Health History and Medication Regimen of a Parkinson's Patient

Categories: HealthNursing

The individual seeking care is a retired siding salesman from Riverside, IA. He is a 70-year-old Caucasian male who has a long history of Paralysis agitans (Parkinson’s disease). In December 2012, he was admitted to the current long-term care facility after previously staying at two similar places. The reason for leaving the previous facility was due to disruptive behavior and dissatisfaction with the staff, as he felt they were unkind to residents. At one point, his prescribed medication caused hallucinations and resulted in unruly behavior towards the staff.

Consequently, he was restrained and taken to the hospital for evaluation before being transferred to his current facility. An interview was arranged in order to collect his health history.

During the initial interview, the client was asked about his comfort level with being questioned and assured that he could decline answering any questions that made him uneasy. Due to the client's paralysis agitans and muscle weakness, he primarily relies on a wheelchair. Before starting the interview, the client was asked about his needs and whether he preferred privacy by closing the door or drawing the curtain; he stated that it was unnecessary.

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It was observed that the client had tremors in his right hand and arm. A few minutes later, the client requested assistance in moving his hand from the bed to the armrest of his wheelchair, which appeared to alleviate the tremors. Throughout their conversation, the client displayed mental clarity and a sense of humor.

According to the text, the client's right hemisphere, responsible for personality, has not been affected by their paralysis agitans.

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The client's physical health was good until 1996 when they experienced a TIA while running. They consulted five specialists and were diagnosed with Paralysis agitans, which worried them due to their father having a similar condition. The client states that their Paralysis agitans has progressively worsened over the past 18 years. Their speech is slow and monotonous, speaking softly and lacking facial expressions. While they can use a walker for walking assistance, they primarily rely on a wheelchair.

The drug's name is "Name of Drug".

Dosage: Carbidopa-Levo 25 - 100 tab, Orally, TID, related to Paralysis agitans

Comtan - 200 mg tablet, Orally, TID, related to Paralysis agitans

Seroquel XR - 50 mg tablet, Orally, In the afternoon, related to Nonorganic psychosis

The client is prescribed Carbidopa-Levodopa 25-100 (25 mg of Carbidopa and 100 mg of Levodopa) and Comtan 200 mg to be taken orally three times a day for paralysis agitans. These drugs increase dopamine levels in the brain, which can cause psychosis as a side effect. To address his nonorganic psychosis, the client is also given Seroquel XR 50 mg orally in the afternoon. The client's chart notes symptoms of sleep apnea, although he claims to be unaware of having the condition and does not use a continuous positive airway pressure (CPAP) machine at night.

The client stated that they typically get around 8 hours of sleep each night without using any sleep aids. They mentioned that as part of their bedtime routine, they consume two beers while watching TV before going to bed. While the client does not have difficulty falling asleep, they occasionally struggle to stay asleep throughout the night. The client also shared that their daytime naps vary depending on whether they were able to stay awake during the entire night. Furthermore, the client believes that the noise level at the long-term care facility is a contributing factor to their sleeping issues.

The client stated that he has been married to his spouse for 48 years and they have a son who is 44 years old, a daughter who is 39 years old, and seven grandchildren. In his free time, he enjoys spending time with his wife and children. Before moving to this care facility, he used to enjoy playing cards and gambling but now plays computer games for entertainment, with assistance from his wife. The client mentioned having mild high blood pressure which was recorded in his medical chart. It was observed that he takes an 81MG Aspirin every day to manage atrial fibrillation.

Aspirin

For A-fib, the recommended dosage is 81 mg taken orally once daily. For pain relief, it is suggested to take 325 mg of acetaminophen orally every 6 hours.

The client has no previous record of heart surgeries or any other surgeries, and there is no indication of the client ever having rheumatic fever. When inquired about blood clots, the client mentioned that their TIA in 1996 could have been caused by arterial emboli. They occasionally feel numbness in their legs and tightness in their hamstrings, resulting in discomfort. To alleviate this pain, they will request their prescribed 650 MG acetaminophen.

When discussing everyday stresses with the client, he expressed that he doesn't experience a lot of stress but becomes irked when the staff turns on the lights every morning at 6:30 am. When asked how he handles stress, the client shared that in his younger years he would travel to Vedic City in Iowa and engage in meditation practices with the Maharishi. He finds meditation to be extremely beneficial in his adult life. Additionally, the client mentioned his fondness for following the Maharishi lifestyle, including consuming only organic foods. However, this is not feasible while residing at a long term care facility. To relax, the client enjoys looking at his pictures displayed on a shelf in his room. The picture that brings him the most solace is a black and white photo of himself in a small airplane with his flight instructor perched on the wing. In his youth, the client used to fly planes as a pilot.

