Physical Therapy and Occupational Therapy in Parkinson’s Disease

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Learning Goal

The core learning goal for this assignment is to accurately define the patient’s condition and device a care plan that would address or mitigate chief complaints and mediate the onset of conditions if possible. Achieving this goal would require diligence in observation and careful weighing of the obtained evidence. In addition to that, consultation with reliable data sources is paramount to establish a good quality of recommendations and suggestions.

Patient Information

A patient is a 65-year-old white male born and raised in Huston, Texas. He is married, has 4 adult children, and lives in his own farmhouse. He adheres to Catholic faith and is a regular churchgoer. Until recently he worked at a local grocery store as a cashier. Drinking habit is occasional and well-controlled, no active or passive smoking habits. In terms of physique, he is moderately overweight and has gait issues. At the age of 64, he survived an ischemic stroke which caused minor memory loss and speech issues. He is allergic to paracetamol which causes a skin rash. His wife and children, concern for his wellbeing noticed shaking hands and moving difficulties which caused them to bring him to the clinic for assessment and care.

History and Chief Complaints

The patient has a history of repeated stable fracture of left and right leg which was regarded as a farmhouse accident. In terms of surgical interventions, he had his appendicitis removed in 2006 with no significant complications. The ischemic stroke resulted from a blood clot the symptoms of which were not duly uncovered. The latter was surgically removed through thrombectomy. The recovery medications he received included anticoagulants (Rivaroxaban) and blood pressure mitigators (Fludrocortisone).

For a period of time he recovered almost fully and regained his strength, yet, presently he experiences symptoms such as low blood pressure, fatigue after short periods of activity, tremor in the left hand, and memory problems and obstructed speech. The patient started having issues with handling change at the grocery store as his left hand started shaking. He also noticed difficulties producing long sentences or long words. In mornings, getting out of bed became an issue as he felt fatigue right away despite having enough sleep. Blood pressure levels as measured by his wife demonstrated 80 systolic and 59 diastolic which accounts for hypotension. Finally, the patient felt discouraged to participate in family activities and acted in a distracted manner.

Physical Assessment

Respiratory	Acceptable expansion noted, wall movements are symmetrical with no abnormalities present. Sound resonates with no friction; irregularities are not registered. The subject does not have a history of smoking.
Cardio/Peripheral	Bradycardia is noted, heart palpitations felt vague, orthostatic hypotension is present.
Gastrointestinal	Bowel sounds are absent, patient defecates 1-2 times a day with no blood or irregularities in the stool reported.
Genitourinary	Urination is unobstructed and regularly, no abnormalities or signs of infection in genitalia.
Musculoskeletal	Strength and resistance test showed2 gravity and 5 lower. Apparently, tremor affects the patient’s left palm muscle’s strength.
Neurological	Pupils react to light and movement normally and equally.
Integumentary	No rash or lumps. Irregular pearliness or smoothness is not detected.
Vital Signs	Test 1. BP 80/59, Temperature 95.9, BPM 56, Respiratory rate 13, RA 90% Test 2. BP 79/56, Temperature 96.1, BPM 58, Respiratory rate 15, RA 89%
Weights	Weight 109 kg. Height 175 cm.

Medical Diagnosis and Definition

A possible diagnosis is Parkinson’s disease caused by a blood clot which caused the death of neurons and resulting low levels of dopamine. In accordance with Mosby’s dictionary of medicine, nursing and health professions, Parkinson’s disease is “a slowly progressive degenerative neurological disorder characterized by resting tremor, pill rolling of the fingers, masklike facies, shuffling gait, forward flexion of the trunk, loss of postural reflexes, and muscle reflexes, and muscle rigidity and weakness” (Toole, 2013, p. 1337). According to the Parkinson’s Foundation (2017), there are five stages of progression and the patient is currently at a second stage. All of the symptoms including body posture, fatigue, restrained movement, and speech are present. Yet, the tremor affects only one side of the body which signifies the early onset of the second stage.

The patient also suffers from hypotension that results from the Parkinson’s disease. Hypotension is an “abnormal condition in which the blood pressure is not adequate for normal perfusion and oxygenation of the tissues” (Toole, 2013, p. 886).

The patient’s excessive weight also tells of obesity as a medical condition. Obesity, as mentioned in the Mosby’s dictionary of medicine, nursing and health professions, is an endogenous or exogenous condition which is characterized by a body mass index greater than 30 (Toole, 2013, p. 1253).

