CaseStudy Parkinson's Disease UNFOLDING Reasoning, Lillian "Lilly" Marie Jones, 76 years old | Already GRADED 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% 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. 1. 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: • Parkinson's disease • Urinary tract infection and dehydration • Lilly has lost ten pounds in the past month. has a BMI of 17.8. • PD will continue to worsen; it is important to assess constantly to adapt to new challenges. • UTI can be a complication of PD because of the patient’s inability to fully empty their bladder. Certain medications for PD can increase the risk of dehydration. • She may be suffering from dysphagia and is underweight RELEVANT Data from Social History: Clinical Significance: • Widowed • One son that lives 30 away • Reluctantly agreed to go to a long- term care facility • The loss of a spouse can cause depression, but she is at increased risk for depression due to PD. Depression is a complication associated with PD. • She is at risk for isolation due to being widowed and her only child living 30 min away. • Loss of independence can be another risk factor for 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." 2. 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: • P: 90 • Pain • Resting pulse is tachycardic and could be due to dehydration. • Pain could be a complication of PD and could be the reason she is tachycardic as well, even though her pain level is not high. 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. 3. 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: • Flat affect • Tremors at rest in hands • Tremor noted in face • Lips, tongue, and oral mucosa pink and tacky dry. • BS hypoactive in all four quadrants • Urinary incontinence • Skin tenting • Depression can cause her to have a flat affect. • Can cause difficulties for her to perform her ADL’s. • Tremors in face can make it hard for her to eat or drink. • Indicates dehydration • Can indicate constipation, consistent with dehydration. • Incontinence could indicate a problem getting to the bathroom in time. Patients with PD may have a hard time getting anywhere fast. • Indicates dehydration. 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.. 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 • HGB 10.8 • PLT 154 • % Neut 65 • Could indicate infection or inflammation due to PD. • Could be iron deficient due to sudden weight loss/lack of nutrition • Helps to find if there is a blood loss or clotting issues. • Could show a bacterial infection such as UTI • W • W • S• S Basic Metabolic Panel (BMP ) Na K Gluc. 7reate. BUN Current: 142 3.7 88 1.4 38 Last Month: 135 3.4 90 1.0 22 5. 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 • K 3.7 • Glucose 88 • Create 1.4 • BUN 38 • Could be slightly more elevated due to dehydration • Slight increase, could be due to dehydration • Stays consistent. Important to monitor for hypo- or hyperglycemia • Checks kidney function. Could be increased due to dehydration. • Increased due to dehydration. • S • S • S • W• W 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 • Could decrease due to lack of proper nutrition • W 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 6. 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: • Clarity Dark • Could indicate UTI • W • Sp gravity 1.030 • Changes with dehydration • W 7. 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 3.4-5.4 Critical Value: 3.0 The more malnutrition a patient suffers from, the lower albumin will be. Assess patient’s nutritional intake Clinical Reasoning Begins… 8. 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 and nutrition Dehydration results from decreased intake and increased output. Patients with PD are more at risk due to tremors that may make it hard to drink and swallow fluids. Nutrition results from inadequate intake or absorption of nutrients. This can also be due to tremors the patients suffers from with PD making it hard to receive adequate intake. Nutrition 9. Collaborative Care: Medical Management (Pharmacologic and Parenteral Therapies) Care Provider orders: Rationale: Expected Outcome: Referral to a speech-language pathologist (SLP) PD has adverse effects the muscles used for speech and swallowing. (What Is Parkinson’s? 2019) Parkinson's disease can affect ADLs and an OT can help the patient maintain independence (What Is Parkinson’s? 2019) PD causes impaired mobility due to tremors, and forward flexion of the trunk. (Treatment, n.d.) Ensures consistent nutrition for a patient with a history of weight loss. (Ackley et al., 2020) Will help to assess nutritional needs (Ackley et al., 2020) Corrects deficiencies for patients receiving parenteral nutrition (Ackley et al., 2020) Blocks the production of acid in the stomach (Adams & Urban, 2019) Levodopa can cross the blood-brain barrier Carbidopa prevents the conversion of levodopa to dopamine in the peripheral tissues. (Adams & Urban, 2019) Will check for electrolyte imbalances (Ackley et al., 2020) Performed to evaluate for anemia (Ackley et al., 2020) Demonstrate sufficient drinking, eating and speech Referral to an occupational therapist (OT) The patient will demonstrate being able to perform ADLs such as eating and bathing, with little to no assistance. Referral to physical