbalanced nutrition less than body requirements related to tremors, slowing the process of eating, difficulty chewing and swallowing. Evidenced by the client occasionally needing assistance with eating.
Pressure sores develop more quickly in patients with a nutritional deficit. Proper nutrition also provides needed energy for participating in an exercise or a rehabilitative program. The goal is to optimize the client’s nutritional status. Impaired verbal communication related to decreased speech volume, decreased ability to speak, stiff facial muscles, delayed speech, and inability to move facial muscles. Evidenced by lack of expression on the client’s face, client’s hindered speech. Loss of dopamine can affect the facial muscles, making them stiff and slow and resulting in a characteristic lack of expression. Speech impairment is referred to as dysarthria and is often characterized as weak, slow, or uncoordinated speaking that can affect volume and pitch. Difficulty speaking and writing because of tremors, hypophonia, and “freeze” incidents. This is an expected consequence of Parkinson’s disease.
Nursing Care Plan- Alteration in impaired physical mobility- Parkinson’s disease Related to:
Client will use a walker to go to breakfast in the mornings and not need assistance with transfers. Client will be able to perform all active ROM by 3 months
Examine current mobility and observation of an increase in damage. Do exercise program to increase muscle strength.
Perform passive or active assistive ROM exercises and muscle stretching exercises to all appendages. To promote increased venous return, prevent stiffness, and maintain muscle strength and endurance. Without movement, the collagen tissues at the joint become ankylosed (permanently immobile) (Berman & Synder, 2012)
Client will gain power of voluntary movements.
Joint contractures will not occur.
Assess the possibility of deep brain stimulation.
Refer to physical therapy.
When the muscle fibers are not able to shorten and lengthen, eventually a contracture forms, limiting joint mobility (Berman & Synder, 2012)
Client’s tremors will decrease.
Encourage deep breathing, imagery techniques and meditation. Encourage holding an object in hand
Suggest holding the arm of the chair.
Stimulating the brain by concentrating on breathing may cease tremors. (www.theparkinsonhub.com)
Client will not experience pain >4 on a scale of 0-10
Before activity observe for and, if possible, treat pain.
Assess patient’s willingness or ability to explore a range of techniques aimed at controlling pain. Administer pain medication per physician orders.
Encourage/assist to reposition frequently to position of comfort. Pain limits mobility and is often exacerbated by movement.
Nursing Care Plan- Alteration in Skin Integrity, Impaired: Risk for – Pressure Sores; Pressure Ulcers, Bed Sores; Decubitus Care Related to:
Client will be free of any pressure ulcers for length of long term stay. Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain or any other signs of infection. Pay special attention to high risk areas and ask client questions to determine whether he is experiencing loss of sensation. Apply barrier cream to peri area/ buttocks as needed.
Use ROHO cushion on wheelchair.
Checking skin once a day will ensure that skin stays intact. (Jarvis, 2012)
Client will be able to express s/s of impaired skin.
Teach skin and wound assessment and ways to monitor for s/s of infection, complications and healing. Use prophylactic antipressure devices as appropriate
Early assessment and interventions may help complications from developing. To prevent tissue breakdown.
Nursing Care Plan- Self Care Deficits
Client will assist with bathing, grooming, dressing, oral care and eating daily. Assist client with bathing, grooming, dressing, oral care and eating daily. Use high back wheelchair.
The effectiveness of the bowel or bladder program will be enhanced if the natural and personal patterns of the patient are respected. Loss of muscle control and lack of coordination
Client will improve muscle control and coordination in all extremities for the length of long term stay. Client will walk to dining room and in hallways- 5 mins a day 5 days a week. Use consistent routines and allow adequate time for patient to complete tasks. Assist client with ambulation.
This helps patient organize and carry out self-care skills.
Client will be able to assist with dressing.
Provide appropriate assistive devices for dressing as assessed by nurse and occupational therapist. Encourage use of clothing one size larger.
Teach and support the client during the client’s activities
Apply extensions on breaks with ball grips
The use of a button hook or of loop and pile closures on clothes may make it possible for a patient to continue independence in this self-care activity. Ensures easier dressing and comfort.
Grips will be easier to grasp with tremors.
Client will be clean, dressed, well groomed daily to promote dignity and psychosocial well-being. Assist with shower as needed.
Assist with daily hygiene, grooming, dressing, oral care, and eating as needed. This promotes dignity and psychosocial well-being.
