Parkinson’s - Nursing Case Study

Pathophysiology

• Primary mechanism: Parkinson's disease primarily involves the degeneration of dopamine-producing neurons in the substantia nigra, a critical area of the brain responsible for regulating movement. This loss of dopamine leads to the hallmark motor symptoms of Parkinson’s, including tremors, rigidity, and bradykinesia.

• Secondary mechanism: Accumulation of Lewy bodies, which are abnormal aggregates of protein, particularly alpha-synuclein, within neurons, contributes to neuronal dysfunction and death. This process further exacerbates the loss of motor control and can also affect cognition and mood.

• Key complication: The progressive decrease in dopamine not only impairs motor function but can also lead to non-motor symptoms such as depression, anxiety, and cognitive decline, significantly affecting the patient's quality of life and necessitating comprehensive nursing care.

Patient Profile

Demographics:

65 years old, male, retired accountant

History:

• Key past medical history: Diagnosed with Parkinson’s disease 5 years ago, hypertension, type 2 diabetes

• Current medications: Levodopa-carbidopa, amantadine, metformin, lisinopril

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing difficulty with movement and balance

• Key symptoms: Resting tremor in the right hand, muscle stiffness, bradykinesia, occasional dizziness, mild memory issues

• Vital signs: Blood pressure 150/95 mmHg, heart rate 92 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F

Section 1

As the nursing team continues to monitor the 65-year-old patient, new complications begin to emerge. During a routine assessment, the patient reports experiencing increased difficulty with speech and swallowing, alongside his existing motor symptoms. These issues suggest a progression in his Parkinson’s disease, potentially indicating the onset of dysphagia and hypophonia, common complications that can arise as the disease advances. The patient also mentions experiencing more frequent episodes of dizziness, which could be indicative of orthostatic hypotension, a condition where blood pressure drops significantly upon standing, often associated with both Parkinson’s and the long-term use of dopaminergic medications.

Clinically, the patient's blood pressure readings show a notable variability, with orthostatic measurements revealing a drop to 110/70 mmHg upon standing. This finding is crucial as it confirms the suspicion of orthostatic hypotension, a factor that can exacerbate his balance issues and increase the risk of falls. Additionally, a neurological exam highlights an increase in bradykinesia and rigidity, as well as a more pronounced resting tremor. These changes necessitate a reassessment of his current medication regimen to optimize symptom control while minimizing side effects.

Given these developments, the healthcare team must engage in careful clinical reasoning to adjust the patient’s care plan. This includes exploring potential medication adjustments, such as altering the dosing schedule of levodopa-carbidopa to better manage his symptoms throughout the day, and considering the addition of medications like fludrocortisone or midodrine to address the orthostatic hypotension. Furthermore, the patient is referred for a speech and swallowing evaluation to mitigate risks associated with dysphagia and to prevent complications such as aspiration pneumonia. These steps are crucial in addressing the new complications and maintaining the patient’s quality of life.

Section 2

A few weeks after the initial adjustments to the patient’s care plan, the nursing team conducts a follow-up assessment to evaluate the response to interventions. The patient reports a slight improvement in his speech clarity and swallowing ability following speech therapy sessions, indicating a positive response to the referral for a speech and swallowing evaluation. However, despite the adjustments in his dopaminergic medication regimen, the patient continues to experience episodes of dizziness, particularly in the morning, suggesting that the orthostatic hypotension remains inadequately managed.

The decision to initiate treatment with fludrocortisone was made to address the orthostatic hypotension, and the patient was advised to increase his fluid and salt intake. Upon re-evaluation, his blood pressure readings show a slight improvement, with standing measurements now at 115/75 mmHg. However, he still experiences dizziness occasionally, especially during prolonged standing. As a result, the healthcare team discusses the possibility of introducing midodrine as an adjunct therapy to further stabilize his blood pressure and minimize the risk of falls.

Meanwhile, the nursing team observes that the patient's motor symptoms, specifically bradykinesia and rigidity, remain persistent, albeit with some fluctuations throughout the day. A recommendation is made to further adjust the timing of levodopa-carbidopa doses to align with his daily activities and reduce off periods. Collaboration with the patient’s neurologist is crucial at this point to refine the medication regimen and consider the potential addition of a dopamine agonist if needed. The focus remains on balancing medication effectiveness with the management of side effects to enhance the patient's functional status and overall quality of life.

