Case Study 1 Due Tuesday by 11:59pm Points5 Available Feb 13 at 12am Feb 20 at 1

Question

Case Study 1 Due Tuesday by 11:59pm Points5 Available Feb 13 at 12am Feb 20 at 11:59pm 8 days A 40 year old complains of slow gait and a hand tremor of a few months duration. HPl. His wife also describes postural instability, drooling of saliva and generalized rigidity. PE. "Mask-like facies; mild involuntary pill-rolling tremor at rest; gait- shortstepped and shuffling. Deep tendon reflex is normal. Plantar responses bilaterally flexed. Lab. N/A Imaging. N/A On gross pathology, there is absence pigment in the substantia nigra. Micro pathology shows presence of Lewy bodies with decreased neurons in the substantia nigra. 1) What would be four nursing differential diagnoses for this patient case? (1.5) 2) Please provide a short term care plan for this patient (1.5pt) 3) Please provide long term care plan for this patient by explaining the rationale behind your protocol. (2pts)

Explanation / Answer

Differential nursing diagnosis:

1.Impaired mobility r/t to muscle rigidity.

2.Impaired verbal communication r/t to dysphonia .

3.self care deficit related to tremor motor disturbance.

4.Risk for aspirations r/t to swallowing deficit.

Short term care plan

1.Impaired breathing pattern

Assess the patient from breathing sounds

Inspect the oral cavity and auscultation over the chest for secretions.

Oral suctioning if required.

Monitor saturation

Chest physiotherapy

Nebulization can be given.

Comfort positions.

Psychological support.

2.Risk for fall r/t to tremor

Assess the patient fall risk score

Provide side railing cot.

Education regarding fall prevention to patient and attenders

Urinals and bed pan to be provided near bedside

Reassess the patient.

Long term care plan:

1.Impaired skin integrity related to prolonged bedridden

Assess the skin integrity score

Provide back care

Comfort positions

Prophylactic measures like alpha bed ,foam dressing

Good nutrition

Hydration level to be met

Good personal hygiene

2.stress related to illness.

Assess the psychological level

Provide diversions like television,read rea books ,listening to music

Rehabilitation for the patients.

Spiritual support.

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