Unfolding Case Study:
Applying the QSEN Competencies to
the care of Patients with Parkinson’s
Disease
Gerry Altmiller, EdD, APRN, ACNS-BC
From QSEN
• Unfolding Case Study (from QSEN): Applying the QSEN
Competencies to the Care of Patients with Parkinson’s Disease
• Students will be instructed to review information on Parkinson’s
Disease prior to class by visiting the National Parkinson’s Disease
website http://www.parkinson.org/parkinson-s-disease.aspx.
• This unfolding case study powerpoint presentation will be provided
in class.
• Students will be encouraged to brainstorm to answer the questions
as the case study unfolds.
• Theory bursts are woven throughout the case study. The
presentation includes links to Lee Siverman’s Voice Training (LSVT),
which is a proven program to help patients with Parkinson’s Disease
speak loudly and walk with a more stable gait.
• Following the class session, the case study will be posted for the
class to retrieve so that theory content is available to them.
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.
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.
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.
Theory Burst
• Parkinson’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 movements
• Generalized slowness-loss of dopamine, a neurotransmitter
in brain needed to initiate movement
• More common in men
• Affects 160 per/100,000; Diagnosis increases with age
• No specific test; diagnosis based on H & P and positive
response to antiparkinson’s medications
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.
The team determines the plan of care for the day is:
 Resume PO medications
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

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Sinemet 25mg/100mg CR PO three times daily
Hytrin 2 mg PO at bedtime
Celebrex 100mg PO twice daily
Lexapro 10 mg PO daily
OOB x 3
Ambulate as tolerated
Progress diet as tolerated; assess swallowing function
Consult Physical Therapy and Speech Therapy
QSEN Competency: Safety
Minimize 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?
• Aspiration risk
– Known Parkinson’s Disease– Slurred speech, drooling- control of muscles
– Post anesthesia
• Falls risk
– Known Parkinson’s Disease
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–
–
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• postural instability
• Sticky feet-inability to initiate movement
Post-operative/post-anesthesia/bed rest
IV infusing
Frail appearance
Medication risks?
• Medication Reconciliation Needed
QSEN Competency: Safety
Minimize risk of harm to patients and providers through both
system effectiveness and individual performance.
How will you address the
safety concerns?
To Reduce Risk of Aspiration
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•
•
•
•
Assess gag reflex
OOB to chair for meals
Full Fowler’s position when possible
Speech/swallowing consult
Administer medications on time to improve
muscle control
To Reduce Risk of Falls
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•
•
•
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Out of bed with assistance
Make position changes slowly
Use 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 control
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.
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 movements
– Medications can cause dyskinesia
• Uncontrolled movements of face, eyelids, mouth, tongue, arms,
hands, legs, squirming movements
Medication Reconciliation
What concerns do you have regarding
Mr. Conley’s medications?
Any interactions?
Why these medications for this patient?
Interactions/Cautions
• Hytrin 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 disease
• Sinemet-Control of Parkinson’s Disease symptoms
Theory 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 levodopa
• MAO-B Inhibitors: (Eldepryl, Azilect) inhibit the
breakdown of dopamine
• COMT inhibitors: slow the breakdown of
levodopa, thus prolonging its action
• Amantadine: promotes effects of dopamine
©Altmiller
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?
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.
• 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
priority
QSEN Competency: Teamwork and Collaboration
Function effectively within nursing and inter-professional teams,
fostering open communication, mutual respect, and shared decisionmaking 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?
QSEN Competency: Safety
Minimize 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 dyskinesia
– Facial grimacing, tongue protrusion, bobbing of head, jerky
movements of the arms, legs, torso, extra squirming
movements.
• Make position changes slowly
– can cause postural hypotension.
QSEN Competency: Teamwork and Collaboration
Function effectively within nursing and inter-professional teams,
fostering open communication, mutual respect, and shared decisionmaking 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?
To Improve Communication with
Parkinson’s Disease Patients
• Be 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 Video
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.
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?
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.
Theory Burst
Exercise slows progression of the disease
(It is neuroprotective)
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•
•
•
May need brace to raise front of foot
Isotonic exercises build strength
Provide pictures of exercises to include at home
Gait training is essential-take big steps
– LSVT Big Training http://lsvtglobal.com/news/video
Scroll down to Pre & Post Treatment Example Video
and click
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.
QSEN Competency: Informatics
Use 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?
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.
•
Redistributive Diet
the negative impact protein has on levodopa precurser of
dopamine
– Protein 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 performance
• High Fiber (to prevent constipation)
• Concerns with caffeine
– Can 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
©Altmiller
After a few days, Mr. Conley is ready for
discharge to home. What important teaching
should be included in his discharge
instructions?
Parkinson’s Disease homecare
• Post-operative care regarding surgical incision site
• Arrangement 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 meds
– Dyskinesia-squirming movements, protrusion of tongue
– “on-off” effect
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.
After caring for Mr. Conley, what improvements
can you suggest for the care of hospitalized
Parkinson’s Disease patients?
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.
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.
The QSEN Competencies
1. 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.