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Question:

Discuss about the Medical History of Charles Williamson.

Mr. Charles Williamson is a 76 year old man who has been admitted to the respite care for 5 days, following a recent fall at home. He has sustained bruises and a skin tear in his right lateral leg.  In regards to his medical history, he was diagnosed with Parkinson disease 10 years ago for which he is taking Sinemet CR (200/50mg tablets) every 4 hours during the day. However, Mr. Williamson thinks the effectiveness of Levodopa therapy starts to wear off after 4 hours and then he fails to control his movement.

Regarding Mr. Williamsons past history, his mother died of pneumonia at the age of 78. She also had Parkinson’s disease for 22 years. His primary carer is his wife Elise at the moment.

On general appearance, Mr Williamson was alert and orientated. However, he was slightly anxious with noticeable tremor in his upper limb. During the assessment, he had a ‘mask like’ face. He was speaking in hoarse and monotonous voice. His physical assessment revealed a normal blood pressure (120/72) in siting position and his heart rate was 76 with rhythm. Mr. Williamson was able to rise from the chair without pushing off with his hands, but a drag /scuffing of the right foot was heard. His movements are slow and rigid and his balance appeared to be unstable. As a result, he needs assistance in ADL (activity of daily living). He also complained of constipation and lack of appetite, and started coughing when a drink of water was given.

Mr. Williamson is admitted to the hospital following a fall at home where he sustained bruising. A skin tear in his right lateral lower leg was also observed. He has been diagnosed with Parkinson’s disease 10 years ago. Parkinson’s disease is a movement disorder associated with dopamine deficiency in the brain.

Dopamine is a chemical messenger that transmits signals between two regions of the brain to coordinate activity. For example, it connects the substantia nigra and the corpus striatum to regulate muscle activity (Mandal 2018).Dopamine is mainly produced by special cells deep inside the brain. It is these cells that die and causes Parkinson’s disease. The dopamine is used by many areas of the brain but it is particularly important in controlling movement. Because of this impact on movement, Parkinson's disorder is classified as a movement disorder (Annon2018). Some of the clinical manifestations of Parkinson disease include shuffling gait, mask like face expression, and muscle weakness affecting writing, speaking, eating, chewing and swallowing (Annon 2018). Some of the risk factors of Parkinson disease are, age, genetic and gender .The older a person gets the greater the risk they develop. If a person who has a close relative (brother, sister, mother, and father) with Parkinson disease, he or she has a slightly higher risk of developing it himself compared to others. Males are slightly more likely to develop Parkinson’s disease compared to females. (Dr Ananya Mandal 2018). The aim of medical management of Parkinson disease is to provide control of signs and symptoms for as long as possible while reducing adverse effects. Patients will be given medication, such as carbidopa-levodopa (for example, Sinemet) that will increase the dopamine in the brain (Upfal2016, p.471). Carbidopa prevent destruction of levodopa elsewhere in body, allowing a much greater portion of the drug to reach the brain (Upfal2016, p.472) There are some side effects of Sinemet , such as loss of appetite and constipation(Upfal2016, p.473),which Mr Williamson stated during assessment.

Medical History and Symptoms

The first identified nursing diagnosis was Mr Williamson’s impaired verbal communication; He was speaking in hoarse and monotonous voice.  When the Parkinson diseases progress the cognitive ability diminishes.  The patients with Parkinson disease may have slurred speech as a result of dysarthria (Gulanick& Myers 2007,p.618). Dysarthria follows when the patient has problems expressing certain sounds or words and they poorly pronounce speech (such as slurring).  The rhythm or speed of speech is changed (Dysarthria –symptom and causes 2018).Since dysarthria can make it harder to move lips, tongue, and jaw; it can also make it tougher for the patient to chew and swallow. Hence, trouble in swallowing can cause the patient to drool. In Mr Williamson’s case, it was noticed that while giving him a drink, he started coughing. Untreated speech disorders may cause a person to experience a great deal of anxiety and over time, this anxiety can elicit anxiety disorders or a phobia of speaking in public(Speech Disorders: Causes, Signs, and Diagnosis 2018).