The client, who identified as Methodist but had not attended church in around five years, acknowledged occasionally praying. He admitted to not being afraid of dying but did express apprehension about falling. In a joking manner, he suggested that his fear might be more related to the landing than the actual act of falling. When evaluating the client's vitals, it was noticed that his blood pressure slightly increased to 129/84, indicating a potential concern for pre-hypertension.

Metoprolol tartrate

25 mg Orally BID Hypertension

The client's chart shows that they are prescribed a 25 mg tablet of metoprolol tartrate orally twice a day for hypertension. Their respiratory rate is normal at 18 breaths per minute and their SaO2 level is recorded as 86%. The client's temperature, taken orally, is 97.6 °F. They have a height of 6 feet and 1 inch and weigh 257 lbs, resulting in a BMI of 33.9. On 10/16/13, the client received an influenza vaccination. According to the chart, the client requires assistance with various daily activities such as dressing and bathing due to stiffness in their arms and legs.

The client has no difficulty swallowing food and does not need help with eating. Occasionally, he may experience a reduced appetite, which he believes is due to his medications. There are no known allergies to any foods. After meals, the client occasionally experiences heartburn or indigestion and manages it by taking 30 ml of an antacid suspension. In addition, he takes one oral multivitamin daily as a supplement.

Antacid Suspension

For heartburn relief, it is recommended to consume 30 ml of the supplement orally every 6 hours. In addition, one tablet of multivitamin should be taken orally once daily.

Supplement

The client contradicted the presence of dentures, despite their documentation in his chart. He sought assistance for transferring and toileting, asserting that his stools are regular and he does not require laxatives. Nonetheless, as per the chart, he has been prescribed 100 mg Docusate sodium capsules orally twice daily to alleviate constipation.

Docusate sodium

100 mg capsule taken orally twice daily.

Constipation

The client's urinary history is free from any kidney or bladder disease. Their urine frequency, amount, and color are within normal range. The client does not encounter any challenges or discomfort during urination. Based on the CNA's observation, the client can stand with handrail assistance while urinating. According to their care plan, the client is classified as urinary incontinent due to impaired mobility and occasional need for intermittent catheterization resulting from BPH (benign prostatic hyperplasia). To address BPH, the client is prescribed a daily oral dose of Tamsulosin HCL at 0.4 mg.

Tamsulosin HCL

0.4 mh Once daily orally for Benign Prostatic Hyperplasia (BPH). The client also has a Do Not Resuscitate (DNR) order and requires assistance with bathing.

Parkinson’s disease, also referred to as paralysis agitans, is a progressive disorder of the nervous system that impacts mobility. As stated by Hubert and VanMeter, it is distinguished by dysfunction in the extrapyramidal motor system due to degenerative alterations in the basal nuclei, specifically in the substantia nigra (UMMC, 2012). The substantia nigra, primarily affected by Parkinson’s disease (PD), comprises a distinct set of neurons that transmit dopamine, a form of chemical signal (UMMC, 2012).

Dopamine is transported to the striatum, which is responsible for balance, movement control, and walking, through long axon fibers (Okun, 2013). Dopamine's impact on these axons regulates regular body movements. In Parkinson's disease (PD), the degeneration and death of neurons in the substantia nigra lead to a dopamine deficiency. Consequently, nerve cells in the striatum become excessively activated. This excessive neuron firing causes an inability to control movements, which is a hallmark of Parkinson's disease (Okun, 2013). The Parkinson's Disease Foundation (2014) explains this process as follows:

Currently, there are over one million Americans living with Parkinson's disease, which is more than the combined total of individuals diagnosed with multiple sclerosis, muscular dystrophy, and Lou Gehrig's disease. Each year, around 60,000 Americans receive a diagnosis for Parkinson's disease. This number does not include the many undetected cases. Globally, it is estimated that between seven to ten million people are affected by Parkinson's disease. While the likelihood of developing Parkinson's increases with age, approximately four percent of cases are diagnosed before the age of 50. Men have a one and a half times higher chance of developing Parkinson's compared to women (p 1). As a degenerative disease, signs and symptoms of Parkinson's progress over time and vary from person to person. The Hoehn and Yahr scale (HY) is a widely used clinical rating scale that helps identify signs and symptoms at different stages of Parkinson's disease (MGH, 2005).

