Case study

Case Study

Student Name Here

Department of Nursing, Herzing University

NU208: Pathophysiology

Carie Johnson, MSN, RN, CMSRN

Case Study

Introduction to Patient

FK is an 84-year-old, Caucasian man who lives with his wife in their home. Subjective data for the patient was mostly obtained from his wife. FK is a retired high school teacher and has been married to his wife for 57 years. They recently starting using home health nursing services; the home health nurse comes to the house 3 days per week to assist with FK’s care due to his progressing Parkinson disease. FK’s wife is an 82-year-old woman with severe scoliosis, and she is not able to assist with ambulation of the patient or help him up when he falls due to her condition. FK was brought to the emergency room after falling. The patient does not remember the incident. The wife reports that she believes the patient fell as he was standing up from his office chair and hit his head on the desk. The home health nurse was not present in the home the day of the incident, and the patient has been falling more frequently lately. Objective data for this patient was obtained through a head-to-toe analysis performed by the nurse on duty. FK has a 1.5-inch laceration on the left temporal area and presented to the hospital showing signs of confusion along with typical signs and symptoms of Parkinson disease. FK was diagnosed with Parkinson disease 8 years ago according to the electronic health record.

Pathophysiology

Parkinson disease (PD) is a neurodegenerative disorder with a normally slow, but continuous, progression (Huether & McCance, 2017). There is currently no cure for PD. In primary PD, symptoms usually begin in middle age, generally after the age of 40 with increased prevalence over the age of 60 (Huether & McCance, 2017). Parkinson disease is more common in men. The cause of PD is not entirely understood, but it has been linked to several gene mutations (those for alpha-synuclein, parkin, and ubiquitin proteins) in inherited forms of the disease, and possibly to environmental toxins affecting the same proteins in non-inherited primary PD (Burchum & Rosenthal, 2019). Inherited PD accounts for only about 10% of diagnoses, a majority of cases are idiopathic or sporadic (Huether & McCance, 2017). Parkinson disease is the second leading degenerative disease of neurons in older adults behind Alzheimer’s disease (Burchum & Rosenthal, 2019).

In PD, there is a loss of dopaminergic neurons in the substantia nigra and dorsal striatum along with misfolded or dysfunctional alpha-synuclein proteins produced by these cells (Burchum & Rosenthal, 2019). This causes damage to the neuronal network called the extrapyramidal system, which helps to regulate movement. Proper functioning in this area of the brain requires a balance between the neurotransmitters dopamine and acetylcholine. Acetylcholine is an excitatory neurotransmitter, while dopamine is inhibitory. In PD, the degeneration of dopaminergic neurons leads to a lack of dopamine. Without dopamine, excitatory stimulation goes unopposed, causing the classic motor manifestations of Parkinson disease including hypertonia and akinesia (Burchum & Rosenthal, 2019). Symptoms usually do not become clinically apparent until 70% to 80% of the dopaminergic neurons are lost, meaning that neuronal degeneration normally begins 3 to 6 years before diagnosis (Burchum & Rosenthal, 2019).

PD manifests as a motor disorder with additional systemic nonmotor and neurological symptoms (Huether & McCance, 2017). The initial onset of symptoms is often difficult to determine because the disease progresses slowly. Early symptoms may include loss of smell, clumsiness of hands with worsening handwriting, tremor, slowed gait, and reduced voice volume (Burchum & Rosenthal, 2019). The classic symptoms often present at diagnosis include resting tremor, rigidity, bradykinesia progressing to akinesia, and postural disturbance and instability (Burchum & Rosenthal, 2019). Masked facies, or an expressionless face, is due to bradykinesia and often seen in PD patients. As neurodegeneration progresses, a flexed, forward leaning posture; difficulty walking; short, accelerated steps; weakness; and disorders of equilibrium typically develop (Huether & McCance, 2017). Other common complications of PD are urinary urgency, urinary retention, sleep disorders and excessive daytime sleepiness, inappropriate diaphoresis, orthostatic hypotension, drooling, gastric retention, and constipation (Burchum & Rosenthal, 2019).