The second identified nursing diagnosis was Mr Williamson’s impaired physical mobility. He was dragging his right foot while moving and his movement was slow and rigid. His balance appeared to be unstable. Patients with Parkinson disease have difficulties initiating movement or changing direction of movement. This results from poor coordination of the muscle groups.  Thus the patient’s movements become slow and hesitant (Sietske and Heyn 2018). Mobility is important for an older patient to maintain their independent living.  Restricted movement affects the performance of most activities of daily living (ADLs).  Mr Williamson requested for assistance with activities of daily living (ADL) since he is restricted with his mobility due to uncontrolled movement. Impaired physical mobility means unsteady gait which can causes increased risk for falls and dependence regarding everyday activities. It also means to have lack of physical conditions, such as reduction of muscle strength, activity intolerance, musculoskeletal and neuromuscular impairment (Impaired physical mobility of Parkinson disease 2018

Verbal communication is used to inform others of our needs or to share knowledge. When verbal communication becomes impaired, it becomes hard for individuals to express the words (Lucus 2018).The task for nurses is to encounter the patient and find out the reason of the communication becoming ineffective. They need to use strategies to improve transmission of information (Gulanick& Myers 2007,pg.622).Some of the  nursing interventions and rationalecould be maintaining eye contact when speaking with patient. This promotes patient to focus(Gulanick and Myers 2007,pg.622).The nurse should give patient some time to express themselves as they may be discouraged and give up if rushed. They need time to organize thoughts before they  speak (Gulanick& Myers 2007,pg.623). Nurses needs to encourage patients to do face and tongue exercise. Regular exercise can reduce rigidity and facilitate muscle relaxation (Gulanick& Myers 2007,pg.622). The patient should also be encouraged to practice reading aloud. This activity will help patient with muscle control. The health organization should provide alternative communication aids, such as picture or word boards.  These aids communication and reduces frustration. A speech therapist should be contacted if indicated; the speech therapist can evaluate the patient’s need of adaptive device such as voice synthesizers or computers (Parkinson's Disease & Speech Therapy | Cleveland Clinic 2018). In Mr Williamson’s case, during the assessment the nurse should maintain eye contact when communicating, so that he can concentrate and respond to the nurse. In addition, the nurse should allow Mr Williamson some time to direct his speech; this will give him time to bring together his thoughts before speaking, and the nurse should avoid using medical jargon, technical terminology used by health care providers. This is because it can sound foreign language to patient and family.

Parkinson's Disease and Treatment

Mobility is also related to body changes from aging such as loss of muscle mass, reduction in muscle strength and function. Gait changes also affect balance as that can significantly compromise the mobility of older patients (Gulanick& Myers 2007,pg.618).Impaired physical mobility restricts movements. Hence, it affects the ability to perform most of the ADLs (activities of daily living). In Mr Williamson’s case, he was affected by impaired physical movement and he requested for assistance with his ADLs. The nurse intervention and rationale would be to encourage patient to perform exercise daily, since exercise reduce muscle  rigidity ,maintain joint mobility and prevents muscle weakening. The nurse can explain the progressive activity to the patient and help the patient or caregivers establish reasonable and obtainable goals. This is because information promotes awareness of the treatment plan and help in setting small attainable goals. This  helps to increase self-confidence and promotes adherence. The nurse should allow the patient to perform tasks at their own rate and encourage independency with safety.  Mostly caregivers are often in hurry and do more than needed, and thereby it slows patient’s recovery and reduces their self-esteem. In Mr Williamson’s case, the nurse should provide tips for getting in and out of chair, using high-seated chair with arms. The high seated chair provides more support and reduces risk of falls with change in position .Also they should encourage him to lift his feet and take large steps while walking. This is because a broad based gait helps to improve balance and reduce shuffling. The registered nurse should administer medication as appropriate like an antispasmodic medication that may reduce muscle spasms that interfere with mobility.

The administration of medicines is an activity of registered nurses. To promote safe care and competent practice, professionals must administer medicines to individuals who are unable to self-administer or unable to take responsibility for decisions about when to take medicines and when not to take medicines (Bryce, J & Foley, 2013).

Mr Williamson was admitted to respite care following a fall at home sustaining bruising and skin tear to his right lateral leg. During the assessment, he was found to be unstable on his leg and he spoke in a hoarse and monotonous voice. Mr Williamson was diagnosed with Parkinson disease and this contributes to his disorders. The first challenge for MrWilliamson is his impaired physical mobility; he needs to be educated regarding hazards of immobility. Importantly he needs to know, how to change his leg position and the significance of exercise. Good information enables the patient to develop some control over the rehabilitation process (Armitage et al. 2009). In addition, the environmental barriers should be removed in home before he is discharged to maintain his safety and prevent any fall (Armitage et al. 2009).Mr Williamson should be consulted with physical and occupational therapists about aids to facilitate ADLs, safe ambulation and to promote muscle strengthening. Aids can increase mobility and allow the patient some control over the environment. Mr Williamson also complained of constipation, so he should be given stool softeners for constipation. He should be also encouraged to eat food items that are high in fibre and drink adequate water to prevent constipation. Immobility promotes constipation and therefore care should be taken to help him overcome this symptom..

