Assessment nursing diAgnosis PlAnning/goAls ... nursing diAgnosis PlAnning/goAls imPlementAtion...
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notices that he is getting clumsy and dropping things. When his son came to visit, he noticed his father had a shuffling, propulsive type of gait and made a doctor’s appointment for him. Mr McKee is diagnosed as having Parkinson’s disease. The health care provider tells him that his stooped posture is part of the process, along with the monotonous, indistinct speech that he has recently developed. The health care provider explains that to get the muscle problems under control he wants to start Mr McKee on two drugs that work well together. He prescribes carbidopa-levodopa (Sinemet 10-100) bid. NURSING CARE PLAN A Client with Parkinson’s Disease Taking Carbidopa Levodopa (Sinemet) Clarence McKee, age 68, lives alone after his wife had a stroke and was placed in a nursing home. He has three children who are all married and live in another state. He has had problems with tremors at rest for quite some time, but attributes it to nerves. He has been retired for over 5 years now, and spends his time looking after his two dogs and playing cards and bingo. He Chapter 19 Anti-Parkinson Agents ASSESSMENT NURSING DIAGNOSIS PLANNING/GOALS IMPLEMENTATION EVALUATION Tremors, gait Impaired physical mobility, related neuromuscular impairment and decreased strength. Client maintains current level of functioning. Arrange home assessment. Arrange for a companion to assist with daily activities. Physical and occupational therapy consults to facilitate activities of daily living, safe ambulation, and muscle strengthening. Remove environmental barriers. Client demonstrates no regression in current level of functioning and experiences no injuries. Drooling, speech patterns Impaired verbal communication related to dysarthria. Client communicates needs adequately. Teach client to speak slowly and distinctly. Use hand signals. Arrange for speech therapy consult, if necessary. Client demonstrates decreased frustration due to an improvement in the ability to express himself. Activities of daily living Risk for self-care deficit syndrome related to neuromuscular impairment. The client will demonstrate ability to participate physically in feeding, dressing, toileting and bathing activities. Evaluate ability to participate in self-care activities. Encourage client to continue with practical activities. Refer client to occupational therapy for needed assistance as disease progresses. Client participates in activities of daily living and demonstrates optimal hygiene and the ability to meet nutritional needs. Impaired balance Risk for injury related to neuromuscular impairment. Client will remain free of injury. Encourage client to change positions slowly, plan ahead, and ambulate with handrails. Watch where and how walking occurs. Remove environmental barriers. Assess gait and balance. Client moves about safely and experiences no falls or injuries. Difficulty in eating, swallowing Imbalanced nutrition: less than body requirements related to difficulty swallowing (dysphagia). Client will demonstrate adequate nutritional status as evidenced by weight gain and adequate oral intake. Client should eat slowly and chew food well. Provide well-balanced, high-fibre diet; supplements as needed. Teach client and caretaker about diet. Weigh weekly. Client maintains body weight and good nutritional status. CONTINUED
Transcript of Assessment nursing diAgnosis PlAnning/goAls ... nursing diAgnosis PlAnning/goAls imPlementAtion...
notices that he is getting clumsy and dropping things. When his son came to visit, he noticed his father had a shuffling, propulsive type of gait and made a doctor’s appointment for him. Mr McKee is diagnosed as having Parkinson’s disease. The health care provider tells him that his stooped posture is part of the process, along with the monotonous, indistinct speech that he has recently developed. The health care provider explains that to get the muscle problems under control he wants to start Mr McKee on two drugs that work well together. He prescribes carbidopa-levodopa (Sinemet 10-100) bid.
NursiNg Care PlaN A Client with Parkinson’s Disease Taking Carbidopa Levodopa (Sinemet)Clarence McKee, age 68, lives alone after his wife had a stroke and was placed in a nursing home. He has three children who are all married and live in another state. He has had problems with tremors at rest for quite some time, but attributes it to nerves. He has been retired for over 5 years now, and spends his time looking after his two dogs and playing cards and bingo. He
Chapter 19 Anti-Parkinson Agents
Assessment nursing diAgnosis PlAnning/goAls imPlementAtion evAluAtion
Tremors, gait Impaired physical mobility, related neuromuscular impairment and decreased strength.
