Nursing: Clinical Case Report

Nursing 1.
NURSING: CLINICAL CASE REPORT
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Nursing 2.
Introduction
The case report provides a medial assessment analysis of Mrs. Jessica George who is 79 years
old patient. She is married to Frank (60 years) her husband who also serves as her primary
caregiver. According to her health status assessment she was diagnosed with Parkinson Disease
(PD) in the last 15 years and she has been receiving treatment from both the Critical Brook and
District Hospitals for Respite care. Based on her medical she does not show any other medical
history however her mother died of Pneumonia at the age of 80 years and had suffered from PD
for 30 years. Her case, therefore, requires some nursing intervention based on the findings from
the assessment report based on her medical history, her general appearance assessment; her
medical believe and clinical assessment by providing pathophysiological patient-centered
nursing care. The purpose of this report will, therefore, be to provide an effective
pathophysiological nursing intervention that will help to solve the identified nursing problems in
the patient case. The structure of the report will involve the analysis of the primary admission
diagnosis of the patient, identification of nursing problems based on the assessment report,
nursing management and development of a discharge plan as well as a summary of the
significant findings of the report.
Primary Admission Diagnosis
Mrs. Jessica was diagnosed with Parkinson Disease (PD) 15 years ago which is the reason why
she has been admitted to the hospital for treatment. This disease refers to a neurodegenerative
disorder, which affects an individual motor function through a progressive deterioration as a
result of the loss of dopamine-producing brain cells. It is, therefore, the second most common
neurodegenerative disorder as well as the most common movement disorder in individuals which
is usually detected at the ages of 60 years and above (Postuma 2016, 196). Pathophysiology

Nursing 3.
refers to the functional changes that accompany a particular syndrome or a disease and therefore
based on the assessment report of the patient; this report will be able to analyze the common
nursing problem facing the patient and the necessary nursing management practice towards an
effective patient-centered nursing care approach. These symptoms will, therefore, help us
understand if the patient has been receiving the appropriate medical attention towards the
treatment of Parkinson Disease which is a neurodegenerative disorder.
The primary patient diagnosis revealed that she was becoming more alert and anxious with a
noticeable tremor in her upper limp. She was also speaking in a horse and monotonous voice and
that she also complain of constipation. The assessment also revealed that the patient she could
cough whenever she is given some water to drink, but she believed that the effectiveness of the
levodopa therapy started to wear off after 4 hours. The clinical assessment also revealed that she
had normal blood pressure (120/72) with a regular respiratory rate of 16 and a heart rate of 82
with a regular rhythm. It was also noted from her physical assessment that she was able to arise
from a chair without pushing off with her hand. However, her movements were slow and rigid,
and drag or scuffing was noted on her left foot. The clinical assessment was able to reveal that
she had a recent fall at home and therefore she was able to sustain bruises and a skin tear to her
left lateral lower leg. Therefore the findings from the assessments and observation have been
able to demonstrate various symptoms which support the previous diagnosis that the patient has
Parkinson Disease. This is because the assessment results were able to present some of the
primary and secondary symptoms of the diagnosed disease such as increased anxiety, tremors,
postural instability, bradykinesia, constipation as well as dementia and skin problems.