Date post: | 14-Apr-2017 |
Category: |
Health & Medicine |
Upload: | college-of-medical-sciences |
View: | 30 times |
Download: | 0 times |
PARKINSON DISEASE Case study
Objectives of Case study PresentationObjectives of Case study Presentation
To share experience and knowledge to friends and supervisors.
To get feedback from the friends and supervisors for further improvement.
To develop confidence in facing the mass and presenting skills.
Rational for the selection of case Parkinson disease is one of the common neurological disease
encountered in Nepal.
PD is about 0.3% of the whole population in developed country.
To gain knowledge about the specific disease, it’s pathology, etiology, sign and symptoms and
management process.
To provide holistic nursing care to the patient using the nursing process.
MethodologyThe methodology adopted to produce this report was based on:• History taking and interviewing to the patient and
his visitors .• Observation and, physical examination to the patient
• Discussion with teachers, senior staffs and doctors • Using various text books and references of Medicine
and related internet search technology.
Patient’s Name :- Mr Dhan Bahadur Gurung
Age/ sex :- 74 yrs/Male
Marital status :- Married
Education :- Literate
Occupation :- Agriculture
Religion :- Hindu5
Address :- Bhotewodar-9, Lumjung Diagnosis :- Parkinson diseaseWard :- Neuro Medical WardBed No. :- 410IP No. :- 7814Date of admission :- 2011/3/25Interview date :- 2011/3/27Date of expired :- 2011/3/28Attending physician :- Prof PVS RanaInformants :- Patient (self) & his son
CONT’D
Chief complains
1.Abnormal movements of upper and lower limbs x 1 year2. Difficulty in walking x 6 months
History of Present illness:
• My patient presented with abnormal rhythmic movement of upper and lower limbs since 1 year. It started on the distal part of both upper limbs simultaneously. It was noticed more during rest that got aggravated during movements. Recently the lower limbs were also affected and was note more on the both great toes.
• Patient also gives history of difficulty in walking in the form of difficulty in initiation and once he starts walking he stoops forward with small and fast steps. However, he freezes during turning and has tendency to fall forward (propulsion) and backward (retropulsion).
contd
• There is also decreased swinging of the hands.• There is no h/o fall injury, memory
impairment, altered sensorium, behavioral change, visual complains, swallowing difficulty, weakness of one half of the body.
No history of hypertension, diabetes. No history of cancer. No history of asthma, COPD, PTB No history of any injury and accident. No history of any surgical illness. No history of psychiatry problem.
Past health history
Smoking :- Non smoker Alcohol : - OccasionalFood habit :- 3 times a day/ non vegetarianFood allergy :- Not knownDrugs allergy :- Not knownBowel and bladder :- Regular bowel and
bladder habitSleeping Pattern :- normal,6-8 hrs. per day
PERSONAL HISTORY
Type of family:- Neuclear FamilyNo. of family:- 4 membersType of house:- Cemented houseNO. of rooms:- 4 Kitchen :- SeparatedFuel used:- Firewood , GasDrinking Water:- Tap waterToilet :- Water sealDrainage System:- Closed drainage
ENVIRONMENTAL HISTORY
contd
• Family history No history of similar illness, hypertension,
diabetes, TB or asthma in family.
• Socio economic history Middle class family.
Family tree
74
30
68 66 63 51
32 25
Expired male
Expired female
Patient
Male
Female
68
28
Father and mother
sisterbrother
daughterson
wife
DEVELOPMENTAL TASK OF OLDER ADULT
IN BOOKS IN MY PATIENT
Seven developmental task for older adult are listed.1.Adjusting to decreasing health and physical strength.
2.Adjusting to retirement and reduced or fixed income
3.Adjusting to death of a spouse.
1 adjusting to decrease health and physical strength .the most common losses one of the health ,significant other a sense of being useful ,socialization ,income and independent living.
2.Adjusting to retirement by engaging in the farming and animal husbandary
3.My patient was not faced death f spouse.
DEVELOPMENTAL TASK OF OLDER ADULTIN BOOKS IN MY PATIENT
4.Accepting self as ageing person.
