case study

1. PARKINSON DISEASE
Case study

2. 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.

3. 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.

4. Methodology
The 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.

5.  Patient’s Name :- Mr Dhan Bahadur Gurung
 Age/ sex :- 74 yrs/Male
 Marital status :- Married
 Education :- Literate
 Occupation :- Agriculture
 Religion :- Hindu
5

6.  Address :- Bhotewodar-9, Lumjung
 Diagnosis :- Parkinson disease
Ward :- Neuro Medical Ward
Bed No. :- 410
IP No. :- 7814
Date of admission :- 2011/3/25
Interview date :- 2011/3/27
Date of expired :- 2011/3/28
Attending physician :- Prof PVS Rana
Informants :- Patient (self) & his son
CONT’D

7. Chief complains
1.Abnormal movements of upper and lower limbs x
1 year
2. Difficulty in walking x 6 months

8. 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).

9. 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.

10.  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

11. Smoking :- Non smoker
Alcohol : - Occasional
Food habit :- 3 times a day/ non
vegetarian
Food allergy :- Not known
Drugs allergy :- Not known
Bowel and bladder :- Regular bowel and
bladder habit
Sleeping Pattern :- normal,6-8 hrs. per day
PERSONAL HISTORY

12. Type of family:- Neuclear Family
No. of family:- 4 members
Type of house:- Cemented house
NO. of rooms:- 4
Kitchen :- Separated
Fuel used:- Firewood , Gas
Drinking Water:- Tap water
Toilet :- Water seal
Drainage System:- Closed drainage
ENVIRONMENTAL HISTORY

13. contd
• Family history
No history of similar illness, hypertension,
diabetes, TB or asthma in family.
• Socio economic history
Middle class family.

14. Family tree
74
30
68 66 63 51
32 25
Expired male
Expired female
Patient
Male
Female
68
28
Father and mother
sister
brother
daughter
son
wife

15. 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

16. DEVELOPMENTAL TASK OF OLDER ADULT
IN 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
arrangement
Eg 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

17. General Inspection:
Gait : Shuffling gait with tendency to fall
forward and backward
 Body Build : Thin
Consciousness : Conscious GCS-15/15
Higher Mental Function : Normal
Facial expression : masked face
Vital signs
Temperature :98.2F
Pulse : 78 beats/min, regular, normal
volume and character
Respiration : 20 b /minute, regular
 Blood Pressure : 120/70 mm Hg in both arms
 Height : 5' 4"
 Weight : 65 kg
PHYSICAL EXAMINATION

18. General examination
• Pallor: absent
• Icterus: absent
• Lymph nodes: not palpable
• Clubbing, cyanosis: absent
• Edema: absent.
• Dehydration: absent.
• Skin normal

19. Physical examination cont
Examination of head, face and neck
1.Inspection of head
Hair colour and texture normal, clean hair, no signs of
any injury
2.Inspection of eyes
No discharge and redness of the eye lid,
but swelling of the eyelid, no eye problem
3. Inspection of ears
No discharge and pain but hearing problem is
present.

20. contd
4. Nose
No discharge , bleeding and smelling problem.
5.Mouth
Poor oral hygiene, missing teeth and dental carries
No cyanosis present.
6. Neck
No enlarged lymph node and thyroid gland .
Normal neck mobility is present

21. 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.

22. • Percussion
Resonant in left side and dullness in right side in RT infra-
scapular region.
• Auscultation:
Normal vesicular breath sound bilaterally.
No added sounds.

23. 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

24. 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.

