Analysis of Nurse’s Teaching Plan for a Client with Parkinson’s Disease

Introduction

Parkinson’s Disease has devastating effects on the fine and gross motor abilities of a person afflicted with the disease and is linked to dementia and cognitive decline in later stages. One hallmark disturbance in mobility related to Parkinson’s Disease is bradykinesia, or a slowing of movement. Because of this and other cardinal motor signs and symptoms of Parkinson's Disease is directly related to our course content, and exemplar Mobility.

The following pages will detail the nurse’s teaching plan for a client with Parkinson’s Disease including the teaching objectives, teaching content and the evaluation of the client’s learning of said content. This will be done utilizing SMART goals (Specific, Measurable, Attainable, Relevant and Timely) to best serve the client and evaluate the learning.

Pathophysiology

An estimated one million people in the United States are living with Parkinson’s Disease. There are approximately 60,000 people diagnosed with Parkinson’s Disease (PD) every year (Kriebel-Gasparro, 2016). PD is a chronic, progressive and degenerative neurological disease affecting motor and nonmotor functioning and is associated with cognitive decline.

The cause of PD is the death of neurons that produce dopamine in the substantia nigra in the midbrain. These cells are a vital component in voluntary movement, involuntary movement and some cognitive functions. The degeneration of these neurons is what causes the motor deficits in PD. What starts the degeneration of these cells is thought to be largely idiopathic.

The client is a 70-year-old man with a PD diagnosis for several years and is experiencing a worsening of physical symptoms. His risk factors are his gender, age, and his father had PD. He is a retired teacher and Army veteran who currently has no signs of dementia or cognitive impairment. Until recently he has been able to tolerate the physical symptoms (tremors) and remain independent. He lives with his wife; whose health is poor. He is being seen, in the primary care setting, for a fall at home and is receiving a new prescription for carbidopa/levodopa to help enhance the effects of his current medication regimen.

Several goals have been put into place for this high-risk client. The client will need to identify three hazards or obstacles in the home environment that can be remedied before the next office visit. The client will also need to list three appropriate food choices to take carbidopa/levodopa with before the end of the prescribing appointment. In addition, the client should be able to demonstrate at least four of the exercises shown in the exercise video before leaving the office. These objectives all relate to mobility by ensuring safety in mobility, minimizing symptoms that impair mobility, and stalling decline in mobility.

Teaching Content

After his consultation with the physician, the nurse entered the client’s private examination room with a packet of information for him and his wife to take home. The nurse started the teaching session by ensuring that the client understood what PD was and how its progression was leading to an increase in the client’s symptoms. The nurse began explaining how hazards in the client’s home could have interfered with his mobility, causing his fall. These hazards were detailed as loose cords, throw rugs, inadequate lighting, stairs, slick surfaces, and rubber soled shoes.

The client was instructed to remove all tripping hazards from walkways, install nightlights for his trips to the restroom in the middle of the night, keep all daily activities on one level of his home if possible, use grab bars and suction cups non-slip mats in his shower, and avoid any shoes or socks with rubber grips to keep from getting caught on the floor. The client was asked if he had any questions regarding hazards present in his home. The nurse then moved into discussing the client’s new PD medication, carbidopa/levodopa. This medication is being added to his current dose of primidone that he has been taking for his tremor.

The nurse discussed that carbidopa/levodopa would help decrease the destruction of neurotransmitters in the client’s brain, leading to relief of his tremor and less rigidity. The nurse stated common side effects of the medication were nausea, vomiting, involuntary muscle movements, and orthostatic hypotension. The client was encouraged to change positions slowly to avoid an unsafe drop in blood pressure.

The client indicated that he commonly experienced unpleasant gastrointestinal symptoms when he took his current medication on an empty stomach. The nurse verbalized that it was important to take carbidopa/levodopa at regular intervals and gave advice on how to decrease gastrointestinal symptoms. The client was instructed that the medication could be taken with food but only if the food was low in protein. The client stated that since his time in the Army, meat and potatoes or bread were eaten at almost every meal.

The nurse had a printed list of low protein foods for the client that was available in the patient teaching section of the electronic computer system at the office. This list included foods such as apple slices and grapes, raw vegetable slices, Jell-O, vegetable-based soups, and rice. The client was instructed to avoid foods such as cheese, eggs, dairy products, meat, and nuts. The client was able to make notes on the printed list and take it home with him.

In addition to the new medication, the nurse educated the client on the importance of exercising a minimum of 150 minutes per week. The client was told that exercising can improve gait, balance, tremors, flexibility, grip strength, and motor coordination. Physical activity of at least 150 minutes per week has also been associated with lower incidence of depression the nurse stated (Neuroprotective). The nurse was able to play an exercise video on the computer in the examination room that the staff at the office made.

The video demonstrated nine simple exercises that the client could do at home. The client and his wife were able to watch the video in just a few short minutes. The nurse asked if the client would like a physical copy of the video to take home or if he would like an email with a link to access the video via YouTube.

The client stated that he had a DVD player at home and, thus, a physical copy of the video was given to client so that he could refer to the information in the future. The nurse ended the teaching session by asking if the client had any additional questions. The client voiced no concerns, so the nurse gathered all the resources for him to take home and made sure that he knew how to contact the office for any concerns.

Evaluation of Learning

It was evident during the teaching that the client wanted to retain as much independence as possible and was willing to do anything he could to do so. With the client’s teaching background, he understood the importance of the information given. The client stated that when he returned home, he and his wife would immediately remove the throw rug in their bedroom, place a nightlight in the master bathroom, and make sure the cords from the lamp and alarm clock were neatly tucked away behind the nightstand.

Before leaving the office, the client also chose a handful of raisins, rice and vegetable stir-fry, and apple slices from a list of foods that could be eaten with his newly prescribed carbidopa/levodopa. He bypassed foods such as a peanut butter sandwich, bacon and eggs, and yogurt on the list, stating that these foods had high amounts of protein. The client was also able to demonstrate each exercise in the video with much more strength and ability than expected, which he attributed to his military background. He stated that his wife would ensure that exercised at least thirty minutes, five days a week, in order to meet the 150-minute goal.

References

1. Kriebel-Gasparro, A. (2016). Parkinson's disease: Update on medication management. The Journal for Nurse Practitioners, 12(3), e81-e89. doi:http://dx.doi.org/10.1016/j.nurpra.2015.10.020
2. Lee, H. M., & Koh, S. B. (2015). Many Faces of Parkinson's Disease: Non-Motor Symptoms of Parkinson's Disease. Journal of movement disorders, 8(2), 92–97. doi:10.14802/jmd.15003
3. Neuroprotective Benefits of Exercise. (2018, October 17). Retrieved from https://www.parkinson.org/Understanding-Parkinsons/Treatment/Exercise/Neuroprotective-Benefits-of-Exercise
4. Parkinson's: Balance & Preventing Falls. (2014, October 7). Retrieved from https://my.clevelandclinic.org/health/diseases/9390-parkinsons-disease-preventing-falls--maintaining-balance
5. Sonne, J., & Beato, M. R. (2018, December 28). Neuroanatomy, Substantia Nigra. StatPearls. Treasure Island, Florida: StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK536995/
6. Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2017). Davis's Drug Guide for Nurses (15th ed.). Philadelphia: F.A. Davis Company.