5. Maintaining satisfactory living arrangement.
6.Redefining relationship with adult children.
7.Finding way to maintaining quality of life.
4. My patient accepted self as ageing person.Structural and functional change associated with ageing eg loss of hearing ,vision problem, dental missing etc
5.My patient maintained satisfactory living arrangementEg comfortable living arrange all physical facilities.
6.Redefining relationship with adult children by give permission to their children whatever they like.
7.My patient maintained quality of life through use leizure time in social work, spiritual activitiesetc
General Inspection:Gait : Shuffling gait with tendency to fall forward and backward Body Build : ThinConsciousness : Conscious GCS-15/15Higher Mental Function : NormalFacial expression : masked face Vital signs Temperature :98.2F Pulse : 78 beats/min, regular, normal volume and characterRespiration : 20 b /minute, regular Blood Pressure : 120/70 mm Hg in both arms Height : 5' 4" Weight : 65 kg
PHYSICAL EXAMINATION
General examination
• Pallor: absent• Icterus: absent• Lymph nodes: not palpable• Clubbing, cyanosis: absent• Edema: absent.• Dehydration: absent.• Skin normal
Physical examination cont
Examination of head, face and neck 1.Inspection of headHair colour and texture normal, clean hair, no signs of any injury2.Inspection of eyesNo discharge and redness of the eye lid, but swelling of the eyelid, no eye problem3. Inspection of earsNo discharge and pain but hearing problem ispresent.
contd4. NoseNo discharge , bleeding and smelling problem. 5.MouthPoor oral hygiene, missing teeth and dental carriesNo cyanosis present.6. NeckNo enlarged lymph node and thyroid gland .Normal neck mobility is present
Respiratory system• Inspection
Shape of the chest- normal Bilateral symmetical movements No venous prominences or scar marks Trachea center. Spine normal
• Palpation Non tender, Temperature normal Vocal fremitus normal Trachea in center.
• PercussionResonant in left side and dullness in right side in RT infra-scapular region.
• Auscultation: Normal vesicular breath sound bilaterally. No added sounds.
Cardiovascular system• Inspection Cardiac impulse in Left 5th intercostal space 2 cm
medial to MCl No abnormal impulse seen.• Palpation Non tender. Apex beat in 5th intercostals 2 cm
medial to MCl, no thrill • Auscultation S1,S2 normal S3,S4 not heard No murmur
Gastrointestinal system• Inspection No dilated superficial veins, no scar marks • Palpation Non tender, soft. liver- normal, spleen- normal
• Percussion Shifting dullness absent
• Auscultation Bowel sounds present (normal). No bruits.
CNS examination
• Level of consciousness:- GCS-15/15• Sleep: normal• Higher Mental Function: Normal
Cranial nerve assessment
1.Olfactory nerve (sensory)– No any damage in frontal head, basilar, and facial
injuries– Able to correctly identify smells– No discharge, bleeding and smelling problem
2.Optic nerve (sensory)– normal Visual acuity, visual fields– Area and extent of visual field is normal
contd3, 4 & 6. Oculomotor nerve), Troclear, Abducent (motor)
– Symetrical ,no discharge ,no swelling eyelid, no ptosis– Normal pupil size, shape, – reactive to light and accommodation
5.Trigiminal nerve (mixed)• Sensory: three branches:
– Normal Opthalmic, Maxillary, Mandibular • Motor:
– Muscles of mastication• normal temporal and masseter muscles• Open mouth symmetry
– Corneal reflex - present
7. Facial Nerve (sensory and motor)• Sensory: normal taste to anterior 2/3 of tongue• Motor: abnormal Facial expression and secretion of saliva
– Wrinkle forehead, raise and lower eyebrows, smile and show teeth, puff cheeks, close eyes
– Observe for symmetry• No facial nerve paralysis
contd8. Acoustic Nerve (sensory)• Vestibulocochlear nerve:
– Hearing (cochlear) and balance (vestibular)• Weber and Rinne tests
– Weber: • NORMAL: hear equally in both ears
– RINNE:• NORMAL: hear air conduction as long as bone (Rinne
positive)
