parkinson - Nursing Case Study

Pathophysiology

• Primary mechanism: Parkinson's disease primarily results from the death of dopamine-producing cells in the substantia nigra, a part of the brain that controls movement. Less dopamine in this area leads to abnormal brain activity, causing impaired movement and other symptoms.

• Secondary mechanism: The disease also involves the accumulation of protein particles called Lewy bodies in the brain cells. These particles contain a protein called alpha-synuclein, which is linked to Parkinson's disease and other dementias.

• Key complication: As Parkinson's progresses, it may lead to cognitive problems, including dementia and memory loss, which are often severe. These are due to the spread of Lewy bodies to other areas of the brain.

Patient Profile

Demographics:

68-year-old male, retired factory worker

History:

• Diagnosed with Parkinson's disease 6 years ago

• Currently on Carbidopa-Levodopa, Rasagiline, and Amantadine

• No known drug allergies

Current Presentation:

• Chief complaint of worsening tremors and difficulty in walking

• Key symptoms include increased stiffness in limbs, slurred speech, impaired balance and coordination, constipation, and cognitive difficulties

• Vital signs reveal a resting heart rate of 90 beats per minute, blood pressure of 140/90 mmHg, respiratory rate of 18 breaths per minute, and oxygen saturation of 96% on room air.

Section 1

Change in Patient Status:

Over the following week, the patient's condition begins to worsen. His motor symptoms, such as tremors and stiffness, become more pronounced, particularly in the morning hours. These symptoms are disrupting his ability to perform basic activities of daily living independently, such as feeding himself and getting dressed. His speech becomes more slurred and harder to understand, and he has also become increasingly lethargic and withdrawn, showing less interest in activities he previously enjoyed. At the same time, he has been experiencing vivid dreams and hallucinations, particularly at night.

In addition to these changes, the patient's cognitive difficulties have also escalated. He has shown a marked decrease in his short-term memory and is having trouble with basic problem-solving tasks. He seems to be easily confused and disoriented, particularly in the late afternoon and evening. His family also reported that he occasionally doesn't recognize familiar faces, including his own children. These changes in his cognitive and emotional state suggest the possible development of Parkinson's disease dementia, a common but severe complication of Parkinson's. The healthcare team must reassess his current treatment regimen and consider additional interventions to manage these new complications.

Section 2

New Diagnostic Results:

Upon reassessment, the patient's Mini-Mental State Examination (MMSE) score has declined significantly from 26 to 19 over a short period, indicating a rapid cognitive decline. The results of his neuropsychological tests further confirm this cognitive impairment, particularly in areas of attention and executive functioning. His motor symptoms have also worsened as reflected by a higher Unified Parkinson’s Disease Rating Scale (UPDRS) score of 45, compared to 35 during his last assessment.

Further, lab results reveal a notable rise in C-reactive protein (CRP) levels to 12 mg/L, indicating a possible underlying systemic inflammation. His complete blood count (CBC) and electrolyte panel return within normal limits, ruling out any immediate metabolic abnormalities. However, an observed decrease in his leukocyte count suggests a possible risk for infection. The diagnostic results thus indicate that the patient's Parkinson's disease is progressing more rapidly than initially expected, warranting a reevaluation of his current treatment plan. This new information presents a critical opportunity for the healthcare team to intervene and slow the progression of the disease, while also managing the patient's increasing cognitive and motor impairments.

Section 3

The patient's status has notably declined, with an increase in both cognitive and motor impairment. He exhibits a marked increase in bradykinesia and rigidity and has developed a shuffling gait, making ambulation challenging and increasing his risk for falls. His cognitive impairment is also more pronounced, with difficulty concentrating, increased forgetfulness, and a noted difficulty in performing tasks that require executive functioning such as managing finances and medications.

In response to these changes, the healthcare team has implemented several interventions. His medication regimen has been adjusted, increasing the dose of his carbidopa-levodopa and adding a dopamine agonist to help manage his motor symptoms. In addition, a physiotherapist has been consulted to initiate a tailored exercise program to improve his strength and balance, with the aim to prevent falls and maintain mobility. The patient has also been referred to a speech therapist due to mild dysphagia and a noticeably softer voice. Despite these interventions, the patient's overall condition continues to decline, and he is showing signs of frustration and depression, indicating a possible need for psychological support.

The new complication that has arisen is the patient's susceptibility to infection due to a decreased leukocyte count. In the context of his elevated CRP levels, this poses a significant health risk. This necessitates close monitoring of his vital signs, particularly his temperature, and any signs of infection such as increased fatigue, changes in behavior, or localized pain and redness. It also underscores the importance of implementing infection control measures such as hand hygiene and potentially isolation precautions. This new complication further complicates the management of his Parkinson's disease and will require careful clinical reasoning and a multidisciplinary approach to care.

Section 4

Despite implementing infection control measures, the patient has developed a persistent low-grade fever, with a temperature of 38.2°C. He also complains of increased fatigue and a new, localized pain in his left lower leg. On examination, the left lower leg appears red and warm to touch, with slight swelling. Additionally, the patient is increasingly confused, a change from his usual cognitive impairment. His latest blood work shows a further decrease in leukocyte count from 3.0 x 10^9/L to 2.2 x 10^9/L, and a rise in CRP levels from 18 mg/L to 32 mg/L, suggesting a developing infection.

Further investigations are ordered, including a Doppler ultrasound of the left leg to rule out a deep vein thrombosis, and blood cultures to identify any bacterial infection. The patient's increased confusion could indicate sepsis, a serious complication which can occur if an infection spreads to the bloodstream. To manage this potential sepsis, the healthcare team implements the Sepsis Six pathway, which includes delivering high flow oxygen, obtaining blood cultures, administering broad-spectrum antibiotics, fluid resuscitation, measuring serum lactate and haemoglobin, and continuous monitoring of urine output. This new complication requires immediate intervention and careful clinical reasoning to manage the infection while also considering the patient's underlying Parkinson's disease.

Section 5

The Doppler ultrasound confirms the suspicion of deep vein thrombosis (DVT) in the patient's left lower leg. The blood cultures also reveal the presence of Staphylococcus aureus, a common bacteria known to cause infections, which in this case, has likely entered the bloodstream, causing sepsis. The patient's condition deteriorates slightly, with increasing confusion and fatigue, heart rate of 110 bpm, blood pressure of 90/60 mmHg, respiratory rate of 22 breaths per minute, and oxygen saturation of 92% on room air. His temperature continues to hover around 38.5°C despite antipyretics and cooling measures.

The healthcare team's immediate priorities shift to treating the DVT and sepsis concurrently. With the confirmation of DVT, the team initiates anticoagulation therapy with low molecular weight heparin to prevent further blood clot formation. Broad-spectrum antibiotics are switched to a targeted regimen for Staphylococcus aureus to combat the sepsis. The patient is also given intravenous fluids to improve his blood pressure and oxygen to address the hypoxia. These interventions need to be carefully balanced with the patient's Parkinson's disease management, factoring in potential drug interactions and the risk of exacerbating Parkinson's symptoms. The patient's condition and response to these interventions will need to be closely monitored. The ongoing challenge for the healthcare team is to manage the patient's acute condition while avoiding exacerbation of his chronic neurological disease.