Nursing Process Essay

The thickening is a 70 year old, Caucasian male who is a retired siding salesman from Riverside, IA, who has an drawn-out account with paralysis agitans (Parkinsons indisposition). The guest was first admitted to the ache boundary fear facility in December 2012. The leaf node explained that he came to be at this facility later on already being in dickens places like this. He was removed/discharged from the last broad- consideration c be facility for being what he call(a)ed disruptive. The lymph node descri ack straight offledge the supply at the last facility as non genuinely miscell each to the residents. There was an incident where the drugs that were prescribed to the node made him hallucinate and he became unruly with the staff and was restrained and jamn to the hospital for evaluation. He was thence tiltred to this long term c ar facility. Wanting to gather the invitees health history, an interview was scheduled.In start the interview with the invitee, he was claimed if he would be comfor stoppagele with being asked some questions and was inform that he did not guard to answer any questions that he was uncomfort able-bodied with. Due to the customers paralysis agitans and his brawninessman weakness he is primarily in a wheelchair. The client was asked if there was anything that he require forward starting and if he would prefer the door be closed or the cape be drawn for privacy, he decl ared that wasnt 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 attend to moving his hand that was resting on the bed to the arm of his wheelchair in doing this it seemed to military service calm the tremors. When speaking with the client, he is of wakeless mind and has a sense of humor.This indicates that the clients paralysis agitans has not affected the playing field in the right hemisphere of the soul that controls personality. The client cel ebrated that he was in respectable strong-arm health until 1996. He then explained that in the spring of 1996, maculation he was running he suffered from a TIA (Transient Ischemic Attack). The client sought out nonrecreational answers from 5 specialists and was diagnosed with Paralysis agitans. The client conveyed this was a concern he had because his start excessively had Paralysis agitans. The client describes that the Paralysis agitans hasprogressively become worse oer the past 18 years. It was observed that his speech was slow and monotonous. The client spoke in a low and discreet volume. A pretermit of nervus nervus facialisis expressions was overly noticed. The client foot walk with the economic aid of a walker further is generally in a wheelchair.Name of drugDosageRouteTimeRelated toCarbidopa-Levo 25 nose in any caseshiedy tab orallyTIDParalysis agitansComtan200 mg tabletby word of let outTIDParalysis agitansSeroquel XR50 mg tabletOrallyIn the afternoonNonorga nic psychosisHe is prescribed 3 tablets to be taken viva voce 3 generation a twenty-four hourslight Carbidopa-Levodopa 25-100 (25 mg of Carbidopa and 100 mg of Levodopa) for paralysis agitans. He is in addition prescribed 200 mg of Comtan to be taken viva voce 3 clocks a day for paralysis agitans. These drugs raise the aim of dopamine in the school principal. A side effect of having elevated levels of dopamine in the brain is psychosis. The client is as tumesce as minded(p) 50 mg of Seroquel XR orally in the afternoon to alleviate his nonorganic psychosis. It is documented in the clients graph 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 endless positive airway force (CPAP) machinewhile sleeping at night.When talking more in depth almost sleep patterns and concerns the client stated that he gets approximately 8 hours a sleep a night, this is without any help from sleep ai ds. When speaking of his bedtime rituals he said that he does have cardinal beers, back to back, at night right before bedtime, while watching television. He does not have trouble fall asleep but did claim that he sometimes has a exhausting time staying asleep at night. When questi whizd almost taking occasional naps passim the day he stated depends on if Ive been up all night. The client then explained that it is the noise level at the long term aid facility that keeps him awake.When inquiring approximately the clients family he stated that he has been married for 48 years and has two children, a son who is 44 years old and a girlfriend that is 39 years old. The client also has cardinal 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 graduate(prenominal) strain pressure and it was noted in his chart that he is given an 81MG acetylsalicylic acid day-by-day for atrial fibrillation.Aspirin81 mgOrallyo.d.A-fibAcetaminophen325 mgOrally either 6 hourPainHe has no history of subject matter surgeries or surgeries of any kind. The client reported that he has never had derelict fever. When asked about blood coagulums, 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 unhingeful. He stated that he exit ask for his prescribed 650 MG of acetaminophen for the pain.When speaking about everyday stresses with the client, he stated that he doesnt have a lot of stress but gets irritated when that staff contort on the lights every