contd9 & 10. Glossopharyngeal and Vagus (Sensory and motor)
– Taste posterior 1/3 of tongue normal– Swallowing, gag reflex normal– Movement of pharynx normal
contd
11. Accessory nerve• trapezius muscle strenth• sternocleidomastoid muscle normal
12.Hypoglossal Nerve• Tongue movements, strength normal• Speech sounds: normal
CNS examination (contd)
• Motor System : Inspection - Mask like face present - resting tremor present - no neurocutanous marker - no facial spasm - no dilated veins, scars
CNS contd
Palpation Motor - Glabellar tap present– Tone: rigidity + bilateral upper and lower limbs,
cogwheel rigidity present– Power: 4+/5 in both the upper and lower limbs
contd
– Reflexes: DTJ BJ TJ SJ KJ AJ
• Right + + + + +
• Left + + + + +
Plantar: Right: flexor Left: flexor
contd
Sensory function:• Deep sensation-vibration present• superficial sensation –pain and touch presentCortical sensation:• Graphasthesia – normal• Stereognosis- normal• One point localization: normal• Two point discrimination- normal• Sensory inattention- normal
Cerebellar sign:Nystagmus: absentAdiadochokinesis: absentFinger nose test: normalHeel shin test : normalRomberg test: NegativeAtaxia : absence
INTRODUCTION TO DISEASE
PARKINSON’S DISEASE• Parkinson’s disease is a slowly progressing
neurologic movement disorder that eventually leads to disability.
The degenerative or idiopathic form is the most common
There is also a secondary form with a known or suspected cause. (parkinsonism)
• Parkinson’s disease affects men more frequently than women
• Nearly 1% of the population older than 60 years of age
Parkinsonian symptoms• usually first appear in the fifth decade of life
• been diagnosed at the age of 30 years.
• Although the cause of most cases is unknown, research suggests several causative factors:
• Genetics, atherosclerosis, excessive accumulation of oxygen free radicals
• Viral infections• Head trauma• Chronic antipsychotic medication• Environmental exposures.
pathophysiology Destruction of dopaminergic neuronal cells in the substantia
nigra in the basal ganglia
Degeneration of the dopaminergic nigrostriatal pathway
Depletion of dopamine store Imbalance of excitatory (acetylcholine) and inhibiting
(dopamine) neurotransmitters in the corpus striatum
Impairment of extrapyramidal tracts controlling complex body movements
Tremors rigidity Bradykinesia
Clinical manifestation• TREMOR- resting tremor is present in 70% of
patients at the time of diagnosis the fingers as if rolling pill.
• RIGIDITY- the limb to move in jerky increments referred to as cogwheeling. Stiffness of the neck, trunk, and shoulders is common
• BRADYKINESIA- Patients take longer to complete most activities and havedifficulty rising from a sitting positionor turning in bed.
• Hypokinesia (abnormally diminished movement) is also common and may appear after the tremor.
CONTD
• Micrographia (shrinking, slow handwriting) develops.
• The face becomes increasingly masklike and expressionless
• Dysphonia (soft, slurred, low-pitched, and less audible speech) may occur due to weakness and incoordination of the muscles responsible for speech
• The patient develops dysphagia, begins to drool, and is at risk for choking and aspiration.
Cogwheeling
Pill rolling tremor
contd• Shuffling gait( forward flexion of the neck, hips, knees,
and elbows). • Difficulty in pivoting and loss of balance (either forward
or backward)• Autonomic symptoms that include excessive and
uncontrolled sweating, paroxysmal flushing, orthostatic hypotension,
• Gastric and urinary retention, constipation, and sexual disturbances
• Depression,• Dementia (progressive mental deterioration)
hallucinations• Sleep disturbances
Shuffling gait
Sign and symptom According to book According to my patient
Tremor- resting tremor
Rigidity- the limb to move in jerky increments referred to as cogwheeling
Bradykinesia- Patients take longer to complete most activities
Hypokinesia (abnormally diminished movement) micrographia (shrinking, slow handwriting) develops.
