NU272 HESI Case Study: Parkinson Disease
After the nurse administers the medications, the client has a large liquid stool. While the nurse and the UAP are changing the bed linens, the client complains of cramps in his legs.
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At the end of the meeting, the wife shares that she is angry because this is happening to her, and she feels guilty thinking about having to put her husband in a long-term care facility. Many of the group members share that they had to go through the same thing, and one woman shared that she put her husband in a facility just last week. After the meeting is adjourned, the wife goes out for coffee with 3 of the group members.
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Because the client walks with a shuffling gait and tends to lean forward when walking, the home health nurse discusses the client's continued weakness, mobility concerns, and safety issues with the wife.
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Later in the day, the primary nurse enters the room and observes the wife sitting in the chair looking worried. The wife shares with the nurse that she has no idea how to pick a nursing home for her husband.
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The PEG tube is inserted without any complications. The client is brought back to his room where his wife is waiting at his bedside.
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The UAP assigned to assist to the client with personal hygiene gets frustrated because the client is not moving as quickly as the UAP thinks he should. The primary nurse observes the UAP yelling at the client that he needs to hurry up or he won't be allowed to take a shower.
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The client chooses to complete a Living Will, along with the Durable Power of Attorney for Health Care. The home health nurse obtains the needed documents. To complete the forms, the client asks the home health nurse to serve as the witness while he signs them.
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The client is alert and oriented enough to realize that he is going home. A hospital bed and bedside commode are delivered to the home, and the hospice nurse is waiting there to meet the ambulance when the client arrives. The hospice nurse tells the client and his wife that they need to discuss an Out-of-Hospital Do-Not-Resuscitate Order (DNR).
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The client is concerned because he is having difficulty eating and bathing independently. He tells the nurse that he is worried about his wife having to do everything for him and that he does not want to be a burden to her.
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The client is in a semi-private room with a man who is alert and sitting in a recliner reading. After saying, hello to the roommate, the wife asks the admitting nurse, what she can do to help make this transition easier on her husband.
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The client tells the nurse that he is starting to have difficulty eating and chokes when swallowing food.
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The client's spouse calls the healthcare provider's office and reports to the nurse that the client has started seeing and talking to people that have been dead for many years. In addition, he has developed jerky movements of his head and has begun smacking his lips.
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The client's wife brings the client to the healthcare provider's office. After assessing the client, the healthcare provider informs the wife that the client is going to get progressively worse. The wife starts crying and tells the healthcare provider she just can't keep caring for the client by herself. The healthcare provider writes a referral for home health care. Previous Section
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The client's wife calls the local hospice agency and requests information about hospice care.
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The client's wife shares with the home health nurse that she doesn't understand why the client is getting constipated when he doesn't eat very much. She tells the nurse that he is losing weight and his clothes are hanging off his body. The home health nurse tells the wife that the client's medications, as well as his inactivity can cause constipation, no matter how little he is eating. The home health nurse is concerned about the client's constipation, lack of appetite, and weight loss.
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The forms are placed in a desk drawer at the client's home. Copies are sent to the client's children, healthcare provider, and to the local medical center to be placed in the client's records. Previous Section
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The next morning the client is started on a continuous enteral feeding at 25 mL/hr via a pump. The client is placed in a semi-Fowler's position.
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The nurse is administering the client's 9:00 a.m. medications via the PEG tube. The client's medications include carbidopa-levodopa scored tablet, benztropine mesylate elixir, and a baby aspirin.
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The wife shares with the home health nurse that it is getting harder and harder to understand what the client is trying to say, even when allowing more time. This is increasing the frustration level for both the client and his wife.
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A visitor in the support group asks the nurse leader how does someone get Parkinson's disease.
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Management Issues
The primary nurse on the 7-3 shift is caring for six clients in addition to this client.
Which statement by the nurse leader best describes Parkinson's disease?
A chemical imbalance in the brain leads to movement and coordination problems. - Parkinson's disease is a progressive neurodegenerative disease characterized by four cardinal symptoms: tremor, muscle rigidity, bradykinesia or akinesia (slow movement/no movement), and postural instability.