Client maintains current level of functioning.
Arrange home assessment. Arrange for a companion to assist with daily activities. Physical and occupational therapy consults to facilitate activities of daily living, safe ambulation, and muscle strengthening. Remove environmental barriers.
Client demonstrates no regression in current level of functioning and experiences no injuries.
Drooling, speech patterns
Impaired verbal communication related to dysarthria.
Client communicates needs adequately.
Teach client to speak slowly and distinctly. Use hand signals. Arrange for speech therapy consult, if necessary.
Client demonstrates decreased frustration due to an improvement in the ability to express himself.
Activities of daily living Risk for self-care deficit syndrome related to neuromuscular impairment.
The client will demonstrate ability to participate physically in feeding, dressing, toileting and bathing activities.
Evaluate ability to participate in self-care activities. Encourage client to continue with practical activities. Refer client to occupational therapy for needed assistance as disease progresses.
Client participates in activities of daily living and demonstrates optimal hygiene and the ability to meet nutritional needs.
Impaired balance Risk for injury related to neuromuscular impairment.
Client will remain free of injury.
Encourage client to change positions slowly, plan ahead, and ambulate with handrails. Watch where and how walking occurs. Remove environmental barriers. Assess gait and balance.
Client moves about safely and experiences no falls or injuries.
Difficulty in eating, swallowing
Imbalanced nutrition: less than body requirements related to difficulty swallowing (dysphagia).
Client will demonstrate adequate nutritional status as evidenced by weight gain and adequate oral intake.
Client should eat slowly and chew food well. Provide well-balanced, high-fibre diet; supplements as needed. Teach client and caretaker about diet. Weigh weekly.
Client maintains body weight and good nutritional status.
CONTINUED
19 BROYLES NCP 1ed SB 9780170193009 TXT 1pp.indd 1 8/17/12 11:08 AM
Assessment nursing diAgnosis PlAnning/goAls imPlementAtion evAluAtion
Bowel habits Constipation related to neurogenic disorder.
Client will maintain adequate patterns of bowel function.
Teach client to maintain adequate roughage and fluid intake. Use stool softeners as needed.
Client is maintaining daily bowel habits with use of stool softener.
Urinary habits Impaired urinary elimination related to autonomic dysfunction.
Client will maintain adequate patterns of urinary function.
Teach client to maintain fluid intake at 2000 mls daily. Assess urine for sediment, colour and odour.
Client is maintaining fluid intake and output of 2000 mls daily. Client knows to report changes in urine colour and odour.
Self-concept, support systems
Situational low self-esteem related to changes in body image and dependence.
Client verbalises positive expressions of self-worth.
Explore strengths and resources with client. Clarify misconceptions and provide accurate information.
Client demonstrates and verbalises increased feelings of self-concept.
Anxiety Anxiety related to change in health status.
Client will verbalise a reduction in the level of anxiety experienced.
Encourage client to verbalise anxieties and fears and how they relate to self-esteem. Clarify client’s misconceptions and provide accurate information.
Client is able to ver balise anxieties and reduction of fear.
Disease symptoms and usual progression
Deficient knowledge (disease process and medication necessary to help control disease).
Client will verbalise understanding of disease process and medication routine.
Teach client that the disease progresses slowly. Instruct client to avoid fatigue, stress, and foods high in vitamin B6. Inform client that medication may darken urine. Report nausea, vomiting, dizziness. Assess vital signs. Take levodopa and amantadine with food. Carbidopa-levodopa will reduce tremors and rigidity.
Client describes dis ease process and progression. Client adheres to medication routine. Client verbalises that foods high in vitamin B6 interfere with the effectiveness of levodopa. Client lists foods high in vitamin B6.
19 BROYLES NCP 1ed SB 9780170193009 TXT 1pp.indd 2 8/17/12 11:08 AM
