Parkinson’s disease (PD) is a degenerative and chronic disorder, which has no known cause or cure (Parkinson’s Disease Foundation, 2016). Although there are medications and nursing care treatments to help the patients, the disease worsens over time. PD affects the nerve cells in those regions of the brain that produce dopamine, a substance responsible for enabling human movement and coordination (Lynn, 2012). Naturally then, with the loss of dopaminergic cells, PD results in restricted mobility, tremor of body parts, lack of body balance, slow movement (bradykinesia), etc. PD-affected people have a tendency to fall and get injured. This often leads them to avoid social gatherings and hence, they suffer from social isolation as a consequence. As part of their treatment and care, nurses are trained to assess the patient situation on a case-by-case basis and offer help accordingly. The current case discusses two of the major priorities of care pertaining to the case of 77 year old Johann, who suffers from Parkinson’s at its degenerative worst and is under nursing care. The chosen patient care priorities chosen are increased risk of fall and injuries, and increased risk of social isolation.
Johann Silvermann, the patient under discussion, is a widower and has been suffering from PD since the last 4 years. He had always lived an independent life, more so after his wife’s demise, where he managed his daily life alone from household chores to picking up grocery and others. Even before he have had been diagnosed with PD, he chose a self-sufficient life, in which he does not want to be any kind of a burden to his brother and his family living close by. Nor is he known to have been socially or psychologically dependent on any neighbour or anyone. Therefore, the worsening of his PD condition pushes him further into the increased risks of social isolation and physical fall without anyone to help. Although he takes medicines for the disease, his physical instability has deteriorated to the extent that he needs nursing care and supervision.
As Johann seems a strong man, less willing to remain dependent on anyone, his nursing care priorities need to take this into account and handle his dignity effectively. Although he is originally fro8m Germany, his cultural values will have a lot of this country’s influence as he has been long living here with financial and social independence. The sports and adventure spirit seems strong in him, which leads him to do holidays each year and enjoy life. Unfortunately, he had not been able to do that this year due to an increased impaired mobility. This might be depressing for Johann and the nurse responsible for his care needs to be careful about it. For Johann, the risk of fall and injury, along with that of social isolation is high. Therefore, these are the two of the care priorities chosen for discussion.
Risk of Fall or Injury
Falls are recurring and the commonest symptom of PD (Contreras & Grandas, 2012). Many studies have observed that 38% to 87% of PD patients experience falls as the disease progresses (Gray & Hildebrand, 2000; Ashburn, et. al., 2001; Balash, et. al.,2005; Hely, et. al., 2008). These falls cause injury that are generally not very severe, but may sometimes even be fatal. Nurses caring for these patients need to understand that these falls are a significant source of morbidity, depression and s87cial seclusion in Parkinson’s-affected people. Hence, the treatment should majorly pivot around preventing falls and injuries as much as possible.
Going by Levett-Jones’ Clinical Reasoning Framework, Johann’s nurse would first need to understand the patient situation as is, gather as much information about him and his illness from his friends and family, process that information and then begin to approach treating the condition. Johann’s hand tremors have reportedly gone worse, for which he is unable to cook, tie shoelaces or perform any other tasks involving fine motor skills. It is unknown to what extent his legs are unstable and whether he may need help with walking too. However, the nurse assigned to manage his care in his home must keep assessing his PD condition, identifying problems/issues as per the Levett-Jones’ cycle.
Contreras & Grandas (2012) feel that fall prevention has become one of the most essential needs in PD patients and one which has often been left inadequately met. This is because people often tend to focus on the fall and post-fall care than fall-prevention strategies. It is hugely important to identify the risk factors and provide care with focus on how falls and injuries can be prevented for Johann. Fall prevention is necessary in the case of Johann for three primary reasons:
- A fall can injure him badly and reduce his mobility to a large extent (Hely, et. al., 2008).
- A fall would land him in a hospital or nursing home, compelling him out of the comforts of his home (Temlett & Thompson, 2006; Hely, et. al., 2008).
- A fall would increase his medical costs manifold and therefore, raise the financial burden of treatment (Spottke, et. al., 2005).
Therefore, the nurse assigned must assess his instability status from time to time — a span of 3 to 4 months — along with other symptoms of the disease progression. Since Johann already has reduced motor skills, chances would be high that his leg movements will be impaired soon (if not already) and he might encounter sudden stiffness of limbs and consequently fall. Gray & Hildebrand’s (2000) study of PD patients reveal that 59% of the respondents experienced falls, of which 40% of the patients encountered injuries although not severe. But what these falls effectively do is to worsen the case further, generating complications, apart from expenses and morbidity.
As part of her nursing care priority, Johann’s nurse should assess his postural instability by:
- Checking his medical history
- Physical examination
- The pull test (Fernandez, et. al., 2009)
To manage these risks, the nurse would need to balance the treatment with both medicines and non-medicinal approaches, although medicines do not directly reduce postural instabilities. Nonpharmacological approaches include (Fernandez, et. al., 2009):
- Imparting body balance training and exercises
- Teaching how to use assistive devices like walking sticks/walkers
- Home safety initiatives like fitting handrails, enhancing the indoor illumination, clearing the floor clutter, removing throw rugs, etc.
There are an estimated over 5 million diagnosed Parkinson’s cases across the globe (WHO, 2006) and therefore, the nursing care approaches to this disease are also well developed with lot of research based on several case findings and pharmacology. In Johann’s case, the two most important nursing case priorities seem to be related to fall/injury and social isolation. Hence, the nurse appointed for his care must prevent falls and keep him meaningfully engaged in conversations or some safe activities so that he feels socially inclusive. What is most important in this case would be to protect the patient’s dignity, without making him conscious of the compromised quality of his life due to Parkinson’s.
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