Tremor- resting tremor
Rigidity- the limb to move in jerky increments referred to as cogwheeling
Bradykinesia- Patients take longer to complete most activities
Hypokinesia (abnormally diminished movement) micrographia (shrinking, slow handwriting) develops.
CONTDIn book In my patientDysphonia (soft, slurred,low-pitched, and less audible speechshuffling gait( forward flexion of the neck, hips, knees, and elbows).
Difficulty in pivoting and loss of balance excessive and uncontrolled sweating,gastric and urinary retention, constipation, and sexual disturbances depression,
dementia (progressivemental deterioration) hallucinations sleep disturbances
Dysphonia (soft, slurred,low-pitched, and less audible speechshuffling gait( forward flexion of the neck, hips, knees, and elbows).
Diagnostic Findings• Laboratory tests and imaging studies are not helpful in the
diagnosis of Parkinson’s disease, • PET scanning has been used in evaluating levodopa
(precursor of dopamine) uptake and conversion to dopamine in the corpus striatum
• Patient’s history and the presence of two of the three cardinal manifestations: tremor, muscle rigidity, and bradykinesia.
• Family member notices a change such as stooped posture, a stiff arm, a slight limp, tremor, or slow, small handwriting.
• The medical history, presenting symptoms, • Neurologic examination, • Response to pharmacologic management are carefully
evaluated when making the diagnosis
Investation of the patient2011/3/25
Hb:12.3 gm/dlTC:84,000 /cmmDC:N-65% L-32% E-2% M-1%ESR:26 mm in 1st hourRBS: 138.1mg/dlBl. Urea:30.1 mg/dlS.Cr:1.0 mg/dlTSH: 0.871microIU/L
NormalM-13-15 F-12-14WBC-400O-1100 Mm 3mm3
Neutrophil-40-70%Lymphocyte-30-35%Esinophil -1-2%ESR: 10-20Blood urea-20-40Rendom Blood sugar- 60-180
TSH: 0.5-4 microIU/LCreatinine- 1.4
Date In my patient In book2o11/3/26
2011/3/27
Urine R/E:Acidic Appearance: ClearColor: P. yellowWBC:3-5/HPFEpithelial cell: 2-4/HPF USG Abdomen: B/L renal cortical cyst, Prostatomegaly Gr.I
R/E:Acidic Appearance: ClearColor: P. yellowWBC:3-5/HPFEpithelial cell: 2-4/HPF
DIAGNOSISIN BOOK IN MY PATIENT
Physical examination and clinical feature
PET scanning has been used in evaluating levodopa (precursor of dopamin)
Neurological examination
Physical examination and clinical feature
Blood investigation
Neurological status
Medical Management
• Treatment is directed at controlling symptoms and maintaining functional independence
• There are no medical or surgical approaches that prevent disease progression.
• Care is individualized for each patient based on presenting symptoms and social, occupational, and emotional needs.
• Pharmacologic management is the main stay of treatment
PHARMACOLOGIC THERAPY
Antiparkinsonian medications act by 1) Increasing striatal dopaminergic activity.
2) Reducing the excessive influence of excitatory cholinergic neurons on the extra pyramidal tract, thereby restoring a balance between dopaminergic and cholinergic activities.
3) Acting on neurotransmitter pathways other than the dopaminergic pathway.
Antiparkinsonian Medications.