Pathophysiology and Clinical Manifestations

The main diagnosed condition, Parkinson’s disease is characterized primarily by a gradual decrease in the number of neurons in the midbrain basal ganglia. This region is responsible for the production of dopamine, a neurotransmitter that connects two halves of the brain and, above all, is accountable for the coordination of speech and movement, muscular activity. A deficiency of cells in one region causes malfunctions and degeneration in all other connected areas, which result in the disease progression and further degradation of physical and psycho-social activity. Mainly, the death of cells is associated with aging and overall slow regenerative processes, yet no scientific proof was found to attribute this issue to a concrete factor or group of factors.

In regards to blood pressure that surfaced as a comorbidity in the patient in question, the phenomenon is explained by the decrease in norepinephrine. The latter is an essential chemical component of a sympathetic nervous system that controls automatic body processes such as blood pressure level and heartbeat rate. Decreased norepinephrine is said to be related to low blood pressure and fatigue. The patient’s tiredness in the mornings due to a rapid attempt to change horizontal body position to a vertical one results in insufficient saturation of organs and tissues with oxygen and other substances required for adequate movement. The common clinical manifestations of Parkinson’s are a tremor, bradykinesia, fatigue, balance impairment, posture disorder, speech difficulty, depression, and other conditions.

Medical and Surgical Management of Diseases and Conditions

The medical management of Parkinson’s disease revolves primarily around mitigating the symptoms and manifestations as presently there is no treatment for it. The core therapeutic intervention is to normalize and maintain the level of chemicals in the brain to restore physical and mental functioning to the pre-disorder level for as long as possible. One of the most common medications is levodopa which replaces the dopamine lost in the brain degradation process. It is usually prescribed with carbidopa that helps manage intoxication (Chaudhuri et al., 2018). The effectiveness of this drug combination is proved even for Parkinson’s patients in advanced stages.

Other possible initiatives may include a surgical procedure for the installation of a brain stimulator that helps relieve the symptoms. A meta-analytic study conducted by Liu et al. (2014) suggests that both deep brain stimulation interventions (DBS) of both globus pallidus and pallidus internus were successfully able to positively affect daily motor functions as well as relieve psycho-social symptoms. The effect lasts at least one year after surgery, yet no further follow-up studies were conducted. Thus, this procedure could be included in a care plan as a possible option to suggest to the patient.

To aid physical movement, there are a number of physical therapies that help maintain independence for a prolonged period of time. It also serves as pain relief if there is such a side effect. As it is commonly known, the progression of Parkinson’s causes loss of upright posture which leads to movement impediments and increases in falls frequency (Radder, et al., 2017). To avoid consequent injuries there exists a necessity for compensatory treatment which is an evidence-based intervention centered on helping the patient to learn strategies and techniques of physical movement to reduce the incidence of falls and retain mobility.

As the patient also experiences speech difficulties, there is also a need for speech therapy. Overall, the nature and the number of side-effects allow for a comprehensive multi-therapeutic approach to management of Parkinson’s. Thus, in their randomized controlled study Ferrazzoli et al. (2018) state that multidisciplinary rehabilitation offers short-term and long-term benefits. A 4-week program that includes aerobic, motor-cognitive, and intensive treatment demonstrated sufficient improvements in life quality, which is an indication that a similar intervention might be of use for this particular patient (Ferrazzoli et al., 2018). Since, as the study suggests, drugs alone cannot sustain positive change for posture, gait, and speech issues, the combined treatment plan might be of use in this case.

Medications

Levodopa and carbidopa are considered one of the most effective drug interventions to date for Parkinson’s symptoms inhibition. Yet, the patient due to obesity, low-movement lifestyle and recent stroke may be in risk for a heart attack, which may advise against taking it. The early stage of progression also validates the use of Monoamine oxidase (MAO-B) inhibitors. However, they are not be used in combination with levodopa and carbidopa as cases of adverse drug interaction were registered.

MAO-B are a comprehensive solution that provide a mild psychological symptom-tackling effect that provides a substantial 20-25% increase in quality of life outcomes (Chekani, Bali, Aparasu, & Mullen, 2016). As the patient demonstrated symptoms of depression, this could become a first-line treatment option for him. To curb tremor and increase the accuracy of fine motor skills there might be a need for amantadine, which in combination with anticoagulants and blood pressure mitigators such as Rivaroxaban and Fludrocortisone could maintain the subject in a mobile and independent state. The initial dosage for Parkinson’s patients is 100 milligrams daily, once a day (“Monoamine oxidase inhibitors (MAOIs),” 2018). The dosage may be increased to a maximum of 200 mg a day after a week of no effect.