Meet the client
A client diagnosed with Parkinson's disease 4 years ago. He has been married and has 2 grown children who live out of state, and one who lives close by. Until recently, the client and his wife had been active in the community. They attended church, played bridge, and enjoyed being with each other. The client had been able to care for himself independently since his diagnosis, but he is now requiring more assistance with activities of daily living and does not want to participate in any usual activities.
How should the home health nurse respond first?
Allow the wife to cry and discuss her feelings. - The wife is grieving and needs comfort and emotional support. The nurse should provide a therapeutic environment, offering presence and support that allows the wife to cry and discuss her feelings.
What is the best response by the nurse?
Ask the director of nursing for the names and phone numbers of persons willing to serve as references for the facility. - Talking to family members and the persons who agree to serve as references for the facility will provide the wife with information about all aspects of the nursing home and may help the wife make the right decision for the client.
Which independent nursing action should be implemented first?
Assess the client's bowel sounds and check his abdomen for distention. - The nurse should assess the client prior to taking any further action.
Which action should the nurse take next?
Assess the client's serum potassium level. - Diarrhea, especially in an elderly client, can lead to hypokalemia. Since leg cramps are a symptom of low potassium, the nurse should assess Leo's potassium level.
Upon the client's return to his room, which intervention should the nurse implement?
Assess the insertion site for signs of bleeding. - The nurse must assess any incision site for bleeding in the immediate postoperative period.
How should the nurse respond?
Bring some pictures and personal items from home and decorate the room. - Suggest that the patient or family bring in personal items such as pictures of relatives and friends, favorite clothing, and valued knickknacks to help make the new setting seem more familiar and comfortable and help adjust to the new living area.
Which statement explains the mechanism of action of carbidopa-levodopa in the treatment of Parkinson's disease?
Carbidopa-levodopa is converted to dopamine and provides an exogenous form of dopamine replacement. - Carbidopa-levodopa, a combination of levodopa and carbidopa, provides an exogenous source of dopamine to the CNS. Levodopa crosses the blood-brain barrier and is converted to dopamine. Carbidopa-levodopa does not cross the blood-brain barrier. Its role is to prevent the breakdown of levodopa in the periphery, allowing more levodopa to cross the blood-brain barrier. This in turn allows lower doses of levodopa to be used and reduces the risk of side effects such as nausea and vomiting.
Which intervention should the nurse implement first?
Check the residual volume. - The nurse must aspirate for gastric contents (residual volume) prior to giving the feeding. Residual amounts greater than 50 to 100 mL (depending on agency policy) indicate the need to hold the feeding since this amount is an indication that the formula is not being digested and further feedings could lead to aspiration.
Which interventions should the nurse implement regarding the administration of these medications? (Select all that apply. One, some, or all options may be correct.)
Crush each tablet individually, dissolve each in warm water, and administer separately via the PEG tube. - Medications should be given in liquid form if at all possible. If not available in a liquid form, pills can be finely crushed and dissolved in warm water prior to administration, after the nurse ascertains that it is permissible for the pills to be crushed. The pills should be administered separately to reduce medication-to-medication interactions. Flush tube with water before medication administration, in-between each medication, and after medication administration. - The tube should be flushed with water prior to medications being given. In addition, multiple research studies indicate that water is the best fluid to prevent or flush clogged tubes. Flushing between each medication will reduce the likelihood of medication-to-medication interactions, and flushing afterward will prevent clogging.
In providing client teaching related to ambulation, which instruction should the nurse include?
Demonstrate how to walk with a wide-based stance. - The client should be instructed to walk erectly, watch the horizon, use a wide-based stance (feet separated), and swing both arms from front to back. This walking technique will help offset the shuffling gait.
Which intervention should the nurse implement first to address the client's weight loss?
Discuss providing supplemental feedings between meals. - As the disease progresses and swallowing becomes more of a problem, supplemental feedings become the main source of nutrition to maintain weight, with meals and other foods taken as the patient can tolerate.
Home Health Nurse Visit
During the initial visit with the home health nurse, the wife expresses frustration, stating that it is getting harder for her to understand what the client is saying, although he can still communicate if she gives him enough time. In addition, the nurse observes that the client has a shuffling gait and has difficulty getting out of the chair.