Parkinson's disease progresses through different stages according to the HY scale. In stage one, there are mild symptoms that affect only one side of the body, including changes in facial expressions, posture, and movement. These symptoms do not usually cause disability. In stage two, walking abilities on both sides of the body start to be affected but with minimal disability. By stage three, symptoms worsen with significant slowing down of body movements, early balance problems while walking or standing, and moderately severe overall dysfunction. Stage four is characterized by severe signs and symptoms but limited ability to walk due to rigidity and bradykinesia. In stage five, individuals become unable to walk or stand and rely on a wheelchair or become bedridden; this final stage is known as the "cachectic stage" requiring constant nursing care.

Complications resulting from Parkinson's disease can include dysphagia (difficulty swallowing) caused by loss of muscle control in the throat.

Dysphagia, or difficulty swallowing, can lead to drooling and the buildup of saliva in the mouth. This increases the risk of malnourishment and aspiration pneumonia (Leopold and Kagel, 1997). Slowed digestion can also cause constipation as a complication. Parkinson's disease can result in urinary retention and urinary incontinence. In later stages of PD, dementia and cognitive difficulties typically occur (University of Maryland Medical Center, 2012). Additionally, depression often accompanies Parkinson's due to changes in brain chemicals, along with anxiety (University of Maryland Medical Center, 2012).

Parkinson's disease (PD) is commonly associated with sleep problems and sleeping disorders, leading to fatigue. Some patients may also experience orthostatic hypotension, a drop in blood pressure that causes light-headedness when standing. Pain is another symptom of Parkinson's disease (Okun, 2013).

Treatments for Parkinson's disease aim to alleviate symptoms as there is currently no cure. The most frequently used treatment involves drug therapy, where medications are taken to increase dopamine levels in the brain. This helps with movement difficulties, walking, and tremor control (University of Maryland Medical Center, 2012). Levodopa is the most prevalent and effective drug for Parkinson's disease as it converts to dopamine in the brain (Okun, 2013).

Alongside medication, surgical procedures such as deep brain stimulation can be performed. This procedure involves implanting electrodes into a specific area of the patient's brain and placing a generator in their chest to regulate it.

According to the University of Maryland Medical Center (2012), electrical impulses from a generator can help alleviate symptoms of Parkinson's disease. It is also important to maintain a balanced diet, including whole grains, fruits, and vegetables, to manage the effects of PD such as constipation. Exercise is recommended to address deterioration in balance, coordination, flexibility, and muscle strength caused by PD and can also reduce anxiety and depression.

The client displays various signs and symptoms of Parkinson's disease, including resting tremors, bradykinesia, hypomimic (mask-like face), slowed speech, and reliance on a wheelchair. The client's score on the Hoehn and Yahr scale indicates significant impairment. Medications are being used to alleviate these signs and symptoms.

The presence of Level 3 physical mobility impairment is due to bradykinesia, akinesia, neuromuscular impairment motor weakness, pain, and tremors (Berman & Snyder, 2012).

The lack of decisive movement within the physical environment, such as movement in bed, transfers, and ambulation, indicates a limited range of motion (ROM) and decreased muscle stamina, strength, and control. This limitation in independent, purposeful physical movement of the body is accompanied by impairment on the right side. The difficulty for the patient to ambulate is attributed to muscular and neuromuscular weakness associated with Parkinson's disease. The client has a defect in the extrapyramidal tract located in the basal ganglia, resulting in a loss of the neurotransmitter dopamine. This condition presents with the classic triad of symptoms: tremor, rigidity, and bradykinesia. Maneuvering becomes challenging due to the tremors associated with paralysis agitans, which cease with voluntary movement and during sleep. Immobility is a common response to Parkinson's disease and puts the client at risk for thrombophlebitis, skin breakdown, pneumonia, and depression. Additionally, immobility hinders circulation and reduces nutrient supply to specific areas, leading to the potential development of pressure ulcers or decubitus ulcers.

