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