Nursing Care Plan- Falls, risk for
Decreased muscle tone
Client will express an understanding of the factors involved in possible injury. Educate the client about what makes them at risk for falls.
Bed should be in lowest position.
Provide assistance to transfer as needed.
Reinforce the need for call light.
If the client is educated and shows an understanding of the factors involved with falls, they are less likely to fall. Prevent fall.
Nursing Care Plan- Impaired Bowel elimination/constipation
Client will have soft formed stool every other day that are passed without difficulty. Encourage physical activity and regular exercise.
Adjust toileting times to meet client’s needs.
Report changes in skin integrity forum during daily care
Ambulation and/or abdominal exercises strengthen abdominal muscles that facilitate defecation. low-fiber diet
Evaluate usual dietary habits, eating habits, eating schedule, and liquid intake. Initiate supplemental high-protein feedings as appropriate.
Change in mealtime, type of food, disruption of usual schedule, and anxiety can lead to constipation. Proper nutrition is required to maintain adequate energy level.
Diminished muscle tone
Encourage isometric abdominal and gluteal exercise
Apply skin moisturizers/barrier creams as needed
To strengthen muscles needed for evacuation unless contraindicated. (http://www.gutsense.org)
Encourage liquid intake of 2000 to 3000 ml per day
To optimize hydration status and prevent hardening of stool
(VanMeter & Hubert, 2014)
My thinking about my resident has definitely changed since the initial day when I conducted a health history assessment on him. I knew that first day that I was going to appreciate getting to know this resident because of how smoothly the conversation flowed. This resident had some amazing stories to tell. I absolutely adore that fact that he and his wife have been married for 48 years. I enjoyed listening to him remember what life was like before being diagnosed with Parkinson’s disease, it appeared to lighten his spirit. I feel very fortunate to have been given the opportunity to care for such a genuine soul. My whole clinical experience was a positive one. I realized that if I lacked the knowledge about a particular task to ask for help.
I liked the fact that clinicals was hands on and that I gained experience in a long term health care facility. Another thing that this clinical rotation taught me was that it takes an exceptional type of person to go into geriatric nursing. Probably the number one thing that I’m going to take away from this clinical experience is the total importance of dignity. I too will be old someday and I applied the golden rule to this experience. I treated others as I want to someday, and hopefully, will be treated. What a fantastic learning experience.
Berman, A., & Snyder, S. (2012). Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice. Upper Saddle River: Pearson Education. Coleman, J., (September 1, 2013) Meditation & Mitigating Parkinson’s Symptoms. Retrieved from http://www.theparkinsonhub.com/your-quality-of-life/article/meditation–mitigating-parkinsons-symptoms.html Costa, M. & Quelhas, R. (2009). Anxiety, Depression, and Quality of Life in Parkinson’s Disease. The Journal of Neuropsychiatry and Clinical Neurosciences 2009; 21:413-419. Jarvis, C. (2012). Physical Examination & Health Assessment. St. Louis: Elsevier Kegelmeyer, D., (July 1, 2013) Functional Limitation Reporting (FLR) Under Medicare: Tests and Measures for High-Volume Conditions. Retrieved from http://www.ptnow.org/FunctionalLimitationReporting/TestsMeasures/Default.aspx Leopold N., Kagel M. (1997). Pharyngo-esophageal dysphagia in Parkinson’s disease. Dysphagia 1997; 12:11–18 Massachusetts General Hospital (MGH) (May, 2005) Hoehn and Yahr Staging of Parkinson’s Disease, Unified Parkinson Disease Rating Scale (UPDRS), and Schwab and England Activities of Daily Living. Massachusetts General Hospital. Retrieved March 2, 2014, from http://neurosurgery.mgh.harvard.edu/functional/pdstages.htm#HoehnandYahr Okun, M. (2013). Parkinson’s Treatment: 10 Secrets to a Happier Life. CreateSpace Independent Publishing Michael S. Okun M.D. Parkinson’s disease Foundation (2014, March) Understanding Parkinson’s. Parkinson’s Disease Foundation. Retrieved March 2, 2014, from http://www.pdf.org/en/understanding_pd University of Maryland Medical Center (2012, September) Parkinson’s disease. University of Maryland Medical Center. Retrieved March 2, 2014, from http://umm.edu/health/medical/reports/articles/parkinsons-disease#ixzz2upFLCggw VanMeter, K. C., & Hubert, R. J. (2014). Gould’s Pathophysiology for the
Health Professions. St. Louis: Elsevier.
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