Immobility also leads to the formation of clots. There are deficits in self-care due to issues with the muscles and nerves, resulting in decreased strength, coordination difficulties, rigidity, and tremors. These deficits are evident in tasks such as dressing, hygiene, and using the toilet, as seen through tremors and motor disturbances. The client is unable to perform basic hygiene tasks such as cleansing the body, combing hair, brushing teeth, and taking care of the skin. Additionally, the client struggles with dressing appropriately and fastening clothing. The patient requires assistance with Activities of Daily Living (ADLs), including bathing, dressing, brushing teeth, and occasional assistance with feeding. Toileting assistance is also needed. This nursing diagnosis is crucial as it ensures hygiene, improves quality of life, and promotes dignity, self-worth, independence, and freedom.

There is a risk of falls due to reduced mobility and an unsteady gait caused by a sedentary lifestyle and Parkinson’s disease. The patient uses a wheelchair and walks with a walker. The patient's gait is affected by Parkinson’s disease, causing festination or a propulsive gait characterized by short, shuffled steps with increasing acceleration. These symptoms occur due to impaired postural reflexes and can lead to falls (VanMeter and Hubert, 2014).

Falls can have psychological effects on patients, including a decrease in self-confidence and a fear of additional falls, ultimately leading to a decrease in mobility and a significant reduction in quality of life (Jarvis, 2012). The patient's impaired bowel elimination/constipation is related to medication, physical disability, and decreased activity. This is evident as the patient does not pass stools daily. The medications given to the patient for Parkinson's disease contribute to the constipation. Additionally, the patient's immobility is also a contributing factor. This nursing diagnosis is important to monitor the patient's bowel movements and prevent fecal impaction. The patient's nutrition is imbalanced and less than the body requirements due to tremors, slower eating process, difficulty chewing, and swallowing. This is evident as the patient occasionally requires assistance with eating.

Patients with a nutritional deficit are more prone to developing pressure sores, and proper nutrition is necessary for participating in exercise or rehabilitative programs. The ultimate objective is to optimize the client's nutritional status. Impaired verbal communication is evident in patients with diminished speech volume and ability, stiff facial muscles, delayed speech, and an inability to move facial muscles. This is demonstrated by the lack of expression on the client's face and hindered speech. The loss of dopamine can cause stiffness and slowness in the facial muscles, resulting in a distinctive lack of expression. Speech impairment, known as dysarthria, often manifests as weak, slow, or uncoordinated speaking that can affect volume and pitch. Parkinson's disease can lead to difficulties in speaking and writing due to tremors, reduced voice volume (hypophonia), and instances where movements temporarily "freeze."

This is a nursing care plan addressing impaired physical mobility in individuals with Parkinson's disease. The plan includes goals and interventions.

Bradykinsia

Client will be capable of using a walker to independently go to breakfast in the mornings and will not require any help with transfers. By 3 months, the client will be able to perform all active range of motion exercises.

Research the current state of mobility and observe any signs of increased damage. Implement an exercise regimen aimed at enhancing muscle strength.

Engage in either passive or active assistive range of motion (ROM) exercises, as well as muscle stretching exercises for all appendages, in order to enhance venous return, prevent stiffness, and preserve muscle strength and endurance. In the absence of movement, the collagen tissues surrounding the joint may become ankylosed, resulting in permanent immobility (Berman & Synder, 2012).

Akinesia

The client will experience improved voluntary movements and will not develop joint contractures. It is recommended to evaluate the suitability of deep brain stimulation and to refer the client to physical therapy. If the muscle fibers are unable to contract and relax properly, it can lead to the formation of a contracture, which can restrict joint mobility (Berman & Synder, 2012).

Tremors

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)

The goal is for the client to not have a pain level greater than 4 on a scale of 0-10. Before engaging in any activity, it is important to observe for and, if possible, address any existing pain. Evaluate the patient's willingness and capability to try different pain management techniques. Follow the physician's orders when administering pain medication. Assist the patient in repositioning frequently to a comfortable position, as pain can limit mobility and worsen with movement. (Source: www.ptnow.org)

Nursing Care Plan- Impaired Alteration in Skin Integrity: Risk for Pressure Sores; Pressure Ulcers; Bed Sores; Decubitus Care Related to:

Goal, Interventions and Rationale for Neuromuscular Impairment

The client's skin will be ulcer-free throughout their long term stay. Check the affected area of skin for any changes in color, redness, swelling, warmth, pain or signs of infection at least once a day. Focus particularly on areas at high risk and ask the client about any loss of sensation. Apply barrier cream to the perineal area and buttocks when necessary.