morning at 630 am. When asked if there was anything that he does when he notices that h e is stressed, the client mentioned that when he was younger he would rifle to Vedic City in Iowa and practice with the Maharishi meditating. He says that meditating has been very cooperative in his adult life. The client also mentioned that he want to borrow the Maharishi lifestyle and eat only organic foods but it is not affirmable to follow that when residing at a long term care facility. former(a) 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 b want and albumin 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 hasnt 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 its not so much the falli ng but maybe its the landing. When assessing the clients vitals it was noted that he has slightly elevated blood pressure of 129/84 and could be cause for concern of pre-hypertension.Metoprolol tartrate25 mgOrallyBIDHypertensionIt 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 get at 18 respirations per minute. SaO2 was at 86%. The clients 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 gainsay to get dressed and undressed due to the stiffness in his accouterments and legs.The client is on a regular diet and states that hedoesnt have any fuss sw take oning f oods and doesnt require help with feeding. When asked about appetite he said that sometimes he doesnt 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 illness/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.Antacid Suspension30 mlOrally either 6 hoursSupplement heartburnMultivitamin1 tabletOrallyo.d.SupplementWhen 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 clients chart he is given a 100 mg capsule of Docusate sodium orally 2 times a day to help with constipation.Docusate sodium100 mg capsuleOrallyBIDConstipationThe client does not have any history of kidney or bladder disorder. 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 link to impaired mobility and PRN straight catheter needed for intermittent retention unessential to BPH. The client is given one 0.4 mg of Tamsulosin HCL orally a day for BPH (benign prostatic hyperplasia).Tamsulosin HCL0.4 mhOrallyo.d.BPHThe client needs assistance with bathing as well. The client also has a DNR order.Parkinsons disease (paralysis agitans) is a progressive disorder of the nervous sy stem that affects ones mobility. According to Hubert and VanMeter, Parkinsons disease is a dysfunction of the extrapyramidal motor system that occurs because of progressive chronic changes in the basal nuclei, principally in the substantia common racoon.(UMMC, 2012) The substantia nigra is the primary area of the brain that is affected by Parkinsons 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, creditworthy for balance, control of movements, and walking, by means of long fibers called axons. (Okun, 2013) These regular sensible structure 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 way out of dopamine, which in turn causes the nerve cells in the striatum to trigger excessively. The excessive firing of neurons makes it inconceivable for one to control their movements, a sign of Parkinsons disease. (Okun, 2013) According to the Parkinsons disease Foundation (2014)As many as one one million million Americans live with Parkinsons disease, which is more than the combined number of people diagnosed with triple sclerosis, muscular dystrophy and Lou Gehrigs disease. Also approximately 60,000 Americans are diagnosed with Parkinsons disease each year, and this number does not reflect the thousands of cases that go undetected. An estimatedseven to 10 million people worldwide are living with Parkinsons disease. Incidence of Parkinsons 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 Parkinsons 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 ramifications of Parkinsons disease. (MGH, 2005)Early stages, like HYs stage one, of Parkinsons 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 corruptive 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 retard of body movements, early impairment of equilibrium with walking and standing and extrapolate dysfunction that is moderately severe. The Hoehn and Yahr scales 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 louver the person is unable to walk or stand so is bedfast or confined to a wheelchair. This stage is referred to as the cachectic stage. Constant nursing care is required in stage volt (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 peril for aspiration pneumonia (Leopold and Kagel, 1997). Constipation can be other complication as to the slowing of the digestive tract. Parkinsons disease can also cause urinary retention and urinary incontinence. Dementia and difficulty intellection comes in later stages of PD. (University of doc Medical common snapping turtle, 2012) Depression is very common in forbearings with Parkinsons. 