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TABLE OF CONTENTS

PAGE

Chapter I: INTRODUCTION

A. Background of the Study....................................................................... 1

B. Rationale for Choosing the Case............................................................ 2

C. Significance of the Study....................................................................... 2

D. Scope and Delimitation.......................................................................... 3

Chapter II: HEALTH HISTORY

A. General Data.......................................................................................... 3

B. Chief Complaint..................................................................................... 4

C. History of Present illness........................................................................ 4

D. Past Medical History.............................................................................. 4

E. Familial History..................................................................................... 4

F. Social History........................................................................................ 5

G. Obstetrics History…………………………………………………….. 5

H. Physical Assessment.............................................................................. 5

Chapter III: DISCUSSION OF THE DISEASE

A. Pathophysiology................................................................................... 15

B. Drug Study........................................................................................... 14

C. Diagnostic and Laboratory Exam......................................................... 23

Chapter IV: NURSING PROCESS

A. Problem List............................................................................................ 25

B. Nursing Care Plan................................................................................... 26

C. Discharge Plan........................................................................................ 29

Chapter I:

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INTRODUCTION

A. BACKGROUND OF THE STUDY

Parkinson’s disease is a slow progressing neurologic movement disorder that

eventually leads to disability. The degenerative or idiopathic form is the most common; there is

also a secondary form with a known or suspected cause. Although the cause of most cases is

unknown, research suggest several causative factors, including genetics, arthrosclerosis,

excessive accumulation of oxygen free radicals, viral infections, head trauma, chronic

antipsychotic medication use and some environmental exposures. Parkinsonian symptoms

usually appear in the fifth decade of life; however, cases have been diagnosed at the age of 30

years. It is the fourth most common neurodegenerative disease. Parkinson’s disease affects men

more frequently than women and nearly 1% of the population older than 60 years of age. (Gray

& Hildebrand, 2000)

Parkinson’s disease has a gradual onset and symptom progress slowly over a chronic,

 prolonged course. The three cardinal signs are tremor, rigidity, and bradykinesia (abnormally

slow movement). Other features include hypokinesia, gait disturbances, and postural instability

(Gray & Hildebrand, 2000)

Laboratory test and imaging studies are not helpful in the diagnosis of Parkinson’s

disease, although PET scanning has been used in evaluating Levodopa (precursor of dopamine)

uptake and conversion to dopamine I the corpus striatum. (Freed et al., 2001) Currently the

disease is diagnosed clinically from the patient’s history and the presence of two or the three

cardinal manifestations: tremor, muscle rigidity, and bradykinesia.

Early diagnosis can be difficult because the patient can rarely pinpoint when symptoms

started. Often a family member notices a change such as stooped posture, a stiff arm, a slight

limp, tremor or slow, small handwriting. The medical history, presenting the symptoms,

neurologic examination, and response to pharmacologic management are carefully evaluated

when making the diagnosis.

B. RATIONALE FOR CHOOSING THE CASE

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Parkinson’s disease strikes 2 in every 1,000 people, most often developing in

those older than age 50; however, it also occurs in children and young adults. Because of 

increased longevity, this amounts to roughly 60,000 new cases diagnosed annually in the

Philippines. Incidence increases in persons with repeated brain injury, including professional

athletes, and persons using psychoactive substances, whether prescribed or illicit. Knowing that

Parkinson’s disease is a disease that leads to disability and the fourth most common

neurodegenerative disease, it has been decided to explore this case because it is a one of the

leading neurodegenerative disease in our country.

In studying this case, the researchers are able to gain knowledge. Having an in

depth knowledge lets the health practitioner to give quality nursing care for the patient. The

health practitioner can also contribute in alleviating the disease through client health education

about dengue. This study could also evaluate and help on the modification of certain practices

regarding the care for clients suffering on Parkinson’s disease.

C. Significance of the study:

This study intends to provide information in rendering nursing care for clients with

Parkinson’s disease. Comprehending different information about Parkinson’s disease would be a

great help for the following people:

First of all, for the clients, this study will facilitate the patient better understanding of his

condition. Due to this aggravation of his or her condition will be prevented.

For the family, this study will help the family to be aware of the condition of their relative. By

doing this, It would be easy to gain the family’s cooperation in treating the illness for faster 

recovery of the client.