Which nursing task(s) can be delegated to the unlicensed assistive personnel (UAP)? (Select all that apply. One, some, or all options may be correct.)
Empty foley catheter and report output for a client wiht a urinary track infection. - Assist with feeding the client breakfast at the dining room table. Help the client ambulate down the hall to the shower area. - Assisting a client to ambulate is a nursing task that can be delegated to a UAP.
How should the nurse respond?
Encourage the wife to provide a soft diet with mainly thick liquids. - Swallowing disorders can be due to poor head control, tongue tremor, or difficulty shaping food in the mouth. A soft diet with thickened liquids is easier to swallow.
Which nursing intervention must be implemented prior to inserting the PEG tube?
Ensure that an informed consent for the PEG tube placement has been signed. - This is an invasive procedure that requires informed consent.
Gastrostomy Tube Insertion
Four days after being admitted to the long-term care facility, the client experiences a choking incident during lunch that requires his transfer to the medical center. After evaluation by the healthcare provider and the speech therapist, a percutaneous endoscopic gastrostomy (PEG) tube for enteral formula feedings is recommended.
How should the social worker respond?
If you and the client are financially qualified, Medicaid will pay for the home. - When an individual has less than $2,000.00 and/or all financial sources are exhausted as a result of prolonged nursing home care, the family, the institution, or both may apply for Medicaid reimbursement.
In planning care, which nursing diagnosis is the priority?
Impaired physical mobility related to muscle rigidity and motor weakness. - Impaired physical mobility is a priority since it impacts every aspect of the client's ability to function safely, and it places him at risk for numerous complications of immobility.
What action should the primary nurse take?
Instruct the UAP to go to the nurse's station. - The nurse needs to remove the UAP from the situation and then address the issue of verbal client abuse. Supervision by the nurse of unlicensed assistve personnel is one of the 5 Rights of Delegation.
How should the nurse respond?
Instruct the client's spouse to bring the client to the healthcare provider's office now. - Uncontrolled movement of face, eyelids, mouth, tongue, arms, hands, or legs (tardive dyskinesia) mental changes, such as hallucinations or delusions are adverse effects of long-term levodopa therapy. Therefore, the client needs to be assessed by the healthcare provider.
Which statement accurately describes the rationale for an Out-of-Hospital Do-Not-Resuscitate Order?
It is an order that will prevent paramedics from starting cardiopulmonary resuscitation. - In the event paramedics are called to treat Leo and he dies, the paramedics must legally start CPR unless he has an "Out-of-Hospital DNR."
What should the home health nurse do with the forms?
Make a copy to scan in the client's medical record. - A copy in the medical record is the best way for all healthcare providers to be aware of the wishes of the client. It is also makes it easy for the document to be reviewed with the client by all healthcare providers.
Which statement provides correct information about payment for hospice care?
Medicare Hospice Benefit will cover the cost for Medicare beneficiaries. - In 1983, the Medicare Hospice Benefit was implemented to cover hospice care for Medicare beneficiaries.
Which statement by the client's wife indicates to the nurse that she understands the role of hospice care in the home?
The hospice nurses and staff will help keep the client comfortable at home until he dies. - The intent of hospice is to provide palliative care for terminally ill persons. Hospice is a coordinated program of interdisciplinary services provided by professional caregivers and trained volunteers to clients with serious, progressive illnesses that are not responsive to a cure.
Which member of the interdisciplinary team can best assist the client in his desire to maintain independence when performing his ADLs?
Occupational therapist. - After evaluating the client's needs in the home, the occupational therapist can make recommendations regarding adaptive devices and teach the client and his wife how to improvise so that the client can perform his ADLs. An occupational therapist can help the patient with ways to increase self-care measures, including eating and dressing.
Which statement correctly explains the rationale for this positioning?
Placing the client in a semi-Fowler's position helps prevent aspiration of the tube feeding. - The most common life-threatening complication of tube feedings is aspiration. Risk of this complication can be reduced by elevating the head of the bed during the feeding and for at least 1 hour after the feeding for bolus feeding; During continous feeding the client should maintain a semi-Fowler's position.