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 wit h depression (University of medico Medical Center, 2012). calmness problemsand sleeping disorders are also associated with PD, with this comes fatigue. Some patients may experience ghost light headed when standing due to the drop in blood pressure (orthostatic hypotension). Pain can also be another symptom link up to Parkinsons disease (Okun, 2013). There is not yet a recuperate for Parkinsons 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 Parkinsons 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 sawbones implants electrodes into a specific lo cation in the patients brain. A source is implanted in the patients chest, which is attached to the electrodes.This generator sends electrical impulses to the patients brain, which may lessen the symptoms of Parkinsons 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 saturation deteriorate with PD so, work is encouraged. Exercise also helps with decreasing trouble and depression. The client exhibits many of the discussed signs and symptoms of Parkinsons disease. The client experiences resting tremors, bradykinesia, mask like slope (hypomimic), slowed speech and is in a wheelchair. He scores very poorly(predicate) according to the Hoehn and Yahr scale. The client is on medications to help diminish the signs an d symptoms of Parkinsons disease. impair physical mobility level 3, related to bradykinesia, akinesia, neuromuscular impairment motor weakness, pain and tremors. (Berman & Snyder, 2012) manifest by neediness of decisive movement within physical environment, including movement in bed, transfers, and ambulation. Limited range of motion (ROM). change magnitude 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 Parkinsons disease, evidenced by it being difficult for the patient to ambulate. The client has a defect of extrapyramidal tract, inthe 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 conscious movement and during sleep (VanMe ter and Hubert, 2014). apathy is an expected human response to Parkinsons disease. The clients immobility puts him at risk for thrombophlebitis, fur breakdown, pneumonia and depression. Immobility impedes circulation and diminishes the supply of nutrients to specific areas. As a result, skin breakdown and make-up of pressure (decubitus) ulcer can occur (Berman and Snyder, 2012).Immobility also promotes clot formation. Self-care deficits related to neuromuscular impairment, immobility, lessen 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 amend his body, comb his hair, clash his teeth and do skin care. . The client is also unable to dress himself satisfactory. He does not have the capability to restrain his clothes. The patient is assisted with ADLs. forbearing 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 ADLs 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 rock-bottom mobility, and unsteady gait secondary to sedentary lifestyle and Parkinsons disease. Patient uses a wheelchair and ambulates with a walker. Patients gait is impaired due to Parkinsons 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 inte stine elimination/constipation related to medication, physical disability and decreased activity. Evidenced by the client not passing stools daily. Medications prescribed to patient for Parkinsons disease attribute to constipation. The patients experience with immobility is also a alter factor for constipation. This nursing diagnosis is important because it allows nursing staff to proctor the patients bowel movements and avoid fecal impaction. Imbalanced victual less than body requirements related to tremors, slowing the process of eating, difficulty chaw and swallowing. Evidenced by the client occasionally needing assistance with eating.Pressure sores buzz off more quickly in patients with a edibleal deficit. Proper nutrition also provides needed energy for participating in an exercise or a rehabilitative program. The goal is to optimize the clients nutritionary status. Impaired verbal communication related to decreased speech volume, decreased ability to speak, stiff facial m uscles, delayed speech, and inability to move facial muscles. Evidenced by lack of expression on the clients face, clients hindered speech. spill 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 unorganized speaking that can affect volume and pitch. Difficulty speaking and musical composition because of tremors, hypophonia, and freeze incidents. This is an expected consequence of Parkinsons disease. care for premeditation Plan- transformation in impaired physical mobility- Parkinsons disease Related toGoals discourseBradykinsia lymph node go out use a walker to go to eat in the mornings and not need assistance with transfers. client leave alone be able to perform all mobile ROM by 3 monthsExamine 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 increase venous return, prevent stiffness, and maintain muscle strength and endurance. Without movement, the collagen tissues at the sum become ankylosed (permanently immobile) (Berman & Synder, 2012)AkinesiaClient leave gain power of involuntary 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 sign and lengthen, eventually a contracture forms, limiting joint mobility (Berman & Synder, 2012)TremorsClients tremors will decrease.Encourage deep breathing, imagery techniques and meditation. Encourage holding an object in handSuggest holding the arm of the chair.Stimulating the brain by concentrating on breathing may cease tremors. (www.theparkinsonhub.com)PainClient will not experience pain 4 on a scale of 0-10 in advance activity observe for and, if possible, treat pain.A ssess patients willingness or ability to explore a range of techniques aimed at controlling pain. handle pain medication per physician orders.Encourage/assist to reposition ofttimes to position of comfort. Pain limits mobility and is often exacerbated by movement.