1.Levodopa (Dopar, Larodopa) is the most effective agent and the mainstay of treatment
• The most commonly prescribed form of carbidopa/levodopa is the 25/100 form, containing 25 mg carbidopa and 100 mg levodopa.
contd2. Dopamine receptor agonists• Ergot derivatives: as bromocriptine or pergolide • Non ergot derivatives as ropinirole, pramipexole
3. Monoamine oxidase inhibitors A) metabolizes norepinephrine and serotonin; monoamine
oxidase (B) metabolizes dopamine.4. Amantadine Amantadine is less potent than levodopa and its effects
disappear after only a few weeks of treatment5. Acetylcholine blocking drugs- Benztropine
contd6.Anticholinergic Therapy. (trihexyphenidyl,cycrimine, procyclidine, biperiden, and
benztropine mesylate) • Effective in controlling tremor and rigidity7.Antidepresant• Amitriptyline is typically prescribed because of its
anticholinergic and antidepressant effect. • Serotonin reuptake inhibitors, such as fluoxetine
hydrochloride (Prozac) and bupropion hydrochloride (Wellbutrin),
• Effective for treating depression.
8.Catechol-O-methyltransferase (COMT) Inhibitors.• The COMT inhibitors entacapone (Comtess)
and tolcapone (Tasmar) have little effect on parkinsonian symptoms
9.Antihistamines.• Diphenhydramine hydrochloride (Benadryl),• Orphenadrine citrate (Banflex), and phenindamine
hydrochloride• (Neo-Synephrine) have mild central anticholinergic
and sedative effects and may reduce tremors.
Medical managementACCORDING TO BOOK ACCORDING TO MY PATIENT
1.levodopa is the 25/100 form, containing 25 mg carbidopa and 100 mg levodopa. . 2. Dopamine receptor agonists3. Monoamine oxidase inhibitors Selegiline:4. Acetylcholine blocking drugs.5. Anticholinergic Therapy. 6.Antidepresant
1.Tab Syndopa plus 1tab 5 times a day 1 tab----------1---------1---------1---------1 6am 10am 2pm 6pm 10pm2.Tab Pramipexole 0.5mg PO TDS to cont3.Tab. Pantoprazole 40mg P/O BD to continue4.Tab. Domperidone 10mg P/O TDS to continue5.Tab. Trihexiphenidyl OD-2mg OD to continue6.Syp. Lactulose 3 tsf P/O HS for 2 weeks7.2% xylocaine oint LA before defecation
SURGICAL MANAGEMENT
• The limitations of levodopa therapy, improvements in stereotactic surgery, and new approaches in transplantation have renewed interest in the surgical treatment of Parkinson disease.
Stereotactic Procedures
Thalamotomy and pallidotomy are effective in relieving many of the symptoms of
Parkinson’s diseaseNeural Transplantation. • Surgical implantation of adrenal medullary tissue into the corpus striatum is performed in
an effort to reestablish normal dopamine release.
• Deep Brain Stimulation. Recently approved by the FDA,
• pacemaker-like brain implants show promising results in relieving tremors.
• The stimulation can be bilateral or unilatera• bilateral stimulation of the subthalamic nucleus is
thought to be of greater benefit to patients than results achieved with thalamotomy,pallidotomy, or fetal nigral transplantation
Application of the Henderson independence theory in this case
Nursing assessmentThe 14 components • Breathe normally. • Eat and drink adequately. • Eliminate body wastes. • Move and maintain desirable postures. • Sleep and rest. • Select suitable clothes-dress and undress. • Maintain body temperature within normal range by adjusting
clothing and modifying environment • Keep the body clean and well groomed and protect the
integument • Avoid dangers in the environment and avoid injuring others. • Communicate with others in expressing emotions, needs, fears,
or opinions.
CONTD
• Worship according to one’s faith. • Work in such a way that there is a sense of
accomplishment. • Play or participate in various forms of recreation. • Learn, discover, or satisfy the curiosity that leads to
normal development and health and use the available health facilities.
NURSING CARE PLAN
1.Analysis Compare data to knowledge base of health and
disease• The patient eat and drink is inadequateNursing diagnosis Identify the patient ‘s ability to meet own need with
or with out assistance .• The patient unable to meet eat and drinks need with
out assistance.
contdNursing planDocument how can assist the individual sick or well.• Assist the patient sit in an upright position during
mealtime. • Advice the visitor semisolid diet with thick liquids is
easier to swallow• Taught to place the food on the tongue, close the lips
and teeth, lift the tongue up and then back, and swallow.• Instruct the patient and his visitor Massaging the facial
and neck muscles before meals • encourage patient is to chew first on one side of the
mouth and then on the other
CONTDNursing implementation Assist the patient in the performance of activities in
meeting human needs to maintain health.• Assist the patient sit in an upright position during
mealtime.• Advice the visitor semisolid diet with thick liquids is
easier to swallow• Taught to place the food on the tongue, close the lips
and teeth, lift the tongue up and then back, and swallow.