25. CNS examination
• Level of consciousness:- GCS-15/15
• Sleep: normal
• Higher Mental Function: Normal

26. 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

27. contd
3, 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

28. 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

29. contd
8. 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)

30. contd
9 & 10. Glossopharyngeal and Vagus (Sensory and motor)
– Taste posterior 1/3 of tongue normal
– Swallowing, gag reflex normal
– Movement of pharynx normal

31. contd
11. Accessory nerve
• trapezius muscle strenth
• sternocleidomastoid muscle normal
12.Hypoglossal Nerve
• Tongue movements, strength normal
• Speech sounds: normal

32. CNS examination (contd)
• Motor System :
Inspection
- Mask like face present
- resting tremor present
- no neurocutanous marker
- no facial spasm
- no dilated veins, scars

33. 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

34. contd
– Reflexes:
DTJ BJ TJ SJ KJ AJ
• Right + + + + +
• Left + + + + +
Plantar: Right: flexor Left: flexor

35. contd
Sensory function:
• Deep sensation-vibration present
• superficial sensation –pain and touch present
Cortical sensation:
• Graphasthesia – normal
• Stereognosis- normal
• One point localization: normal
• Two point discrimination- normal
• Sensory inattention- normal

36. Cerebellar sign:
Nystagmus: absent
Adiadochokinesis: absent
Finger nose test: normal
Heel shin test : normal
Romberg test: Negative
Ataxia : absence

37. INTRODUCTION TO DISEASE

38. 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

39. Parkinsonian symptoms
• usually first appear in the fifth decade of life
• been diagnosed at the age of 30 years.

40. • 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.

41. 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

43. 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.

44. 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.

45. Cogwheeling

46. Pill rolling tremor

47. 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

48. Shuffling gait

49. 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.

50. CONTD
In book In my patient
Dysphonia (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).

51. 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

52. Investation of the patient
2011/3/
25
Hb:12.3 gm/dl
TC:84,000 /cmm
DC:N-65% L-32% E-
2% M-1%
ESR:26 mm in 1st
hour
RBS: 138.1mg/dl
Bl. Urea:30.1 mg/dl
S.Cr:1.0 mg/dl
TSH: 0.871microIU/L
Normal
M-13-15 F-12-14
WBC-400O-1100 Mm 3mm3
Neutrophil-40-70%
Lymphocyte-30-35%
Esinophil -1-2%
ESR: 10-20
Blood urea-20-40
Rendom Blood sugar- 60-180
TSH: 0.5-4 microIU/L
Creatinine- 1.4

53. Date In my patient In book
2o11/3/26
2011/3/27
Urine
R/E:Acidic
Appearance: Clear
Color: P. yellow
WBC:3-5/HPF
Epithelial cell: 2-4/HPF
USG Abdomen: B/L
renal cortical cyst,
Prostatomegaly Gr.I
R/E:Acidic
Appearance: Clear
Color: P. yellow
WBC:3-5/HPF
Epithelial cell: 2-4/HPF

54. DIAGNOSIS
IN 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

55. 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

56. 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.

57. 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.

58. contd
2. 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 treatment
5. Acetylcholine blocking drugs- Benztropine

59. contd
6.Anticholinergic Therapy.
(trihexyphenidyl,cycrimine, procyclidine, biperiden, and
benztropine mesylate)
• Effective in controlling tremor and rigidity
7.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.

60. 8.Catechol-O-methyltransferase (COMT) Inhibitors.
• The COMT inhibitors entacapone (Comtess)
and tolcapone (Tasmar) have little effect on
parkinsonian symptoms

61. 9.Antihistamines.
• Diphenhydramine hydrochloride (Benadryl),
• Orphenadrine citrate (Banflex), and phenindamine
hydrochloride
• (Neo-Synephrine) have mild central anticholinergic
and sedative effects and may reduce tremors.

62. Medical management
ACCORDING TO BOOK ACCORDING TO MY PATIENT
1.levodopa is the 25/100
form, containing 25 mg
carbidopa and 100 mg
levodopa. .
2. Dopamine receptor
agonists
3. 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 10pm
2.Tab Pramipexole 0.5mg PO TDS to
cont
3.Tab. Pantoprazole 40mg P/O BD to
continue
4.Tab. Domperidone 10mg P/O TDS to
continue
5.Tab. Trihexiphenidyl OD-2mg OD to
continue
6.Syp. Lactulose 3 tsf P/O HS for 2
weeks
7.2% xylocaine oint LA before
defecation

63. 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.