Another is for the nurses; this study will assist the nurses to render quality care for the clients

with Parkinson’s disease. This will also facilitate a good health teaching about the illness. This

would also help them restore the client in his or her optimum level of functioning.

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For the Community, this study will provide them information to prevent occurrence of 

Parkinson’s disease. It can also help them understand the client who is experiencing this kind of 

disease of disease and thus helping the client to recover faster.

Lastly, for the Future Researchers, this study will serve as a guide for the future researchers.

They can also research for more information that will develop this research.

D. Scope and delimitation

This case study focuses on Parkinson’s disease. This includes the vital information such

as patient’s profile, nursing health history, nursing assessment, clinical examinations the client

has undergone. The pathophysiology of the case was also included in the study.

This case study includes only information about Parkinson’s disease and the quality care

to be given to the patient. The quantity and quality of information is limited on the client,

significant others and client’s medical records that served as basis for this case study.

CHAPTER II

HEALTH HISTORY

A. GENERAL INFORMATION

 Name: Patient AL

Date of Birth: April 11, 1935

Age: 75 years old

Address: Quezon City

Religion: Roman Catholic

Source of Information: Patient’s Chart and Information from the relatives4

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Date of Admission: March 13, 2011

Time of Admission: 9:00 AM

Gender: Female

Civil Status: Widowed

 Nationality: Filipino

Occupation: None

B. CHIEF COMPLAINT

DOB

C. HISTORY OF PRESENT ILLNESS

Admitting case of 75 years old, female, known hypertension, known diabetes

mellitus admitted for observation. She was diagnosed of Parkinson’s disease for 20 years,

maintained in Carbidopa and Levodopa promifexate (Siprol) for 20 years. Patient is on drug

holiday of anti-Parkinson’s disease, admission for due observation.

D. PAST MEDICAL HISTORY

  Patient AL has hypertension and diabetes mellitus but no known asthma and

allergies of any kind. She is diagnosed of having Parkinson’s for 20 years.

E. FAMILIAL HISTORY

Patient AL has no history of Hypertension, asthma and has no known allergies of 

any kind in both the mother and father side. However, there is history of pulmonary

tuberculosis on the mother side and a history of kidney disease and arthritis on the

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father’s side. She is also diagnosed of diabetes mellitus but has no known familial history

of it.

F. SOCIAL HISTORY

Patient AL is non-alcoholic and non-smoker 75 years old women.

G. OBSTETRICS HISTORY

G5P5

H. PHYSICAL ASSESSMENT

General Survey

Patient’s Name: Patient AL

Age: 75 years old

Ward: MCU General Pay Ward

V/S

BP: 130/90

Temp.: 36.6

PR: 82

RR: 18

Date Assessed: March 15, 2011

Shift: 7:00AM – 2:00PM

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H. PHYSICAL EXAMINATION

BODY PART

EXAMINED

TECHNIQUES ACTUAL

FINDINGS

INTERPRETATION

HEAD

SKULL

Size, shape,

symmetry

Palpation, and

inspection

Rounded, smooth

skull contour 

 NORMAL

Presence of nodules,

masses and

depressions

Palpation, and

inspection

Absence of nodules

and masses

 NORMAL

SCALP

Color and

appearance

Inspection Color same as facial

skin

 NORMAL

Area of tenderness Palpation and

inspection

  No signs of  

tenderness

 NORMAL

HAIR 

Evenness of growth,

thickness of  

thinness

inspection Unevenly

distributed hair and

Falling hair 

ABNORMAL

Falling hair because

of ageing and

nutritional

deficiency.

Texture of oiliness

over the scalp

inspection Silky, smooth

resilient

 NORMAL

FACE

Facial features,

symmetry of facial

movements

inspection Symmetric facial

movements

 NORMAL

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EYES

VISUAL FIELDS

Peripheral fields Inspection Able to see objects

in the peripheral

 NORMAL

EARS

AURICLES

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EYEBROWS

Hair distribution,

alignment, skin,

quality, and

movement

inspection Evenly distributed

hair, intact skin,

symmetrically

aligned, equal

movement

 NORMAL

EYELASHES

Hair distribution, and

direction of curl

Inspection Evenly distributed

hair, curled outward

 NORMAL

IRIS

Shape and color Inspection Round and black NORMAL

PUPILS

Shape and color Inspection

(PERRLA)