therapy (PT) The patient will demonstrate flexibility, and mobility. Patient will maintain Weekly weights weight with no weight loss Patient will adhere to diet and supplement plan to Registered Dietician consult (RD) meet nutritional needs. Patient will restore and maintain essential MVI po daily micronutrients Patient will demonstrate controlled symptoms of Ranitidine 150 mg po BID prn GERD Patient will demonstrate improved mobility with decreased muscle rigidity Carbidopa-Levodopa 20-100 mg po and tremors TID Patient will maintain satisfactory electrolyte balances Basic metabolic panel (BMP) Patient will demonstrate Complete blood count (CBC) acceptable levels of HgB 10. PRIORITY Setting: Which Orders Do You Implement First and Why? (Management of Care) Care Provider Orders: Order of Priority: Rationale: • Referral to a speech 1.BMP, CBC • pathologist • Referral to an occupational 2.Dietary consult • therapy • Referral to physical 3.Referral to speech • therapy pathologist • Weekly weights 4.MVI • • Dietary consult • MVI po daily • Ranitidine 150mg po BID 5.Carbidopa-Levodopa • prn • Carbidopa-Levodopa 20- • 100mg po TID 6.Referral to an OT • BMP, CBC 7. Referral to PT • 8. Weekly weights • 9. Ranitidine • Need to look for electrolyte imbalances because they can be deadly There needs to be a way to get the patient the nutrition she needs, and the dietary consult will help Help the patient to develop and maintain the ability to swallow to eat and drink independently. Replace the micronutrients lost Decrease symptoms of PD so patient can perform ADL’s. Help the patient learn to do things such as feed and dress their self Help patient to maintain muscle strength and ROM. Ensures prior orders of nutrition and self-feeding are effective Reduce GERD S&S Collaborative Care: Nursing 11. What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY: Imbalanced nutrition PRIORITY Nursing Interventions: Rationale: Expected Outcome: • Ascertain healthy body weight for age • Experts like a dietician can determine nitrogen • Patient will comply and height. Refer to a dietitian for balance as a measure of the nutritional status of with nutritional plan complete nutrition assessment and the patient. The dietician can also determine the • Patient will have methods for nutritional support patient’s daily requirements of specific nutrients enough strength to • If patient lacks strength, schedule rest to promote sufficient nutritional intake. (Ackley et finish meals periods before meals and open al., 2020) • Patient will packages and cut up food for patient. • Nursing assistance with activities of daily living • For patients with impaired swallowing, (ADLs) will conserve the patient’s energy for demonstrate ability to swallow food and water coordinate with a speech therapist for activities the patient values. Patients who take evaluation and instruction. longer than one hour to complete a meal may require assistance. (Ackley et al., 2020) • Adjustments of the thickness and consistency of foods to improve nutritional intake may be provided by a speech therapist. (Ackley et al., 2020) 12. 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 Neurological GU GI Assess strength in limbs and tremors Assess for progression of PD Assess color, spec gravity and clarity for dehydration Assess bowel sounds for possible constipation due to dehydration, lack of nutrition 13. 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: Dehydration Nursing Interventions to PREVENT this Complication: Assessments to Identify Problem EARLY: Nursing Interventions to Rescue: Aid the patient if he or she is unable to eat without assistance and encourage the family or SO to assist with feedings, as necessary. Administer parenteral fluids as prescribed. Consider the need for an IV fluid challenge with immediate infusion of fluids for patients with abnormal vital signs. Begin to advance the diet in volume and composition once ongoing fluid losses have stopped Weigh daily with same scale, and preferably at the same time of day. Monitor serum electrolytes and urine osmolality, and report abnormal values. Assess color and amount of urine. Report urine output less than 30 ml/hr for 2 consecutive hours. Encourage frequent drinking of fluids Monitor I&O, VS regularly, and nutritional intake. 14. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity/Basic Care and Comfort) Psychosocial PRIORITIES: Depression PRIORITY Nursing Interventions: Rationale: Expected Outcome: CARE/COMFORT: Caring/compassion as a nurse Providing the patient emotional support. The patient has no SO and son lives far away so she will be lonely and need emotional support. Patient will feel valued EMOTIONAL (How to develop a therapeutic relationship): Discuss the following principles needed as conditions essential for a therapeutic relationship: The nurse will need to establish a therapeutic relationship by building trust. Following through on what she said she will do and being genuine with the patient will also build trust. The nurse will also need to spend time listening to the patient to make her feel valued. Patient will trust nursing staff and adhere to treatment plans SPIRITUAL: • F-Faith or beliefs: • I-Importance and influence • C-Community: • A-Address: Finding out about the patients’ spiritual beliefs