Nursing Diagnosis: Impaired Verbal Communication

The second challenge for Mr Williamson is to develop his verbal communication. His voice was hoarse during the assessment. Clear information should be given to him about how to do undertake speech exercise and the nurses should convey the importance of it before he is discharged. This may include different face and tongue exercise that can reduce rigidity and ease muscle relaxation. Mr Williamson should be provided with an appointment with speech therapist. A speech therapist can estimate the patient’s need and can provide him with adaptive devices such as voice synthesizers. In addition, the nurse can offer alternative communication aids such as, picture or word boards. These aids can reduce communication frustration.

It appears that Mr Williamson’s medication for Parkinson disease(Sinemet200/50mg tablets) wear off after 4 hours. Hence, the dosage needs to be increased. A doctor needs to review him before his discharge. A community nurse can be also appointed to help Mr Williamson with his ADLs and his medications.

This report clearly states that Parkinson disease contributes to symptoms such as impaired physical immobility, impaired verbal communication , imbalance in nutrients and many more. Parkinson disease cannot be cured (Sietske N. Heyn 2018). However, many treatments are available that can allow a person with Parkinson’s to lead a fulfilling and productive life. Treatments can assist in managing the symptoms and providing a high quality of life for many years to come. Parkinson disease can be managed by medications and doing exercises that are allocated by physio and speech therapist(Sietske N. Heyn 2018).Educating the patient and the family to manage Parkinson disease is very important, such as educating about medication, diet, and exercise, using safe measures during walking and the ways to use walking aids safely (Parkinson Disease 2018). Currently, there is no known cause or understanding of why a person develops Parkinson’s disease. However, there are many theories for the occurrence of the disorders. It is generally thought that multiple factors are responsible, such as genetic changes, environmental factors, oxidative stress or a combination of these (Parkinson Disease 2018). A patient should always be given good information and support from caregivers and families. A good support at all times encourages patients to achieve a goal and maintain their life style.

References

Armitage, G, Adams, J, Newell, R, Coates, D, Ziegler, L & Hodgson, I 2009, "Caring for persons with Parkinson’s disease in care homes: Perceptions of residents and their close relatives, and an associated review of residents’ care plans", in , Journal of Research in Nursing, vol. 14, no. 4, pp. 333-348, viewed 12 April 2018.

Bryce, J & Foley, En.d. 2013, Nursing guidelines: Management of medicines in aged care.

Dr Ananya Mandal, M 2018, Parkinson's Disease Pathophysiology, in , News-Medical.net, viewed 11 April 2018, <https://www.news-medical.net/health/Parkinsons-Disease-Pathophysiology.aspx>.

Dysarthria – Symptoms and causes 2018, viewed 12 April 2018, <https://www.mayoclinic.org/diseases-conditions/dysarthria/symptoms-causes/syc-20371994>.

Gulanick, M & Myers, J 2007, Nursing care plans, Elsevier Mosby, Edinburgh.

Impaired physical mobility - mynurse 2018, viewed 12 April 2018, <https://mynurse.weebly.com/impaired-physical-mobility.html>.

Impaired Physical Mobility of Parkinson's Disease 2018, viewed 12 April 2018, <https://nanda-nursing-care-plan.blogspot.com.au/2012/06/impaired-physical-mobility-of.html>.

Lucas, A 2018, The Importance of Verbal & Non Verbal Communication, in , LIVESTRONG.COM, viewed 12 April 2018, <https://www.livestrong.com/article/156961-the-importance-of-verbal-non-verbal-communication/>.

Parkinson disease, viewed 11 April 2018, <https://www.medicalnewstoday.com/info/parkinsons-disease/risks-of-parkinsons-disease.php.>.

Parkinson's Disease & Speech Therapy | Cleveland Clinic 2018, viewed 12 April 2018, <https://my.clevelandclinic.org/health/diseases/9392-speech-therapy-for-parkinsons-disease>.

Parkinson's Disease 2018, viewed 12 April 2018, <https://brainfoundation.org.au/disorders/parkinsons-disease>.

Sietske N. Heyn, P 2018, Parkinson's Disease 17 Early Symptoms, Causes, Treatment, Stages, in , MedicineNet, viewed 12 April 2018, <https://www.medicinenet.com/parkinsons_disease/article.htm#can_parkinsons_disease_be_prevented>.

Speech Disorders: Causes, Signs, and Diagnosis 2018, viewed 12 April 2018, <https://www.healthline.com/health/speech-disorders#complications>.

Upfal, J 2016, Australian drug guide, Black Inc., Melbourne, Vic.

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