• Instruct the patient and his visitor Massaging the facial and neck muscles before meals
• encourage patient is to chew first on one side of the mouth and then on the other
contd
Evaluation Successful outcome of nursing care are based on the
speed which the patient perform independently the activities.
• My patient able to eat and drink adequately with out assistance.
2.Analysis Compare data to knowledge base of health and
disease. • The patient unable to Move and maintain desirable
postures. Nursing diagnosis Identify the patient ‘s ability to meet own need with
or with out assistance .• The patient unable to meet move and maintain
desirable posture with out assistance.
contd
Nursing planDocument how can assist the individual sick or well. • Help the patient Walking, range of motion exercise.• Instruct the patient Postural exercises are important
to counter the tendency of the head and neck to be drawn forward and down.
• A physical therapist may be helpful in developing an individualized exercise program• Taught to the patient concentrate on walking erect,
to watch the horizon, and to use a wide-based gait .
CONTDNursing implementation Assist the patient in the performance of activities in
meeting human needs to maintain health.• Help the patient Walking, range of motion exercise.• Instruct the patient Postural exercises are important to
counter the tendency of the head and neck to be drawn forward and down.
• A physical therapist may be helpful in developing an individualized exercise program• Taught to the patient concentrate on walking erect, to
watch the horizon, and to use a wide-based gait .
contd
Evaluation Successful outcome of nursing care are based on the
speed which the patient perform independently the activities.
• My patient was able to move and maintain body posture with out assistance.
contd3. Analysis Compare data to knowledge base of health and
disease. • The patient unable to keep body clean and well -
groomed Nursing diagnosis Identify the patient ‘s ability to meet own need
with or with out assistance .• The patient unable to keep body clean and well -
groomed with out assistance.
CONTDNursing planDocument how can assist the individual sick or well.• Encouraging, teaching, and supporting the patient during self
activities.• Provide homely Environment to compensate for functional
disabilities.• Provide to the patient adaptive or assistive devices.• provide hospital bed with bedside rails,• An occupational therapist can evaluate the patient’s needs in
the hospital• Teach the patient and visitor how to improve the self care.
CONTDNursing implementation Assist the patient in the performance of activities in meeting
human needs to maintain health.• Encouraging, teaching, and supporting the patient during
self activities.• Provided homely Environment to compensate for
functional disabilities.• Provided to the patient adaptive or assistive devices.• provided hospital bed with bedside rails,• An occupational therapist help the patient’s self care
needs in the hospital• Assist the patient in morning care and bathe.• Teach the patient and visitor how to improve the self care.
contd
Evaluation Successful outcome of nursing care are based on the
speed which the patient perform independently the activities.
• My patient was able to keep body clean and well -groomed with out assistance .
contd
4.Analysis Compare data to knowledge base of health and
disease. • The patient unable to elimination of body wasteNursing diagnosis Identify the patient ‘s ability to meet own need
with or with out assistance .• The patient unable to eliminate the body waste
with out assistance.
CONTD
Nursing planDocument how can assist the individual sick or well.The patient may have severe problems with constipation. • Teach the patient regular bowel routine may be
established to follow a regular time pattern, consciously.• Encourage the patient to increase fluid intake, and eat
foods with a moderate fiber content.• Laxatives should be given as doctor order. • manage raised toilet seat because the patient has
difficulty in moving from a standing to a sitting position
CONTDNursing implementation Assist the patient in the performance of activities in meeting
human needs to maintain health.• Teach the patient regular bowel routine may be established
to follow a regular time pattern, consciously.• Encourage the patient to increase fluid intake, and eat foods
with a moderate fiber content.• Laxatives should be given as doctor order. • manage raised toilet seat because the patient has difficulty
in moving from a standing to a sitting position Evaluation Successful outcome of nursing care are based on the speed
which the patient perform activities independently.• My patient was able the to eliminate the body waste with out
assistance.
