Gerry Altmiller EdD APRN ACNSBC You are assigned to care for Mr Conley age 70 who was admitted to your unit postoperative yesterday for excision of a strangulated inguinal hernia His VS are stable IVF infusing D545 NS at 100mlhr bowel sounds have returned and his surgical si ID: 670314
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Unfolding Case Study:Applying the QSEN Competencies to the care of Patients with Parkinson’s Disease
Gerry
Altmiller
,
EdD
, APRN, ACNS-BCSlide2
You are assigned to care for Mr. Conley, age 70, who was admitted to your unit post-operative yesterday for excision of a strangulated inguinal hernia. His VS are stable, IVF infusing D5.45 NS at 100ml/hr, bowel sounds have returned, and his surgical site is clean, dry, and intact. He is ordered percocet for pain PO PRN and and is currently pain free. He is beginning a clear liquid diet this am.
His past medical history includes mild hypertension, benign prostatic hypertrophy, degenerative joint disease, and Parkinson’s Disease.Slide3
QSEN Competency: Teamwork and CollaborationFunction effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
During team huddle with the surgeon and medical resident, you report concerns from the AM assessment which include that Mr. Conley’s speech is slurred, soft, and slow and his face is expressionless with some drooling. He has a noticeable tremor of the right hand. His appearance is thin and frail. Slide4
Theory BurstParkinson’s Disease is a chronic, progressive, neurodegenerative disorder characterized by:Tremor at rest
Pill-rolling, tremor resembles rotary motion; often first sign
Handwriting begins large and trails off
Slowness in initiation of movement (
bradykinesia)
arm swing with walking, swallowing saliva, blinking, blank facial expression, stooped posture
Increased muscle tone (rigidity)
Cog-wheel rigidity; jerking quality to purposeful movementsGeneralized slowness-loss of dopamine, a neurotransmitter in brain needed to initiate movementMore common in menAffects 160 per/100,000; Diagnosis increases with ageNo specific test; diagnosis based on H & P and positive response to antiparkinson’s medicationsSlide5
QSEN Competency: Teamwork and CollaborationFunction effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
The team determines the plan of care for the day is:
Resume PO medications
Sinemet
25mg/100mg CR PO three times daily
Hytrin
2 mg PO at bedtime
Celebrex 100mg PO twice dailyLexapro 10 mg PO dailyOOB x 3
Ambulate as toleratedProgress diet as tolerated; assess swallowing function
Consult Physical Therapy and Speech TherapySlide6
QSEN Competency: SafetyMinimize risk of harm to patients and providers through both system effectiveness and individual performance.
What immediate safety priorities for the day do you identify and why?Slide7
Aspiration riskKnown Parkinson’s Disease-Slurred speech, drooling- control of musclesPost anesthesia
Falls risk
Known Parkinson’s Disease
postural instability
Sticky feet-inability to initiate movementPost-operative/post-anesthesia/bed rest
IV infusing
Frail appearance
Medication risks?Medication Reconciliation NeededSlide8
QSEN Competency: SafetyMinimize risk of harm to patients and providers through both system effectiveness and individual performance.
How will you address the safety concerns?Slide9
To Reduce Risk of AspirationAssess gag reflexOOB to chair for mealsFull Fowler’s position when possible
Speech/swallowing consult
Administer medications on time to improve muscle controlSlide10
To Reduce Risk of FallsOut of bed with assistanceMake position changes slowlyUse of walker to increase stability
Call bell within reach
Use of soled shoes
Ask for Physical Therapy consult
Administer medications on time to improve muscle controlSlide11
QSEN Competency: Evidence-based PracticeIntegrate the best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.
Theory Burst
Staff education regarding Parkinson’s Disease medication therapy
Aimed at correcting imbalance of neurotransmitters in brain-dopamine
Must be on time due to end of dose wear-off
When medications work, the patient is
“on”
and able to initiate movements; Once levels drop, patient experiences “off” time and unable to initiate movementsMedications can cause dyskinesia
Uncontrolled movements of face, eyelids, mouth, tongue, arms, hands, legs, squirming movementsSlide12
Medication Reconciliation
What concerns do you have regarding Mr. Conley’s medications?
Any interactions?
Why these medications for this patient?Slide13
Interactions/CautionsHytrin and Sinemet both cause orthostatic hypotension
Celebrex (NSAID) may decrease effectiveness of
hytrin
Rationales for use in Mr. Conley
Lexapro-many Parkinson’s Disease patients experience depression
Hytrin
-control HTN and decreases symptoms of BPH
Celebrex- Decrease inflammation and pain of degenerative joint diseaseSinemet-Control of Parkinson’s Disease symptomsSlide14
©AltmillerTheory Burst
Medication aimed at Parkinson’s Disease symptom relief:
Sinemet
:
levodopa with
carbidopa
crosses the blood-brain barrier & converts to dopamine.
Carbidopa inhibits an enzyme that would breakdown the levodopaMAO-B Inhibitors: (Eldepryl
, Azilect) inhibit the breakdown of dopamine
COMT inhibitors:
slow the breakdown of
levodopa
, thus prolonging its action
Amantadine
:
promotes effects of dopamineSlide15
Mrs. Conley arrives to assist with Mr. Conley’s hygiene needs. While speaking with you, she states “He hasn’t gotten his pills yet and he didn’t get them yesterday! I am so upset! When he doesn’t get his pills, this is what happens. He didn’t look like this at home.” How should you respond to Mrs. Conley?What actions can you take as his nurse?Slide16
QSEN Competency: Patient Centered CareRecognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient preferences, values, and needs.
