Case Study 1 Due Tuesday by 11:59pm Points5 Available Feb 13 at 12am Feb 20 at 1
ID: 239612 • Letter: C
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.