contd5.Analysis Compare data to knowledge base of health and
disease. • The patient unable to Communicate with others in
expressing emotions, needs, fears, or opinions. Nursing diagnosis Identify the patient ‘s ability to meet own need with or
with out assistance .• The patient unable to unable to Communicate with
others in expressing emotions, needs, fears, or opinions with out assistance.
CONTDNursing planDocument how can assist the individual sick or well.• Speech disorders are present in most patients with Parkinson’s disease. • Patients are reminded to face the listener, exaggerate the
pronunciation of words, speak in short sentences, and take a few deep breaths before speaking.
• A speech therapist may be helpful in designing speech improvement
• Assist the family and health care personnel to develop and use a method of communication to meet the patient’s needs. • Encourage the patient express the feeling and opinion.• A small electronic amplifier is helpful if the patient has difficulty
being heard
CONTDNursing implementation• Assist the patient in the performance of activities in meeting
human needs to maintain health. • Speech disorders are present in most patients with Parkinson’s
disease. • Patients are reminded to face the listener, exaggerate the
pronunciation of words, speak in short sentences, and take a few deep breaths before speaking.
• A speech therapist may be helpful in designing speech improvement
• Assist the family and health care personnel to develop and use a method of communication to meet the patient’s needs. • Encourage the patient express the feeling and opinion.• A small electronic amplifier is helpful if the patient has difficulty
being heard
contd
Evaluation Successful outcome of nursing care are based on the
speed which the patient perform independently the activities.
• My patient was able to communicate with others in expressing emotions, needs, fears, or opinions with out assistance.
Daily Progress reportDaily Progress report
Date :- 2011/3/ 25Admission day A patient was admitted in neuro medical ward from neuro OPD with history of resting tremor ,regidity and bradykinesia.
Today start on Syndopa
On admission patient’s vitals sign were: B.P=120/70 mm of hg, R.R=22/min, Pulse=78/min, Temp.=98ºf according to nursing report.
Date :- 2011/3/ 26 2nd day of admission • Vitals signs:• B.P= 120/90, pulse= 80/min, R.R=22/min, Temp.=98.6ºf, • His bradykinesia improved and tremors decreased. Side
effects of Syndopa were not observed during his stay at the hospital
• Planned to be started on Ropark but was not started due to unavailability of the drug.
• He had increased frequency of urination with urge incontinence with no evidence of prostatomegaly on USG abd.
Daily Progress reportDaily Progress reportDate :- 2011/3/ 27 Vitals signs:• B.P= 120/70, pulse= 82/min, R.R=20/min,
Temp.=98.8ºf
• Urological consultation was done for urinary symptoms and was found to have Detrussor Hyper-reflexia.
• He was prescribed Tab. Roliten OD-2mg OD and Tab. Oxyspas 5mg TDS.
Daily Progress reportDaily Progress reportDate :- 2011/3/ 28 Vitals signs:• B.P= 110/70, pulse= 80/min, R.R=22/min,
Temp.=98.8f• Today no any plan • Treatment continue.• Patient feels far better today.
Daily Progress reportDaily Progress report• Date :- 2011/3/ 29• Vitals signs:• B.P= 120/70, pulse= 82/min, R.R=20/min,
Temp.=98.8ºf• His surgery consultation was done and was
found to have 2 degree hemorrhoid at 11 o’clock position and was advised for surgery
• He is being discharged on persistent request
Advice on Discharge
1.Tab Syndopa plus 1tab 5 times a day 1 tab----------1---------1---------1---------1 6am 10am 2pm 6pm 10pm
2.Tab Pramipexole 0.5mg PO TDS to cont3.Tab. Pantoprazole 40mg P/O BD to continue4.Tab. Domperidone 10mg P/O TDS to continue5.Tab. Trihexiphenidyl OD-2mg OD to continue6.Syp. Lactulose 3 tsf P/O HS for 2 weeks7.2% xylocaine oint LA before defecation
Discharge teaching
• Prevention from injury• Adequate maintaining hygiene.• Encourage to take nutritional diet • Encourage express feeling with family
member.• Regular taking antiparkinson medicine.• Follow up after 1 month in OPD.