(www.ptnow.org) treat Care Plan- transformation in Skin Integrity, Impaired Risk for Pressure Sores Pressure Ulcers, bed Sores Decubitus Care Related toGoal interventions principleNeuromuscular impairmentClient will be free of any pressure ulcers for length of long term stay. Monitor site of skin impairment at least(prenominal) 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 skitter to peri area/ buttocks as needed.Use ROHO cushion on wheelchair.Checking skin once a day will ensure that skin corset intact. (Jarvis, 2012)ImmobilityClie nt 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 reserveEarly assessment and interventions may help complications from developing. To prevent tissue breakdown.(Jarvis, 2012) nursing Care Plan- Self Care DeficitsRelated toGoalInterventionRationaleImmobilityClient 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 coordinationClient 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 p atient to complete tasks. Assist client with ambulation.This helps patient organize and carry out self-care skills.TremorsClient 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 sizing larger.Teach and support the client during the clients activitiesApply extensions on breaks with ball gripsThe use of a button hook or of coil 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.Neuromuscular impairmentClient 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 forRelated toGoalInterventionRationaleDecr eased muscle toneClient will express an instinct of the factors manifold 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/constipationRelated toGoalInterventionRationaleInactivity, immobilityClient will have soft formed stool every other day that are passed without difficulty. Encourage physical activity and regular exercise.Adjust toileting times to meet clients needs.Report changes in skin integrity forum during daily careAmbulation and/or abdominal muscle exercises strengthen abdominal muscles that facilitate defecation. low-fiber diet survey usual dietary habits, eating habits, eating schedule, and liquid intake. Initiate supplemental high-protein feedings as appro priate.Change in mealtime, type of food, disruption of usual schedule, and foreboding can lead to constipation. Proper nutrition is required to maintain adequate energy level.Diminished muscle toneEncourage isometric abdominal and gluteal exerciseApply skin moisturizers/barrier creams as neededTo strengthen muscles needed for evacuation unless contraindicated. (http//www.gutsense.org)MedicationsEncourage liquid intake of 2000 to 3000 ml per dayTo 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 diag nosed with Parkinsons 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 experience 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 rotationtaught me was that it takes an exceptional type of person to go into geriatric nursing. probably the number one thing that Im going to take away from this clinical experience is the total importance of dignity. I too will be old someday and I applied the well-disposed rule to this experience. I treated others as I want to someday, and hopefully, will be treated. What a fantastic learning experience.ReferencesBerman, A., & Snyder, S. (2012). Kozier & Erbs Fundamentals of Nursing Concepts, Process, and Practice. Upper Saddle River Pearson Education. Coleman, J., (September 1, 2013) Meditation & Mitigating Parkinsons Symptoms. Retrieved from http//www.theparkinsonhub.com/your-quality-of-life/article/meditationmitigating-parkinsons-symptoms.html Costa, M. & Quelhas, R. (2009). Anxiety, Depression, and spirit of Life in Parkinsons Disease. The Journal of Neuropsychiatry and Clinical Neurosciences 2009 21413-419. Jarvis, C. (2012). somatic 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 Parkinsons disease. Dysphagia 1997 121118 Massachusetts General infirmary (MGH) (May, 2005) Hoehn and Yahr Staging of Parkinsons Disease, Unified Parkinson Disease Rating Scale (UPDRS), and Schwab and England Activities of occasional Living. Massachusetts General Hospital. Retrieved March 2, 2014, from http//neurosurgery.mgh.harvard.edu/functional/pdstages.htmHoehnandYahr Okun, M. (2013). Parkinsons Treatment 10 Secrets to a Happier Life. CreateSpace Independent Publishing Michael S. Okun M.D. Parkinsons disease Foundation (2014, March) apprehension Parkinsons. Parkinsons Disease Foundation. Retrieved March 2, 2014, from http//www.pdf.org/en/understanding_pd University of Maryland Medical Center (2012, September) Parkinsons disease. University of Maryland Medical Center. Retrieved March 2, 2014, from http//umm.edu/health/medical/reports/articles/parkinsons-diseaseixzz2upFLCggw VanMeter, K. C., & Hubert, R. J. (2014). Goulds Pathophysiology for theHealth Professions. St. Louis Elsevier.