Dementia with Lewy body can develop in patients with Parkinson disease due to accumulation of alpha-synuclein which causes plaque formation similar to that seen in Alzheimer’s disease (Burchum & Rosenthal, 2019). The first symptoms of dementia in PD patients usually include visual hallucinations, delusions that family members or friends are someone else, delirium, and REM sleep disorder (Huether & McCance, 2017). Dementia is more common in PD patients over the age of 70. Unfortunately, psychosis and hallucinations can be caused or worsened by the drugs used to treat other PD symptoms. Depression also occurs in about 50% of PD patients (Burchum & Rosenthal, 2019).

Health History

FK was diagnosed with Parkinson disease about 8 years prior to this ER visit. The patient and spouse report that symptoms have worsened significantly in the past two years after being managed by levodopa treatment for several years. The patient has a history of injuries from falls and several subsequent ER visits in the past year. Prior to PD diagnosis, FK was in good health, with no other chronic diseases, major surgeries, or accidents. FK was hospitalized and treated with medication for kidney stones three years ago. The patient is up to date on all wellness examinations and vaccinations appropriate for his age. The patient had chicken pox at age 10 but has no history of other major childhood illnesses including measles, mumps, polio, rheumatic fever, or scarlet fever and received all childhood vaccinations appropriate at that time. FK does not have a history of any medication, environmental, or food allergies. The patient’s father was diagnosed with Parkinson disease in his 70s; there is no other significant family history that the patient was able to report. Due to the number of current medications reported by the patient’s spouse, a thorough medication reconciliation should be performed and reviewed by the prescribing doctor for discrepancies or necessary changes prior to discharge.

Nursing Physical Assessment

Objective Assessment

Patient’s vital signs are within normal range for his age: temperature 98.6 degrees Fahrenheit, blood pressure (supine) 125/85 mmHg, pulse ox 98%, pulse (supine) 70 beats per minute and regular, respirations 18 per minute and unlabored. Blood pressure was not tested for orthostatic hypotension due to injury but should be measured before discharge. The patient reports that his “head hurts”, “more on the left” and rates pain at a 3 on a 10-point scale. The patient is unsure of pain onset and aggravating or relieving factors. The patient has a 1.5-inch laceration on the left temporal area; the surrounding area is tender to touch, and the wound is was actively bleeding on arrival. Two scars are visible on the head which FK’s wife reports are from previous falls. FK is alert and oriented to person and place but is not oriented to time or situation. Speech is sluggish and quiet with an absence of inflection. There are no indications of hearing difficulty or observed hearing accommodation. EOMs are intact and no nystagmus are present. Corneal light reflex is symmetric and equal bilaterally; PERRLA passed, and the patient wears corrective glasses. FK’s face is symmetric but with significant lack of expression. Patient walks with a stooped posture, and with short, shuffling steps. Patient was assisted with ambulation into the room by a nurse. Upper and lower extremities show resistance to full ROM with rigidity in flexion and extension. Strong tremor is noted in hands with occasional “pill rolling” motions.

Chest expansion is symmetric, and no adventitious lung sounds are noted. Patient does not report chest pain or shortness of breath. No heaves or lifts, and apical pulse is equal to radial pulse. Heart rhythm is regular with no extra sounds or murmur. Pulses are present in all extremities and equal bilaterally. General skin is tan-pink in color, warm, dry and intact outside of head wound. Patient has poor skin turgor, but normal for age. Several hematomas are apparent in various stages of healing on all extremities. Bowel sounds are present. Abdomen is soft with no masses or tenderness. Patient does not report any nausea, vomiting, or urinary problems, but does report frequent constipation. Wife reports that FK has lost a significant amount of weight in the past year and the patient has a very thin appearance.