Diversional TherapyDiversional Therapy “is a client centred practice [that] recognises that leisure and recreational experiences are the right of all individuals.”
These are often quite diverse and can range from:Games, outings,, computers, gentle exercise, music, arts and crafts.·
contd
• Individual emotional and social support• Sensory enrichment, activities like massage
and aromatherapy, pet therapy• Discussion groups, education sessions like
grooming, beauty care, cooking
• The diversional therapy programme has definitely had a positive influence on patient’s life and will continue to do so for as long as he is living at the hospital
• The divertional therapy suggested for my patient is Gardening and gentle exercise,
• Social, cultural and spiritual activities
DIVERSIONAL THERAPY
IN BOOK IN PATIENT
Games, outings,, computers, gentle exercise, music, arts and crafts. Individual emotional and social supportSensory enrichment, activities like massage and aromatherapy, pet therapyDiscussion groups, education sessions like grooming, beauty care, cooking
•Individual emotional and social support•Gentle exercise.•Talking with other patient •Listening music by mobile phone.
SPECIAL GAGETS USED IN MY PATIENT
• Sphygmomanometer• Stethoscope • ECG monitoring • X-ray machine• Tunings fork• Knee hammer.• Thermometer• Pulse oxymeter.• U.S G mechine.
Incidence of the Parkinson disease• PD is the second most common neurodegenerative disorder
after Alzheimer's disease
• The prevalence (proportion in a population at a given time) of PD is about 0.3% of the whole population in developed country.
• In CMS hospital PD is 3.5% of whole neurological disease.
• PD is more common in the elderly and prevalence rises from 1% in those over 60 years of age to 4% of the population over 80.[
contd• The mean age of onset is around 60 years, although
5–10% of cases begin between the ages of 20 and 50.
• PD may be less prevalent in those of African and Asian country.
• Some studies have proposed that it is more common in men than women, but others failed to detect any differences between the two sexes.
• The incidence of PD is between 8 and 18 per 100,000 person–years.
Learned from the experience
This case study gives following opportunity and
knowledge such as
1. Identified the complete health need of older adult and give nursing care
2. Provide comprehensive nursing care to the older adult patient.
3. Assist in different type of diagnosis procedure of the patient.
4. Analyze the concept and approach to nursing practice according to trend and technology
5. Identified the factors influencing nursing practice.6. Develop competency in handling various gadgets. 7. Identified the plan, implement and evaluate the
educational need of the patient and patient family.
Reference1. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing
10th edition p-1986 2. Black J.M &Hawks J.H. Medical Surgical Nursing Clinical
Management For Positive Outcome, 8th edition ,vol -2 p-19023. Mark A & Loscalzo. J “Harrison’s Principle of Internal
Medicine” ,17th Edition Vol-II, p-15634. A lagappan. R.”Manual of Practice Medicine” 3rd edition 2007 p
2-26.5.en.Wikipedia.org /wiki/parkinsonism6.www.medicinet.com /article.htm
contd6. Grbbb.NR,& Newby D.E. “Davidson’s ,Principle & Practice of
Medicine” ,20th Edition, p-6067. Potter A Patricia “Fundamental of Nursing Potter Perry” p-238 8. Mosby’s “Nursing Drug Reference” , 23rd Edition, 20109.Tripathi.K.D ,”Essential of Medical Pharmacology” ,Jaypee ,4th
Edition.10. En.Wikipedia.org /wiki/abdominal _aortic aneurysm11. www.nlm .nih.gov../000162 htm12. Emedicine .medscape .com/article /4633 13 www.sirweb.org/uwe/patient/abdomnal_aortic.
Thank you