Use the ROHO cushion on the wheelchair to help prevent skin damage. It is important to check the skin daily to maintain its integrity (Jarvis, 2012). Immobility may result in the client being unable to effectively communicate signs/symptoms of impaired skin. It is important to educate the client on how to assess their skin and wounds, as well as how to monitor for signs of infection, complications, and healing. Be sure to utilize prophylactic antipressure devices as necessary.

Early assessment and interventions may prevent complications from developing in order to prevent tissue breakdown (Jarvis, 2012).

Nursing Care Plan for Self Care Deficits related to immobility:

Goal:

Intervention:

Rationale:

Client will provide assistance with daily activities such as bathing, grooming, dressing, oral care, and eating. They will also use a high back wheelchair for transportation. The effectiveness of the bowel or bladder program will be improved when the patient's natural and personal patterns are taken into account. Loss of muscle control and coordination may occur. During the long term stay, the client will work towards improving muscle control and coordination in all extremities. They will walk to the dining room and in hallways for 5 minutes a day, 5 days a week. It is important to establish consistent routines and give the patient enough time to complete tasks. Additionally, assistance with ambulation will be provided.

This helps patients in organizing and performing self-care skills. Tremors are addressed by assisting the client with dressing and providing appropriate assistive devices. Encouragement is given to use clothing one size larger. The client is taught and supported during their activities with the use of extensions on breaks along with ball grips. To enable independence in dressing, button hooks or loop and pile closures on clothes can be used. This ensures easier dressing and comfort, especially for those with tremors. In cases of neuromuscular impairment, emphasis is placed on daily cleanliness, grooming, and dressing to promote dignity and psychosocial well-being. Assistance is provided as needed for tasks such as showering, hygiene, grooming, oral care, and eating.

A nursing care plan is created for the risk of falls. The plan outlines the related factors, goals, interventions, and rationales.

Decreased muscle tone. Client will be educated on the factors that may lead to injury and understand them. This includes being informed of their risk for falls. The bed should always be in the lowest position to prevent falls. Assistance should be provided as necessary for transferring. The importance of using the call light will be reinforced. By educating and ensuring that the client comprehends the factors that contribute to falls, the likelihood of a fall can be minimized.

Nursing Care Plan- Impaired Bowel elimination/constipation Related to: Goal Intervention Rationale Inactivity, immobility Client will have soft formed stool every other day 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

Assess the typical dietary patterns, eating schedule, and liquid consumption. Start additional high-protein meals when necessary.

Changes in mealtime, type of food, disruption of usual schedule, and anxiety can result in constipation. To maintain adequate energy levels, it is necessary to have proper nutrition.

Diminished muscle tone

Encourage the practice of isometric abdominal and gluteal exercise and remember to apply skin moisturizers/barrier creams as needed.

One way to enhance the muscles required for evacuation, unless it is advised otherwise, is by exercising them. (http://www.gutsense.org) Medications

According to VanMeter & Hubert (2014), it is recommended to encourage a daily liquid intake of 2000 to 3000 ml. This will help optimize hydration status and prevent the hardening of stool.

My perspective on my resident has certainly changed since the initial day when I performed a health history assessment on him. I immediately knew that I would value getting to know this resident due to the smooth flow of our conversation. This resident shared incredible stories. I truly admire the fact that he and his wife have been married for 48 years. It was a joy to listen to him reminisce about life before being diagnosed with Parkinson's disease, as it seemed to uplift his spirit. I feel incredibly fortunate to have had the opportunity to care for such an authentic individual. Overall, my clinical experience was positive. I learned that if I lacked knowledge about a particular task, it was important to ask for help.

I appreciated the hands-on aspect of the clinicals and the opportunity to gain experience in a long-term healthcare facility. This clinical rotation also emphasized the unique qualities needed for geriatric nursing. The utmost importance of dignity is the main takeaway from this experience. I applied the golden rule and treated others as I hope to be treated in my old age. Overall, it was a fantastic learning experience.

The following references are mentioned in the text below: - 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.The information about Parkinson's disease can be found at the University of Maryland Medical Center website (http://umm.edu/health/medical/reports/articles/parkinsons-disease#ixzz2upFLCggw) and in the book "Gould's Pathophysiology for the Health Professions" by K. C. VanMeter and R. J. Hubert (2014).

Updated: Feb 21, 2024
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Health History and Medication Regimen of a Parkinson's Patient. (2016, Apr 23). Retrieved from https://studymoose.com/nursing-process-essay

Health History and Medication Regimen of a Parkinson's Patient essay
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