Subjective Assessment

FK’s wife reported that he has been falling with increased frequency in the past year, usually when standing up from a sitting position or while walking more than a short distance. They have been given education on orthostatic hypotension after previous incidents, but she reports that FK often does not slow down when standing up unless reminded. FK’s wife is concerned that he is becoming increasingly hostile and disoriented. He will “sometimes get angry with me and does not seem to know who I am”, “he thinks we are keeping him locked up in the house and will try to leave alone”, and “he sometimes thinks we are in our old apartment”. She reports that FK is especially resistant to following safety rules. He will frequently attempt to go down to the basement and will not use the walker that has been provided for him; “I think he doesn’t remember why he needs to do these things or thinks I am making it up.” She also reports that FK has been “talking to people who aren’t there” at an increasing frequency.

Additional Assessments Needed

A full mental status and psychiatric examination should be done for this patient. PD patients are at an increased risk for both delirium and dementia (Huether & McCance, 2017) and the cause of the current disorientation along with the increasing neurologic symptoms should be diagnosed by a qualified healthcare provider. These symptoms could be due to developing dementia or could be side effects of PD medications (Burchum & Rosenthal, 2019) - it will likely be difficult to diagnose the root cause and may require multiple follow-up visits. Although the multiple injuries in various stages of healing and the paranoia described by FK’s wife are likely due to falls and neurologic symptoms or side effects, this patient should still be screened for possible elder abuse. A complete fall risk assessment, like the Hendrich II Model, should be completed by the nurse as well (Ackley et al., 2017).

Related Treatments

The patient received stiches to close the open head wound, but the primary concern is management of progressing PD and preventing further incidents and complications. There are currently no proven methods to prevent neuronal damage or to reverse damage that has occurred in PD, therefore, treatment is aimed at management of symptoms and preserving function as long as possible (Burchum & Rosenthal, 2019). Drug selection and dosages are determined by the progression of the disease and the level of symptom interference with activities of daily living.

Current Treatments

FK is currently taking the following medications and supplements: Rytary (levodopa/carbidopa), amatadine, lorazepam, clonazepam, fludrocortisone, and citrulline. Rytary is a combination drug of levodopa and carbidopa, a hallmark of PD treatment. Levodopa is the most effective drug for Parkinson disease (Burchum & Rosenthal, 2019). It is converted to dopamine after absorption into the CNS which helps to restore the balance between dopamine and acetylcholine in the extrapyramidal system (Burchum & Rosenthal, 2019). Carbidopa has no direct effects of its own, but it inhibits the destruction of levodopa in the intestine and peripheral tissues, allowing levodopa dosage to be lowered significantly (Burchum & Rosenthal, 2019). Unfortunately, levodopa can cause dyskinesias. Amantadine, originally developed as an antiviral agent, is used to help manage dyskinesias caused by levodopa (Burchum & Rosenthal, 2019). Lorazepam and clonazepam are benzodiazepines used to treat anxiety disorders (Burchum & Rosenthal, 2019). Fludrocortisone is a mineralocorticoid prescribed to treat orthostatic hypotension for certain patients. It causes sodium reabsorption and water retention (Burchum & Rosenthal, 2019). Citrulline is an amino acid supplement, sometimes used for patients with dementia and/or muscle weakness.

Additional Treatments Available

Additional treatments can be used to manage other symptoms of PD as they emerge or become problematic. Diet alterations and medications can be used to treat urinary retention and constipation (Burchum & Rosenthal, 2019). Amitriptyline has been proven effective in the treatment of depression in PD patients (Burchum & Rosenthal, 2019). To treat dementia, donepezil and rivastigmine are appropriate for PD patients because they have been shown to produce modest improvement in cognitive function without significantly worsening motor function (Burchum & Rosenthal, 2019). If an anti-psychotic medication is needed, second-generation anti-psychotics clozapine and quetiapine are the drugs of choice for PD patients; first-generation anti-psychotics should be avoided because these drugs block dopamine receptors (Burchum & Rosenthal, 2019).