Rivaroxaban and Fludrocortisone should be renewed to remedy the low blood pressure problem as well as prevent a repetition of clotting. Rivaroxaban should be taken orally 15 mg twice a day for 3 weeks (“Rivaroxaban uses, side effects & warnings,” 2018). Fludrocortisone can hamper the immune system, so it is not advised if the patient has a fungal infection. As physical examination uncovered none, the drug is relatively safe to use. The dosage should be 0.1 mg daily initially, and 0.2 mg per day, if no transient hypertension is registered after a week (“Fludrocortisone uses, side effects & warnings,” 2018). It is important to note that taking Fludrocortisone reduces natural potassium reserves, which requires a patient to adhere to a potassium-rich diet.

Spiritual and Cultural Assessment

Social, Cultural, Spatial	The patient is an American with Irish roots. He is deeply committed to Catholic faith and devoted to his family. Yet, the possibility of Parkinson’s progression and preliminary diagnosis, as well as his deteriorating physical condition (tremors, movement impediment and speech problems), immerse him into a depressive state. Children and relatives assist him in finding distractions and try to involve him in various family activities. Faith serves as a major contributor to mental stability and hopeful moods.
Erikson’s Developmental Tasks	The patient is in the late adulthood stage where the dichotomy between integrity and despair surfaces. Yet, he seems to view his past positively and has no apparent regrets about it. Confronted with diagnosis, he demonstrated bitterness and despair as to what awaits him next. It is the symptoms of the disease that make him uncomfortable as he was regarded by his relatives as an avid speaker.
Maslow’s Hierarchy of Needs	Currently, the patient does not lack in any aspect except for esteem. Sensing his progressing loss of self-sufficiency, he gives in to dark thoughts especially given the knowledge his condition is unfortunately permanent. The notions of mitigation nonetheless allowed for a brief, hopeful spell.

Diagnostic Studies

The Parkinson’s disease is known for its problematic diagnostics as there is no universal and accurate test that could help with any rational degree of certainty state the presence of this condition. Among medical professionals, there is a term named “parkinsonism” that relates to symptoms which have other nature than the disease in question. As such, in this case, the recent ischemic stroke was a reason to apply parkinsonism. Yet, the presence of other symptoms such as tremor, fatigue, postural instability, and early bradykinesia suggest that ischemic stroke could not have caused all of these conditions. One of the most effective ways to diagnose Parkinson’s is through medication (Radder et al., 2017). The medication plan suggested above, if effective, could prove this dire state. In addition, the patient should undergo a test battery consisting of motor function, olfaction, and depression tests.

Nursing Diagnoses

Nursing Diagnosis #1: Risk for Heart Attack/Second Stroke

Intervention	Rationale	Patient-specific statement
Introduce a healthier diet	Obesity is one of the predictors of heart diseases and strokes which requires a patient to withdraw from unhealthy eating habits.	Due to the patient’s deteriorating movement and speech, he may soon encounter chewing issues which may necessitate the provision of assistance at food consumption. Left-hand tremor that may soon transfer to the right limb may also impede food taking.
Daily evaluation of vitals, especially BP.	Abnormal blood pressure rates may indicate a pre-stroke condition which will then require urgent medical help.	Due to the presence of close relatives in the vicinity, the vitals may be checked by them.

Nursing Diagnosis #2: Risk of Non-Adherence to Medication

Intervention	Rationale	Patient-specific statement
Patient/family education	As the patient will not be hospitalized, all prescribed medications will be administered by the patient himself or his close relatives.	Increased attention should be paid to voluntary discontinuation of medicines, as it could lead to withdrawal symptoms (particularly pertinent to Levodopa/Carbidopa) (“Carbidopa and levodopa uses, side effects & warnings,” 2018).
Regular home visits	Home visits may reveal non-adherence early, before side-effects inflict significant damage.	The patient lives in a rural area, which makes it troublesome to access him.

Nursing Diagnosis #3: Risk of Depression Progression

Intervention	Rationale	Patient-specific statement
Exercise	Radder et al. (2017) suggest that physical exercises, especially group ones assist in distracting the patient from dark thoughts thereby increasing their quality of life.	The patient lives in a rural area which might present difficulties to travel to care center often, which might result in absenteeism and limited effect of the intervention.
Attend coping group meetings of Parkinson’s patients	Coping strategies if adhered to may be effective in recognizing and reconciling with the disease.	The remote nature of the patient’s dwelling might present the same problem as specified above.