Acknowledge concerns
Identify current plan of care for the day
Ask Mr. & Mrs. Conley to contribute to plan and goal development
Ascertain positive gag reflex
Notify pharmacy that
Sinemet
dose is high prioritySlide17
QSEN Competency: Teamwork and CollaborationFunction effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
Mr. Conley’s
Sinemet
CR (sustained release) arrives on the unit.
What important nursing considerations are associated with this medication administration?Slide18
QSEN Competency: SafetyMinimize risk of harm to patients and providers through both system effectiveness and individual performance.
Sustained release meds cannot be crushed or chewed.
Observe for therapeutic effect
dose adjustments are based on patient tolerance.
Observe for “
on-off
” phenomenon-
Unpredictable loss of drug effectiveness which lasts 1 min-1 hour, followed by equally abrupt return of function; may occur with end of dose wear-off.Observe for dyskinesiaFacial grimacing, tongue protrusion, bobbing of head, jerky movements of the arms, legs, torso, extra squirming movements.Make position changes slowly
can cause postural hypotension.Slide19
QSEN Competency: Teamwork and CollaborationFunction effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
The speech therapist arrives and evaluates Mr. Conley with you. She determines that Mr. Conley’s swallowing allows for safe feeding. As she asks him questions, he is slow to answer and Mrs. Conley frequently answers questions for him.
What interventions can you suggest to help improve Mr. Conley’s communication? Slide20
To Improve Communication with Parkinson’s Disease PatientsBe patient-give the patient time to answer even though speech is slow.Do not finish sentences for the patient.
Assist family to understand need to allow patient to speak for him/herself.
Intentional effort to be
loud
Being loud has trickle down effect; requires patient to open mouth more and articulate more
http://lsvtglobal.com/loud-certification Click and scroll down to view Featured VideoSlide21
QSEN Competency: Teamwork and CollaborationFunction effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
The physical therapist arrives to evaluate Mr. Conley with you. It is determined that he can transfer from the bed to the chair with assistance and he should begin chair exercises. Mrs. Conley questions why he has to do this.
What would be the best explanation to provide Mrs. Conley?Slide22
QSEN Competency: Evidence-based PracticeIntegrate the best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.
Theory Burst
Exercise slows progression of the disease
(It is
neuroprotective
)
May need brace to raise front of foot
Isotonic exercises build strengthProvide pictures of exercises to include at homeGait training is essential-take big stepsLSVT Big Training http://lsvtglobal.com/news/video Scroll down to Pre & Post Treatment Example Video and clickSlide23
A regular house diet is delivered for Mr. Conley for lunch. Mr. Conley attempts to eat with assistance from his wife but complains that it is too much work and he is not hungry.Slide24
QSEN Competency: InformaticsUse information and technology to communicate, manage knowledge, mitigate error, and support decision making.
You document the poor intake for lunch in the electronic health record and decide to search for diet information regarding Parkinson’s Disease patients.
What dietary accommodations would be most appropriate for Mr. Conley?Slide25
QSEN Competency: Evidence-based PracticeIntegrate the best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.
Redistributive Diet
the
negative impact protein has on
levodopa
precurser of dopamineProtein impairs levadopa absorption
More protein at the end of day when patient is going to bed; less protein in the day to enhance daytime motor performanceHigh Fiber (to prevent constipation)
Concerns with caffeineCan aggravate symptoms but may help with apathy/drowsiness
Small bites; food that is easy to chew
Adequate hydration
(to prevent constipation and orthostatic
hypotension)
Allow food from home to improve appetite
©AltmillerSlide26
After a few days, Mr. Conley is ready for discharge to home. What important teaching should be included in his discharge instructions?Slide27
Parkinson’s Disease homecare Post-operative care regarding surgical incision siteArrangement of post-discharge office visit
Promote exercise as
neuroprotective
; refer to
http://lsvtglobal.com Encourage loud speaking and big movements
Promote independence
Chairs with arms, raise back legs if needed to assist rising
Evaluate side effects of medsDyskinesia-squirming movements, protrusion of tongue“on-off” effectSlide28
QSEN Competency: Quality ImprovementUse data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems.
After caring for Mr. Conley, what improvements can you suggest for the care of hospitalized Parkinson’s Disease patients?Slide29
QSEN Competency: Quality ImprovementUse data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems.
Take new information to the Falls Prevention Committee to include that Parkinson’s Disease medications must be given on time to prevent “off” times as a falls prevention measure.
Suggest identifying information on chart to ensure hand-off includes falls and aspiration risk for Parkinson’s
Disease patients.
Provide staff education on Parkinson’s Disease; as population ages, there is increasing prevalence.Slide30
The QSEN Competencies1. QSEN Competency: Patient Centered Care
Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient preferences, values, and needs.
2. QSEN Competency: Teamwork and Collaboration
Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
3. QSEN Competency: Evidence-based Practice
Integrate the best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.
4. QSEN Competency: Quality Improvement
Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems.
5. QSEN Competency: Safety
Minimize risk of harm to patients and providers through both system effectiveness and individual performance.
6. QSEN Competency: Informatics
Use information and technology to communicate, manage knowledge, mitigate error, and support decision making.