will help the nurse plan ways for the patient to cope with disease and depression. This can also help the patient find ways in which the community she has been involved in can help support her and help her cope. Patient will feel comfortable with treatments and nurse will demonstrate respect for patients’ beliefs. CULTURAL Considerations (IF APPLICABLE) If the patient knows the nurse respects their cultural beliefs, the patient is more likely to trust the nurse and go along with treatments. Patient will feel like her beliefs are respected Evaluation: Three weeks later… Lilly has slowly adjusted to her new home at Sunnyside Health Care Center. She now eats in the dining room with other and has an assigned feeding assistant for meals times. I&Os are monitored daily as well as weekly weights. A registered dietitian has developed a meal plan and snacks specific to her food preferences. SLP has evaluated her ability to swallow and is currently working with her to strengthen muscles and maintain range of motion. OT has evaluated Lilly's ability to perform ADLs and she now has adaptive tools to assist her ADLs. PT is working with Lilly to maintain mobility. Interdisciplinary meetings are held monthly. Lilly and her son, Jack, are invited to attend to discuss progress and express any concerns. 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. 15. 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/50.9 kg Weight gain of 2lbs is a sign that interventions are working Improving RELEVANT Assessment Data: Clinical Significance: TREND: Improve/Worsening/Stable: Slow to respond to questions, Tremors noted in bilateral hands. Movement slow and rigid. PD is a progressive disease Stable 16. 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: Patient has shown good, all around improvement Patient should be assessed for safety concerns such as fall risks and infection. 17. Based on your current evaluation, what are your CURRENT nursing priorities and plan of care? (Management of Care) CURRENT Nursing PRIORITY: Safety PRIORITY Nursing Interventions: Rationale: Expected Outcome: Assess ambulation and movement Aids in planning of interventions. Stooped posture may cause the patient to collide with objects. Exercising increases flexibility and improves strength and balance. Patient will remain safe from environmental hazards resulting from cognitive impairment. Remind patient to maintain an upright posture and look up when walking Family will ensure safety precautions are instituted and followed. Teach range of motion exercises and stretching to be performed daily. Patient will remain in a safe environment with no complications or injuries obtained. 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, female BRIEF summary of the primary problem: Patient has HTN, GERD and PD. Primary problems are stable and are being managed. Patient had dehydration and malnutrition upon admission. Patient has received a dietary consultation and is receiving PT, OT, and Speech therapy to manage PD. Day of admission/post-op #: 4 weeks Background: Primary problem/diagnosis: Parkinson’s disease, dehydration, and malnutrition. RELEVANT past medical history: HTN, GERD and PD RELEVANT background data: Widowed, one son who lives a little farther away. No close family. Assessment: Most recent vital signs: T: 98.0 F/36.9 C (oral) P: 70 (regular) R: 14 (regular) BP: 120/78 O2 sat: 99% room air Weight: 112 lbs/50.9 kg RELEVANT body system nursing assessment data: Neurological, GI, and GU RELEVANT lab values: No recent labs. Prior labs drawn a month ago TREND of any abnormal clinical data (stable-increasing/decreasing): Patient is stable. How have you advanced the plan of care? Patient has continued to receive PT, OT, and ST Patient response: Patient is responding to interventions and improving in nutritional status and PD symptoms. INTERPRETATION of current clinical status (stable/unstable/worsening): Patient is stable Recommendation: Suggestions to advance the plan of care: Continue to monitor safety and for infections and dehydration as a complication of PD. Education Priorities/Discharge Planning 18. What educational/discharge priorities will be needed to develop a teaching plan for this patient and/or family? (Health Promotion and Maintenance) Education PRIORITY: Family education of PD PRIORITY Topics to Teach: Rationale: S&S of Parkinson disease Parkinson’s is a progressive disease. Education helps the family to know what is normal and abnormal. Caring and the “Art” of Nursing 19. 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 probably feeling scared and lonely. She has nobody familiar and is in an unfamiliar environment. Build trust with the patient. Show the patient that you care and be consistent with the patient. Make sure that the nurse is honest with the patient and always explains what she is doing to ease the patient’s anxiety. Use Reflection to THINK Like a Nurse 20. 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? That patients need to be observed and assessed frequently in long term care facilities Finding solutions to solve dehydration What could have been done better? What is your plan to make any weakness a future strength? I could have interpreted the labs better Continue to learn lab values and how they relate to different concepts Show Less