Diet Plan

The patient needs to adhere to a strict diet the goal of which is to decrease weight and supply his body with all elements necessary to undergo multidisciplinary care plan. As specified in the medications section, the systematic intake of MAO-B may drain the patient of potassium which requires him to increase the consumption of potassium-rich foods. In addition, the patient should reduce the input of fat-rich products and red meat as they may increase the risk of stroke and heart attack. Cereals, fruits, and vegetables, on the other, hand need to be included in the diet due to the high vitamin content.

It is equally important to maintain the frequency of meals per day in the 3-5 range avoiding periods of no-food/excessive food consumption during the day. Evening meals should contain fewer calories than morning and supper ones to ensure healthy night-time digestion. Consumption of fluids in large quantity will also help mitigate the side-effects of medications and assist in resolving weight issues.

Discharge Plan

Hospitalization is required mostly in severe complications or due to fall damage (Paul et al., 2017) and the patient has not yet experienced any of those. Therefore, there is no need for a discharge plan. However, after completion and discussion of analyses, physical examination, and care plan approval, there is a need to schedule follow-up visits (Swearingen, 2004). They will provide regular updates on the patient’s reaction to medications and will grant an opportunity to confirm or disprove diagnosis. In addition, they can assist in correcting the care plan if needed.

Patient Education

Patient education needs to be centered on adherence to diet and medication plan as well as improvement of psychological condition. Acting in agreement with the set course of actions is one of the central issues to the successful implementation of care plans and treatment outcomes (Swearingen, 2004). The patient needs to be reminded of the quality of life that will increase if he follows the trajectory for improvement. Patient’s family also should become a target for an explanation of the medication intake course, dosages, and other specifics, as the patient may soon need increased attention. It is especially vital to note that discontinuation, even if decided need to be reported to the care provider. All changes in health and vitals need to be monitored and recorded.

Student Evaluation

I believe the patient’s health care, spiritual, and other needs are addressed by the proposed plan. The measures appear to be adequate and warranted by relevant seminal research. The key learning goal I managed to tackle is that I received a comprehensive understanding of care plan devising and application to a specific patient. Yet, there is still plenty of topics to advance in and room for professional growth.

References

Carbidopa and levodopa uses, side effects & warnings. (2018). Web.

Chaudhuri, K. R., Antonini, A., Poewe, W., Standaert, D., Odin, P., Zamudio, J., & Bergmann, L. (2018). A long-term study on effectiveness of levodopa-carbidopa intestinal gel treatment in advanced Parkinson’s disease patients. Neurology, 90(15), 66.

Chekani, F., Bali, V., Aparasu, R., & Mullen, P. D. (2016). A systematic review of the impact of adjuvant antiparkinson medications on disability and quality of life of patients with Parkinson’s disease. Value in Health, 19(3), 67-78.

Ferrazzoli, D., Ortelli, P., Zivi, I., Cian, V., Urso, E., Ghilardi, M. F., … Frazzitta, G. (2018). Efficacy of intensive multidisciplinary rehabilitation in Parkinson’s disease: A randomised controlled study. Journal of Neurology and Neurosurgical Psychiatry, 89(8), 828-835.

Fludrocortisone uses, side effects & warnings. (2018). Web.

Liu, Y., Li, W., Tan, C., Liu, X., Wang, X., Gui, Y., … Chen, L. (2014). Meta-analysis comparing deep brain stimulation of the globus pallidus and subthalamic nucleus to treat advanced Parkinson disease. Journal of Neurosurgery, 121(3), 709-718.

Monoamine oxidase inhibitors (MAOIs). (2018). Web.

Parkinson’s Foundation. (2017). Stages of Parkinson’s. Web.

Paul, S. S., Harvey, L., Canning, C. G., Boufous, S., Lord, S. R., Close, J. C. T., & Sherrington, C. (2017). Fall‐related hospitalization in people with Parkinson’s disease. European Journal of Neurology, 24(3), 523-529.

Radder, D. L. M., Sturkenboom, I. H., van Nimwegen, M., Keus, S. H., Bloem, B. R., & de Vries, N. M. (2017). Physical therapy and occupational therapy in Parkinson’s disease. The International Journal of Neuroscience, 127(10), 930-943.

Rivaroxaban uses, side effects & warnings. (2018). Web.

Swearingen, P. (2004). All in one care planning resource. St. Louis, MO: Mosby.

Toole, M. (ed.). (2013). Mosby’s dictionary of medicine, nursing & health professions. 9th ed. St. Louis, MO: Elsevier Health Sciences.

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