64. Stereotactic Procedures
Thalamotomy and pallidotomy are
effective in relieving many of the symptoms of
Parkinson’s disease
Neural Transplantation.
• Surgical implantation of adrenal medullary
tissue into the corpus striatum is performed in
an effort to reestablish normal dopamine
release.

65. • 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

67. Application of the Henderson
independence theory in this
case

68. Nursing assessment
The 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.

69. 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.

70. NURSING CARE PLAN
1.Analysis
Compare data to knowledge base of health and
disease
• The patient eat and drink is inadequate
Nursing 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.

71. contd
Nursing plan
Document 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

72. CONTD
Nursing 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

73. 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.

74. 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.

75. contd
Nursing plan
Document 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 .

76. CONTD
Nursing 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 .

77. 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.

78. contd
3. 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.

79. CONTD
Nursing plan
Document 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.

80. CONTD
Nursing 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.

81. 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 .

82. contd
4.Analysis
Compare data to knowledge base of health and
disease.
• The patient unable to elimination of body waste
Nursing 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.

83. CONTD
Nursing plan
Document 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

84. CONTD
Nursing 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.

85. contd
5.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.

86. CONTD
Nursing plan
Document 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

87. CONTD
Nursing 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

88. 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.

89. Daily Progress reportDaily Progress report
Date :- 2011/3/ 25
Admission 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.

90. 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.

91. Daily Progress reportDaily Progress report
Date :- 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.

92. Daily Progress reportDaily Progress report
Date :- 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.

93. 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

94. 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 cont
3.Tab. Pantoprazole 40mg P/O BD to continue
4.Tab. Domperidone 10mg P/O TDS to continue
5.Tab. Trihexiphenidyl OD-2mg OD to continue
6.Syp. Lactulose 3 tsf P/O HS for 2 weeks
7.2% xylocaine oint LA before defecation

95. 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.

96. Diversional Therapy
Diversional 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.
·

97. contd
• Individual emotional and social support
• Sensory enrichment, activities like massage
and aromatherapy, pet therapy
• Discussion groups, education sessions like
grooming, beauty care, cooking

98. • 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

99. DIVERSIONAL THERAPY
IN BOOK IN PATIENT
Games, outings,, computers,
gentle exercise, music, arts and
crafts. Individual emotional and
social support
Sensory enrichment, activities
like massage and
aromatherapy, pet therapy
Discussion groups, education
sessions like grooming, beauty
care, cooking
•Individual emotional and
social support
•Gentle exercise.
•Talking with other patient
•Listening music by mobile
phone.

100. SPECIAL GAGETS USED IN MY PATIENT
• Sphygmomanometer
• Stethoscope
• ECG monitoring
• X-ray machine
• Tunings fork
• Knee hammer.
• Thermometer
• Pulse oxymeter.
• U.S G mechine.

101. 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.[

102. 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.

103. 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.

104. Reference
1. 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-1902
3. Mark A & Loscalzo. J “Harrison’s Principle of Internal Medicine” ,
17th
Edition Vol-II, p-1563
4. A lagappan. R.”Manual of Practice Medicine” 3rd
edition 2007 p
2-26.
5.en.Wikipedia.org /wiki/parkinsonism
6.www.medicinet.com /article.htm

105. contd
6. Grbbb.NR,& Newby D.E. “Davidson’s ,Principle & Practice of
Medicine” ,20th
Edition, p-606
7. Potter A Patricia “Fundamental of Nursing Potter Perry” p-
238
8. Mosby’s “Nursing Drug Reference” , 23rd
Edition, 2010
9.Tripathi.K.D ,”Essential of Medical Pharmacology” ,Jaypee ,4th
Edition.
10. En.Wikipedia.org /wiki/abdominal _aortic aneurysm
11. www.nlm .nih.gov../000162 htm
12. Emedicine .medscape .com/article /4633
13 www.sirweb.org/uwe/patient/abdomnal_aortic.

106. Thank you