If the patient is found to have dementia with Lewy bodies after a psychiatric evaluation, treatments for this additional diagnosis should be considered by the prescribing doctor. There is no cure for progressive dementias. Therapies for these diseases are focused on maintaining remaining abilities, restoring functions if possible, and accommodation for functions that cannot be restored. Education of the family is important with dementia (Burchum & Rosenthal, 2019).

If drug therapy is ineffective for treatment of Parkinson disease symptoms, deep brain stimulation is currently the only other widely accepted treatment option (Burchum & Rosenthal, 2019). Treatments being researched for PD are gene therapy and implants of stem cells and fetal cells (Burchum & Rosenthal, 2019). Dysphagia, if present, and immobility problems may need interdisciplinary collaboration with physical or occupational therapy to help improve function and quality of life.

Nursing Interventions

Risk for Falls

The biggest nursing concern with this patient is an increased risk for falls. PD can cause orthostatic hypotension, disorders of equilibrium related to postural abnormalities, and a lack of capability to adjust posture to avoid falling (Huether & McCance, 2017). Levodopa/carbidopa, lorazepam, clonazepam, and amantadine are associated with an increased risk for falls in elderly patients (Burchum & Rosenthal, 2019). Fall prevention precautions should be implemented while this patient is hospitalized. Nursing interventions include using a “high-risk fall” bracelet to alert staff, ensuring call light is within reach of the patient at all times and instructing the patient to call for assistance to get out of the bed, placing the patient in a room close to the nurses’ station, providing non-slip footwear, ensuring adequate lighting, keeping the bed at the lowest height, using facility approved mobility devices to assist with ambulation, and frequently checking on the patient to assist with toileting or other needs (Ackley et al., 2017).

Constipation

This patient reported frequent constipation. In PD, this can be related to weakness of muscles, lack of exercise, inadequate fluid intake, and decreased autonomic nervous system stimulation (Ackley et al., 2017). This is something the nurse can help address through interventions such as dietary teaching – recommending a fiber intake of 18 to 25 grams daily and foods high in fiber such as leafy green vegetables, whole grain bread and pasta, and prune juice (Ackley et al., 2017). The nurse can also ensure fluid intake during hospitalization and teach the patient and family about maintaining an adequate fluid intake of 1.5 to 2 liters of fluid per day. Providing assistance with ambulation around the ward several times throughout the day can help facilitate bowel movement (Ackley et al., 2017). If these interventions are inadequate, the nurse can also request an order for a routine stool softener from the primary care provider (Ackley et al., 2017). Caregiver Role Strain

A final significant diagnosis with this case is caregiver role strain. The wife expressed that she is not able to assist with ambulation due to her own health status and that FK is becoming increasingly difficult to help. FK’s hostility and hallucinations could cause severe emotional distress and affect the caregiver-care receiver relationship (Ackley et al., 2017). Nursing interventions include assessment of the caregiver for signs of depression, anxiety, and deteriorating physical health (Ackley et al., 2017). The nurse can utilize the Caregiver Strain Risk Index to measure the impact of caregiving on the wife’s emotional health (Ackley et al., 2017). The nurse should provide emotional support to the caregiver and encourage her to discuss concerns and fears. If significant role strain is found, the nurse can refer the family to social services or use a multidisciplinary team during discharge to provide the family with information about options to improve care provision within their financial means (Ackley et al., 2017).

References

Ackley, B. J., Ladwig, G. B., & Makic, M. B. F. (2017). Nursing diagnosis handbook: an evidence-based guide to planning care (11th ed.). Elsevier.

Burchum, J. R., & Rosenthal, L. D. (2019). Lehne's Pharmacology for Nursing Care (10th ed.). Elsevier.

Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology. (6th ed.). Elsevier.