Round and black NORMAL

Elasticity Inspection

(PERRLA)

 Normal elasticity NORMAL

Visual acuity Inspection

(PERRLA)

  Normal visual

equity

 NORMAL

CORNEA

Curvature Inspection Even curvature of  

the cornea

 NORMAL

Aligned and

coordination

Inspection Both eyes move in

 parallel alignment

 NORMAL

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SALIVARY GLANDS

Color Inspection Same color of buccal

mucosa and floor of 

mouth

 NORMAL

TONSILS

Color, size,

discharge

Inspection Tonsils are pink, no

discharge and normal

size

 NORMAL

Gag reflex Inspection Present NORMAL

MOUTH

LIPS

Symmetry of  

contour, color and

texture

Inspection Smooth and moist lips NORMAL

TEETH

Color, number and

condition and

 presence of dentures.

Inspection White to yellowish in

color, shiny tooth

enamel, no intact

dentures

 NORMAL

NECK AND LYMPH NODES

Movement andcoordination

Inspection Discomfort uponexertion to face to the

right

ABNORMAL  because of rigidity

of the muscles due

to decrease

dopamine.

Flexion Inspection Difficulty in moving

towards the right

direction

ABNORMAL

  because of  

depletion of  

dopamine which is

responsible for 

muscle contraction.

Appearance Inspection No lesions NORMAL

LYMPH NODES

Tenderness Inspection and Absence of tenderness NORMAL

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 palpation

Presence of lymph

nodes

Inspection and

 palpation

Lymph nodes are

 palpable

ABNORMAL

SKIN

Presence of edema Inspection and

 palpation

 No edema NORMAL

Lesions according to

location distribution,

color, configuration,

size, shape, type of 

structure

Inspection No lesions or abrasions NORMAL

Skin moisture Inspection Slightly dry skin NORMAL

Skin temperature Inspection and

 palpation

Uniform in temperature

and within normal range

 NORMAL

Skin Inspection Absence of rashes NORMAL

NAILS

Fingernail plate

shape

Inspection Convex curvature: angle

of nail plate about 160

degrees

 NORMAL

Fingernail plate and

toenail bed color 

Inspection Pinkish color NORMAL

Fingernail and

toenail texture

Inspection and

 palpation

Smooth in texture NORMAL

Tissue surrounding

nails

Inspection Intact epidermis NORMAL

Presence of  

capillaries

Inspection Highly vascular, prompt

return of pink  

color(<2secs)

 NORMAL

UPPER EXTREMITIES

Arms and forearms Inspection With tremors ABNORMAL

  because of  

imbalance between

acetylcholine

(excitatory) and

dopamine

(inhibiting).

CHEST

Symmetry Inspection, and Symmetric, ribs are NORMAL11

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 palpation sloped downward at 45

degree angle relative to

the spine muscle

development is equal,

anteroposterior to

transverse diameter in

ratio 1:2

Alignment of the

chest

Inspection and

 palpation

Vertically aligned NORMAL

Chest expansion Inspection Expand freely and

without difficulty

 NORMAL

ABDOMEN

Symmetry Inspection Uniform in color NORMAL

LOWER EXTREMITIES

Legs and Thighs Inspection Rigid; cannot flex or  

extend

ABNORMAL due

to decrease

dopamine that is

responsible for 

contraction.

Complexion Inspection Uniform in color NORMAL

Movement of lower 

extremities

Inspection With tremors ABNORMAL due

to imbalance

 between

acetylcholine and

dopamine.

A. MEDICAL DIAGNOSIS

Parkinson’s disease and diabetes mellitus

CHAPTER III:

DISCUSSION OF THE DISEASE

A. REVIEW OF ANATOMY AND PHYSIOLOGY

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The adrenal glands (also known as suprarenal glands) are endocrine glands that sit on

top of the kidneys; in humans, the right suprarenal gland is triangular shaped while the left

suprarenal gland is semilunar shaped. They are chiefly responsible for releasing hormones in

conjunction with stress through the synthesis of corticosteroids such

as cortisol and catecholamines, such as epinephrine. Adrenal glands affect kidney function

through the secretion of aldosterone, a hormone involved in regulating plasma osmolarity.