Section 3

During a subsequent follow-up visit, the nursing team conducts a thorough assessment to evaluate the patient's response to the modified treatment plan. The patient's blood pressure readings remain relatively stable, with standing measurements averaging around 120/78 mmHg, indicating a positive response to the introduction of midodrine alongside fludrocortisone. Despite this improvement, the patient reports new intermittent episodes of palpitations and mild headaches. The team attributes these symptoms to the vasopressor effects of midodrine, prompting a careful re-evaluation of the dosing schedule to minimize these side effects while maintaining effective blood pressure control.

In addition to the cardiovascular changes, the patient experiences increased fatigue and a noticeable decrease in his ability to initiate movements, particularly in the late afternoon. This suggests that the current levodopa-carbidopa regimen may not be optimally timed to manage his motor symptoms throughout the day. A discussion with the neurologist leads to a decision to introduce a small dose of a dopamine agonist to complement the existing therapy, aiming to smooth out the fluctuations and improve his overall motor function.

Furthermore, the patient has developed mild edema in his lower extremities, raising concerns about fluid retention as a side effect of fludrocortisone. The nursing team collaborates with the interdisciplinary team to adjust his dietary recommendations, focusing on balancing his salt intake with fluid management. These developments highlight the complexity of managing Parkinson’s disease with concurrent conditions, necessitating ongoing adjustments and vigilant monitoring to optimize patient outcomes. This evolving scenario underscores the importance of individualized care plans and the need for regular reassessment to address emerging complications effectively.

Section 4

During the next follow-up appointment, the nursing team conducts a focused assessment on the patient's new complications, particularly the edema and changes in motor function. Upon examination, the patient's blood pressure remains well-controlled with readings averaging 118/75 mmHg, suggesting that the adjusted dosing schedule for midodrine is effective in minimizing palpitations and headaches. However, the patient continues to exhibit mild pitting edema in the lower extremities, with a 2+ rating around the ankles. This prompts the team to further investigate potential fluid overload and electrolyte imbalances.

Laboratory results reveal a slight increase in serum sodium levels at 146 mEq/L, indicating a potential side effect of fludrocortisone's mineralocorticoid activity. Despite the dietary interventions, the patient struggles with maintaining adequate hydration while controlling salt intake. The interdisciplinary team considers the introduction of a mild diuretic to alleviate edema, but this decision is weighed against the risk of exacerbating orthostatic hypotension, a common challenge in Parkinson's management. Meanwhile, the patient's motor symptoms have shown some improvement following the addition of a dopamine agonist, with less pronounced "off" periods in the afternoon, though fatigue remains an issue.

The team engages in a collaborative discussion to address the complexity of these overlapping complications. It becomes evident that a delicate balance is required to manage the interplay between fluid retention, blood pressure stability, and motor function. The decision is made to continue monitoring the patient's response to the dietary changes closely while considering alternative strategies to optimize his medication regimen. This situation highlights the necessity for dynamic clinical reasoning, as the team must constantly evaluate and adjust the treatment plan to account for the multifaceted nature of Parkinson’s disease and its associated comorbidities.

Section 5

Following the discussion, the interdisciplinary team decides to initiate a low-dose thiazide diuretic to address the patient's persistent edema, while maintaining close monitoring for signs of orthostatic hypotension. Over the next few weeks, the patient is instructed to keep a daily log of blood pressure readings, weight, and symptoms, which he shares at the subsequent follow-up appointment. During the visit, the nursing team conducts another focused assessment, noting that the edema has slightly improved, now rated at 1+ around the ankles. However, the patient reports experiencing increased episodes of dizziness, particularly when rising from a seated or lying position, suggesting a potential exacerbation of orthostatic hypotension.

Vital signs reveal a resting blood pressure of 115/72 mmHg, with a significant drop to 100/68 mmHg upon standing, confirming the suspicion of orthostatic changes. Despite the positive impact on edema, this adverse effect prompts the team to reconsider the current diuretic regimen. Lab results show stable serum sodium levels at 144 mEq/L, but potassium levels have decreased to 3.4 mEq/L, indicating mild hypokalemia likely secondary to diuretic use. The patient also mentions feeling more fatigued than usual, raising concerns about the impact of electrolyte imbalances on his overall energy levels and motor function.

In response to these developments, the team engages in a detailed discussion to reassess the treatment plan. They consider adjusting the diuretic dosage and implementing potassium supplementation to mitigate hypokalemia. Additionally, the team explores non-pharmacological interventions, such as compression stockings, to manage orthostatic symptoms without further complicating the fluid and electrolyte balance. This case exemplifies the ongoing need for dynamic clinical reasoning, as the team must continuously adapt the treatment strategy to balance the management of Parkinson’s disease symptoms with the patient's evolving health status and associated complications.