WebQuest

Functional Assessment in the Older Adult

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Functional Status Case Study

A 72 year old male came into the office complaining of  tremors, uncontrollable actions and movements, severe depression and demention.   Upon exam, his heart rate is 67 bpm, blood pressure is 96/52,  and a respiratory rate of  18.  His lung sounds are clear and his heart sounds are strong and has a normal rhythm   He states he has been sweating ' a lot" and having trouble sleeping at night.  He notes he is having trouble with day to day activity and having trouble verbally communicating with other.  He states it has only happened in the last 6 months.  

Answer question 1 - 4:  

1.  What types of assessments should be done immediately?
2.  What is a possible medical diagnosis?
3.  What is some possible nursing diagnosis?
4.  What type of assessments would be appropriate for this patient ?  What type of functional status assessment tools would be appropriate? 

The doctor ordered blood work, an xray, CTscan and MRI and with the current signs and symptoms diagnosed the patient with Parkinson Disease.  The doctor started this patient on Carbidopa-levodopa, REQUIP and Cogentin to decrease the side effects of Parkinson disease symptoms.  The doctor and nurse team up to educate the patient on what Parkinson is and how it will affect his functional status in the future.    The nurse creates a pamphlet teaching plan to education the  patient on his disease and what interventions may help to reduce activity intolerance and promoting functional independence.  

The pamphlet reads: 

 Parkinson's is caused by damage to brain cells, specifically in the substance nigra.  A group of cells that regulate the movements that are not desired (involuntary). As a result, the patient can not control / restrain the movements unconsciously. Mechanisms of how the damage was unclear.  Parkinson disease is often associated with abnormalities of neurotransmitters in the brain of other factors such as:  
  • Deficiency of dopamine in the substantia nigra in the brain respond to the symptoms of Parkinson's disease   
  • The underlying etiology may be associated with the virus, genetic toxicity, or other unknown causes 
Signs and Symptoms of Parkinson's Disease

Parkinson's disease had clinical symptoms as follows:
  1. Bradykinesia (slow movement), disappears spontaneously,
  2. Tremor is settled,
  3. Actions and movements are not controlled,
  4. The autonomic nervous disorders (insomnia, sweating, orthostatic hypotension,
  5. Depression, dementia,
  6. Face like a mask (NCP NANDA, 2012). 

Question  5-6: 

5.  What does Carbidopa-Levodopa, REQUIP and Cogentin do for the patient?  
6.  What are some key nursing interventions related to functional status for this patient? 


Within a month of starting to take his medication, the patient sees his symptoms lessen significantly and his blood pressure is now within normal limits of 115/76.   The patient states he is feeling better.   


Answers:

1.  What types of functional assessments should be done immediately?
  1. Assess cranial nerves, cerebral function (coordination) and motor function.
  2. Observation of gait and while performing the activity.
  3. Assess history of symptoms and their effects on body functions.
  4. Assess the clarity and speed of speech.
  5. Assess signs of depression.
2.  What is a possible medical diagnosis?  Parkinson disease

3.  What is some possible nursing diagnosis? Ineffective perfusion,  Activity intolerance, Ineffective breathing pattern, Impaired sleep disturbance, possibly many nursing diagnosis.

4.   Neurological assessments: cranial nerves, mental status assessment, mobility assessment, head to toe physical examination including vital signs, and psychosocial status, lab  Assessments tools used:  Glasgow coma scale, mobility assessment, Lawton IADL's

5. What does Carbidopa-Levodopa, REQUIP and Cogentin do for the patient?  

Levodopa is converted to dopamine via the action of a naturally occurring enzyme called DOPA decarboxylase. This occurs both in the peripheral circulation and in the CNAafter levodopa has crossed the blood brain barrier. Activation of central dopamine receptors improves the symptoms of Parkinson's disease.  However, activation of peripheral dopamine receptors causes nausea and vomiting. For this reason levodopa is usually administered in combination with a DOPA decarboxylase inhibitor (DDCI), in this case carbidopa, which is very polar (and charged at physiologic pH) and cannot cross the blood brain barrier (wikipedia, 2012).  

REQUIP: Requip has some of the same effects as a chemical called dopamine, which occurs naturally in your body. Low levels of dopamine in the brain are associated with Parkinson's disease. Requip is used to treat symptoms of Parkinson's disease, such as stiffness, tremors, muscle spasms, and poor muscle control (Drugs.com, 2012).

Cogentin:  Benztropine reduces the effects of certain chemicals in the body that may become unbalanced as a result of disease (such as Parkinson's), drug therapy, or other causes. It helps treat muscle spasms, stiffness, tremors, sweating, drooling and poor muscle control.  

7.  What are some key nursing interventions related to functional status for this patient? 

1. Impaired physical mobility related to the stiffness and muscle weakness.
Purpose: the client is able to perform physical activity according to ability.
Criteria: the client can participate in training programs, joint contractures did not occur, increased muscle strength and the client indicates an act to meninktkan mobility.
Intervention :
  • Assess existing mobility and the observation of increased damage.
  • Conduct training program increases muscle strength.
  • Encourage warm bath and massage the muscle.
  • Help clients to perform ROM exercises, self-care as tolerated.
  • Collaboration physiotherapists for physical exercise.
2. Self-care deficit related to neuromuscular weakness, decline in strength, loss of muscle control / coordination.
Purpose: self-care are met.
Criteria: the client may indicate a change of life for the needs of self-care, client is able to perform self-care activities in accordance with the level of ability, and identify personal / community that can help.
Intervention
  • Assess the ability and the rate of decline and the scale of 0-4 to perform ADL.
  • Avoid anything that can not be done and help the client if necessary.
  • Collaboration of laxatives and consult a doctor of occupational therapy.
  • Teach and support the client during the client's activities.
  • Environmental modifications.
3. Impaired verbal communication related to the decline in speech and facial muscle stiffness.
Purpose: to maximize the ability to communicate.
Interventions:
  • Keep the complications of treatment.
  • Refer to speech therapy.
  • Teach clients to use facial exercises and breathing methods to correct the words, volume, and intonation.
  • Deep breath before speaking to increase the volume and number of words in sentences of each breath.
  • Practice your talk in short sentences, reading aloud in front of the glass or into a voice recorder (tape recorder) to monitor progress (NCP NANDA, 2012). 

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