Anatomically, the adrenal glands are located in the retroperitoneum situated atop

the kidneys, one on each side. They are surrounded by an adipose capsule and renal fascia. In

humans, the adrenal glands are found at the level of the 12th thoracic vertebra. Each adrenal

gland is separated into two distinct structures, the adrenal cortex and medulla, both of which

 produce hormones. The cortex mainly produces cortisol, aldosterone, and androgens, while the

medulla chiefly produces epinephrine and norepinephrine and dopamine. The combined weight

of the adrenal glands in an adult

human ranges from 7 to 10 grams.

Cortex

The adrenal cortex is devoted to the synthesis of corticosteroid hormones. Specific

cortical cells produce particular hormones including cortisol, corticosterone, androgens such

as testosterone, and aldosterone. Under normal unstressed conditions, the human adrenal glands

 produce the equivalent of 35–40 mg of cortisone acetate per day. In contrast to the direct

innervation of the medulla, the cortex is regulated by neuroendocrine hormones secreted by

the pituitary gland and hypothalamus, as well as by the renin-angiotensin system.

The adrenal cortex comprises three zones, or layers. This anatomic zonation can be appreciated

at the microscopic level, where each zone can be recognized and distinguished from one another 

  based on structural and anatomic characteristics. The adrenal cortex exhibits functional 

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 zonation as well: by virtue of the characteristic enzymes present in each zone, the zones produce

and secrete distinct hormones.

Zona glomerulosa (outer)

The outermost layer, the zona glomerulosa is the main site for production

of mineralocorticoids, mainly aldosterone, which is largely responsible for the long-

term regulation of blood pressure.

Zona fasciculata

Situated between the glomerulosa and reticularis, the zona fasciculata is

responsible for producing glucocorticoids, chiefly cortisol in humans. The zona

fasciculata secretes a basal level of cortisol but can also produce bursts of the hormone in

response to adrenocorticotropic hormone (ACTH) from the anterior pituitary.

Zona reticularis

The inner most cortical layer, the zona reticularis produces androgens,

mainly dehydroepiandrosterone (DHEA) and DHEA sulfate (DHEA-S) in humans.

Hormones secreted by the Adrenal Cortex

Glucocorticoids: The name glucocorticoid is formed of three words i.e. glucose, cortex and

steroid.

Mineralocorticoids: Includes Aldosterone, Progesterone and deoxycorticosterone.

Androgens: The word androgen is an umbrella term used for different hormones responsible for 

the development of male characteristics This hormone is produced as intermediate chemical in

the process that yields testosterone. It is a 19-carbon steroid hormone.

Medulla

The adrenal medulla is the core of the adrenal gland, and is surrounded by the adrenal

cortex. The chromaffin cells of the medulla are the body's main source of the

circulating catecholamines adrenaline (epinephrine) and noradrenaline (norepinephrine). Derived

from the amino acid tyrosine, these water-soluble hormones are major hormones underlying

the fight-or-flight response.

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To carry out its part of this response, the adrenal medulla receives input from

the sympathetic nervous system through preganglionic fibers originating in the thoracic spinal 

cord from T5–T11. Because it is innervated by preganglionic nerve fibers, the adrenal medulla

can be considered as a specialized sympathetic ganglion. Unlike other sympathetic ganglia,

however, the adrenal medulla lacks distinct synapses and releases its secretions directly into the

 blood.

Hormones secreted by the Adrenal Cortex

Epinephrine- (also known as adrenaline) is a hormone and a neurotransmitter .  It increases

heart rate, constricts blood vessels, dilates air passages and participates in the fight-or-flight 

response of thesympathetic nervous system. Chemically, epinephrine is a catecholamine,

a monoamine produced only by the adrenal glands from the amino 

acids  phenylalanine and tyrosine.

Norepinephrine- norepinephrine also underlies the fight-or-flight response, directly

increasing heart rate, triggering the release of glucose from energy stores, and increasing blood

flow to skeletal muscle. It increases the brain's oxygen supply. Norepinephrine can also

suppress neuroinflammation when released diffusely in the brain from the locus ceruleus. 

Dopamine- is a catecholamine, from which other important catecholamines

(adrenaline and noradrenaline) are derived, but it is also an important neurotransmitter in its own

right, especially in the brain. Of particular importance are central nervous pathways involved

with the co-ordination of movement and with behavior and emotion.