Which action should the nurse implement?
Provide the client with information about a Durable Power of Attorney for Health Care. - This document is used for listing the person(s) to make health care decisions should a patient become unable to make informed decisions for self.
Long-Term Care Placement
The nurse and social worker at the hospital discuss possible long-term care facilities with the client and his wife. The client wants to be near home so his wife can visit often. The social worker provides the wife with the names of several nursing homes close to their home. The wife expresses concern about how they will pay for the nursing home care.
Which intervention will the nurse recommend to the wife to address this problem?
Stand directly in front of the client when he is speaking. - The soft, low-pitched, monotonous speech of a client with Parkinson's requires the client to make a conscious effort to speak slowly, with deliberate attention to word pronunciation. The client should face the listener, take a few deep breaths before speaking, speak in short sentences, and exaggerate the pronunciation of words.
Complications of Enteral Nutrition
The client has been back at the nursing home for 3 weeks. He is becoming progressively weaker and has had several episodes of diarrhea, but he has not had any weight loss. The primary nurse is preparing to administer an intermittent enteral tube feeding of 480 mL over the next 6 hours.
Legal Issues
The client shares with the home health nurse that he fears he may become unable to make decisions for himself. He states that he wants his wife to be able to make decisions for him. He is worried that his children will try to decide what is best for him and states that he does not want them making any decisions about his health care.
Medications
The client was prescribed the antiparkinsonian medication carbidopa-levodopa shortly after being diagnosed with Parkinson's disease. Before starting the medication, the nurse in the healthcare provider's office explained the action of carbidopa-levodopa as part of medication teaching.
Hospice
The client's condition is deteriorating daily. He tells his wife that he wants to die at home. The client's wife tells the nurse about her husband's request and tearfully says that someone told her that hospice care will allow her to take her husband home to die and can she take her husband home on hospice care.
Return Home
The client's discusses the client's wishes with his healthcare provider. Since the healthcare provider believes that the client's prognosis is less than 6 months, a referral for hospice care is made. The client is experiencing small strokes that are causing further deterioration, and he has signs of congestive heart failure. The hospice nurse comes to the nursing home to discuss the preparations for the client's transfer home. The client's wife expresses concern about how she will pay for hospice care.
Physiological Needs
The home health nurse visits the client's home weekly. One week after the initial visit, the client shares with the nurse that he has not had a bowel movement in 3 days.
Referral
The wife asks the home health nurse what other people do who have family members with Parkinson's. She states that she feels so alone in this. The home health nurse recommends that the wife attend a support group sponsored by the National Parkinson Foundation. The wife attends a support group, where the nurse leader begins by explaining the disease.
What is the best response by the nurse leader?
There is really no known specific cause for Parkinson's disease. - The cause of Parkinson's is unknown, but research suggests several causative factors, including genetics, atherosclerosis, excessive accumulation of oxygen free radicals, viral infections, head trauma, chronic antipsychotic medication, and some environmental exposures.
Transfer to the Nursing Home
Three days later, the client is transferred from the medical center to a long-term care facility near his home. The client is aware of where he is going and understands that this is the only reasonable option the wife has available. Even though the wife realizes that this is the best course of action, she is ambivalent and apprehensive about her husband going to the nursing home. She calls the home healthcare nurse and expresses her concern that the nursing home won't take good care of her husband.
What is the best response by the nurse?
To be eligible for hospice care, the client must have fewer than 6 months to live. - The nurse should provide factual information to the wife about hospice care.
A Complication Occurs
Two weeks later, the client falls while walking from the living room to the bathroom, hitting his head on a coffee table. He is transported to the medical center and admitted to the medical floor for head injury observation and possible transient ischemic attack (TIA). The wife calls the home health nurse to report what happened. When the home health nurse visits them in the hospital the next day, the wife is crying and tells the nurse that she just can't take care of the client at home anymore.
How should the home health nurse respond?
You may want to visit at different times, rather than following a routine visiting schedule. - By visiting at different times, the wife will be able to observe the quality of care throughout the day.