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 Covered in
Category/Subcategory 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 Physiological changes occur with aging in all organ systems.
Hx of hypertension, Hypertension increases the risk of heart disease, stroke, and other cardiovascular
disease
Hx of gastro esophageal reflux disease (GERD) GERD is a highly prevalent disease caused by the exposure of the esophagus to
refluxed gastric contents, PPIs are the mainstay of current treatment
Parkinson's disease 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).
Lost ten pounds in the last month, 5 fett-6inches In patients with low body weight, the brain becomes starved and they can develop
weighs 110 lbs. and BMI of 17.8 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
Son found his mother in her room alone staring into Chronic loneliness can have a significant impact on the overall health, including
space 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 Coping with the death of a significant other isn’t easy. Grief can affect our body,
mind, emotions, and spirit.
Medical power of attorney, the son Jack, lives 30 A medical power of attorney is a legal document that names one person the health
minutes away 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.
Was a homemaker, an active participant in her Knowing this can help show just how differently Lilly is acting now that she is at
community, and had many hobbies. She reluctantly Sunnyside Health Care Center. These changes in her behavior can be a sign of
agreed to go to Sunnyside Health Care Center after depression.
her son accepted a job that required him to travel.
, 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 Pain is part of the body's defense system, producing a reflexive retraction from the painful stimulus, and
after waking, better when tendencies to protect the affected body part while it heals, and avoid that harmful situation in the future.
walking a while 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 The patient’s slow response to questions and postural instability can be a clinical
to questions. Sitting with a forward leaning manifestation of her Parkinson Disease. Flat affect is a severe reduction in emotional
posture. 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
Neuro: Tremors noted at rest in hands.
Disease
HEENT: tremor noted. Lips, tongue, and
The patient s lips, tongue, and oral mucosa is tacky dry. This can be caused by not
oral mucosa pink and tacky dry. drinking enough fluids, sleeping with mouth open, dry hot weather, eating dry foods,
or medication side effects.
Abdomen: BS hypoactive in all four Hypoactive, or reduced, bowel sounds often indicate that intestinal activity has
quadrants. slowed down. Hypoactive bowel sounds are normal during sleep, after the use of
certain medicines, and after abdominal surgery. Decreased or absent bowel sounds
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 Covered in
Category/Subcategory 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 Physiological changes occur with aging in all organ systems.
Hx of hypertension, Hypertension increases the risk of heart disease, stroke, and other cardiovascular
disease
Hx of gastro esophageal reflux disease (GERD) GERD is a highly prevalent disease caused by the exposure of the esophagus to
refluxed gastric contents, PPIs are the mainstay of current treatment
Parkinson's disease 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).
Lost ten pounds in the last month, 5 fett-6inches In patients with low body weight, the brain becomes starved and they can develop
weighs 110 lbs. and BMI of 17.8 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
Son found his mother in her room alone staring into Chronic loneliness can have a significant impact on the overall health, including
space 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 Coping with the death of a significant other isn’t easy. Grief can affect our body,
mind, emotions, and spirit.
Medical power of attorney, the son Jack, lives 30 A medical power of attorney is a legal document that names one person the health
minutes away 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.
Was a homemaker, an active participant in her Knowing this can help show just how differently Lilly is acting now that she is at
community, and had many hobbies. She reluctantly Sunnyside Health Care Center. These changes in her behavior can be a sign of
agreed to go to Sunnyside Health Care Center after depression.
her son accepted a job that required him to travel.
, 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 Pain is part of the body's defense system, producing a reflexive retraction from the painful stimulus, and
after waking, better when tendencies to protect the affected body part while it heals, and avoid that harmful situation in the future.
walking a while 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 The patient’s slow response to questions and postural instability can be a clinical
to questions. Sitting with a forward leaning manifestation of her Parkinson Disease. Flat affect is a severe reduction in emotional
posture. 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
Neuro: Tremors noted at rest in hands.
Disease
HEENT: tremor noted. Lips, tongue, and
The patient s lips, tongue, and oral mucosa is tacky dry. This can be caused by not
oral mucosa pink and tacky dry. drinking enough fluids, sleeping with mouth open, dry hot weather, eating dry foods,
or medication side effects.
Abdomen: BS hypoactive in all four Hypoactive, or reduced, bowel sounds often indicate that intestinal activity has
quadrants. slowed down. Hypoactive bowel sounds are normal during sleep, after the use of
certain medicines, and after abdominal surgery. Decreased or absent bowel sounds