CHAPTER III

A. PATHOPHYSIOLOGY

Modifiable Factors Non-modifiable

Factors

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Environmental factors,

atherosclerosis,

Diabetes mellitus

Genetics and age

Destruction of Dopaminergic neuronal cells in

the substantia nigra in the basal ganglia

Depletion of dopamine storesDegeneration of the dopaminergic nigrostriatal

athwa

Imbalance of excitatory (acetylcholine) and

inhibiting (dopamine) neurotransmitters in the

More excitato

ry neurotransmitters than

inhibiting transmitters leading to imbalance

that affects voluntary movement

Impairment of extrapyramidad

tract controlling complex body

movements

Parkinson’s disease  TremorsRigidity

Bradykinesia Decrease ArmDifficulty in

Loss of balance

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B. DRUG STUDY

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D. LABORATORY AND DIAGNOSTIC STUDIES

Urinalysis

Clinical chemistry

Complete Blood Count

Result Unit Reference Value

Erythrocytes NUMC 4.03 X10’’ 12/L 4.6 – 6.20 x 10’’

12/L

Hemoglobin 12.60 g/dl 13.5-18.0 g/dl

Hemoglobin SUBSTC 1.953 Mmol/L 2.09-2.79 mmol/L

Erythrocytes VOLFR 0.37 0.42-0.50

Leukocytes NUMC 7.2 x 10’’a/L 4.5-

11x10’’g/L

Results Unit Reference Value

Segmenters 0.60 0.56

Lymphocytes 0.34 0.34

Monocytes 0.1 0.04

Thrombocytes NUMC Adequate X10’’g/L

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150-400x 10’’ g/L

MCV 92.8 Fl 80-96 fl

MCH 31 Pg 27-31pg

MCHC 0.34 0.04

Patient AL has decreased erythrocytes and hemoglobin count. On the other hand,

her leukocyte count particularly the segmenters has an increased value.

A decrease RBC is usually seen in anemia of any cause with the possible exception of 

thalassemia minor, where a mild or borderline anemia is seen with a high or borderline-high

RBC.

Below normal hemoglobin may lead to anemia that can be the result of iron deficiency or 

other deficiencies such as B12 and folate, inherited hemoglobin defects, such as sickle cell

anemia or thalassemias, other inherited conditions, such as enzyme defects, cirrhosis of the liver,

excessive bleeding, excessive destruction RBC, kidney disease other chronic illnesses, bone

marrow failure or aplastic anemia, or cancers that affect the bone marrow.

An increase WBC count is indicative of infection. Furthermore, there is an increase in the

segmenters count with acute infections especially when caused by bacteria, trauma or surgery,

leukemia, malignant disease, necrosis.

Clinical Chemistry

SI CONVENTIONAL

FBS 4.70mmol/L 85.45 mg/dl

Cholesterol 4.60mmol/L 177.84 mg/dl

HDL-Cholesterol 1.48 mmol/L 131.56 mg/dl

LDL- direct 2.68 mmol/L 103.61 mg/dl

VLDL .67 225.90 mg/dl

SGOT 14.40 U/L

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- Rigidity of the lower 

extremities

- Difficulty in

swallowing

- Difficulty in speaking

- Dependency on

significant others when

feeding.

- Impaired walking

- Impaired swallowing

- Impaired verbal

communication

- Self-care deficit: Feeding

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COURSE IN THE WARD:

Patient AL, a 75 years old female with known hypertension, diabetes mellitus and

was admitted for observation. She was diagnosed of Parkinson’s disease for 20 years,

maintained in Carbidopa and Levodopa promifexate (Siprol) for 20 years. Patient is on

drug holiday of anti-Parkinson’s disease, admission for due observation.

March 15, 2011

  Receive patient conscious and coherent, comfortably lying in her bed with no

contraptions attached; I and O monitoring qshift, vital signs monitoring q4. The patient

shows no signs of DOB, but complaints of her difficulty in swallowing.

E.DISCHARGE PLAN

M - Instructed the patient to continue medication as ordered

• Metformin Hydrochloride 500mg/tab

• Carbidopa 25 mg 3-4 times a day

• Levodopa

• Felodipine 5mg/tab

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