NRSG374 Mr Nathan Rollins AT2
INTRODUCTION
This case study will focus on patient centred care of Mr Nathan Rollins, a 64-year-old
man with an extensive cardiac health history and a recent diagnosis of rapidly
progressive Parkinson’s Disease (PD). Mr Rollins has been caring for his wife at
home who has been recovering from a hip replacement surgery related to
degenerative changes from Rheumatoid Arthritis (RA). Together the two of them had
led an active life working hard to support each other after many years of work and
enjoy their much-loved garden and home. Nathan’s wife Heather has noticed that he
has been experiencing increased pain and shortness of
eath assisting her with her
ADL’s, however, does not know how to get any help or if they are even eligible.
KEY CONCEPTS
1. Importance of patient centred care
2. Movement and Non-Movement Issues faced by the patient with PD
3. Early Palliative Care Refe
al and MDT involvement in the PD setting
4. Highlight the importance of Advanced Care Directives
NRSG374: Principles of Nursing: A Palliative Approach
AT2 Case Study
NRSG374 Mr Nathan Rollins AT2
Title: NATHAN AND HEATHER’S STORY
SETTING THE SCENE
Mr Nathan Rollins is a 64-year-old man who has been ma
ied to Heather for 42
years, they were never able to have children however both worked until recently and
are now self-funded retirees. Nathan worked as a commercial industrial electrician,
he was a heavy smoker up until 10 years ago when he had an ST Elevation
Myocardial Infarction (STEMI) and required urgent Cardiac Arterial Bypass Graft
Surgery (CABGS) surgery. Nathan with the help of Heather recovered well from his
quadruple bypass, returning to work for another 9 years until Heather required a hip
eplacement related to degenerative changes from her Rheumatoid Arthritis (RA).
The two retired at this stage of their lives with Nathan becoming Heather’s carer,
assisting his wife with her recovery and rehabilitation at home, including most ADL’s
involving hygiene, dressing, and transfe
ing. It was during this time that Heather
noticed that Nathan was experiencing tremor’s, rigidity and drooling as he bent over
to put on her shoes rarely ve
alising pain but was exhibiting it. Nathan was
eviewed by his general practitioner (GP) and after several tests and consultations
with specialists he was diagnosed with rapidly progressing Parkinson’s Disease.
• It is 0700 hours and you have been assigned to work on Nathan’s discharge
from the medical ward that you have been allocated to during your final year
clinical placement. The RN that you are buddied with has explained to you
that Nathan is due for discharge this week however prior to this a refe
al to
the regional community palliative care team needs to be attended to.
NRSG374 Mr Nathan Rollins AT2
Nathan is continuing to experience fluctuating symptoms of his Parkinson’s
Disease that have recently caused increasing musculoskeletal and nervous
system pain. The Palliative Care Team have consulted during this admission
providing useful advice for not only pain interventions but also his fatigue and
mild cognitive changes including lack of concentration. It was decided in a
family meeting that ongoing review from palliative services would be useful in
supporting Nathan and Heather to remain at home and support each other.
THE EPIDEMIOLOGY OF PARKINSON’S DISEASE
Studies supported by Parkinson’s Australia (PA) and the Australian Institute of
Health and Wellbeing (AIHW) estimate that there are approximately 70,000 people
living with PD in Australia, thus it is the most common disorder of movement within
the country (Parkinson’s Australia, XXXXXXXXXXIt is important to note that PD is not a
disease of the aged population only, but that 11,900 new cases were estimated to be
diagnosed in 2015 an that 12,000 of the 70,000 individuals within Australia that live
with PD are of working age, impacting quality of life for the individual, their family and
the Australian workforce. The average lifespan for an individual living with PD from
onset to death is approximately 12.4 years although this is dependent upon lifestyle
and other co-mo
idities. Whilst both nationally and internationally there is major
esearch occu
ing on the treatment and management of PD is considered a life
limiting illness that with the early refe
al and involvement of palliative care services
can improve the QoL of individuals with this diagnosis (Tysnes & Storstein, 2017).
NRSG374 Mr Nathan Rollins AT2
THE AETIOLOGY AND PATHOGENESIS OF PARKINSON’S
DISEASE
Parkinson’s Disease is a movement disorder of the neurological system, involving an
early degeneration and death of dopaminergic neurons impacting both motor and
non-motor aspects of an individual’s life (Kalia & Lang, XXXXXXXXXXDiagnosis of PD is not
a simple task with no known absolute single test or scan, diagnosis is generally
made by a neurologist that considers your medical history, results from various tests
and symptoms as
adykinesia, tremor, postural instability and tremor (Williams, &
Wilkins, XXXXXXXXXXPain impacts the quality of Life of between 40-85% of Parkinson’s
Disease (PD) patients, presenting as nociceptive and / or neuropathic pain, often
equiring input from pain specialists (Antonini, Tinazzi, A
uzzese et, al., 2018).
There are no treatments that will halt the neurodegenerative process of PD, cu
ently
the approach is one that’s focus is treatment of symptoms and quality of life
PERSON-CENTRED CARE
The importance of person-centred care is emphasised in the National Safety and
Quality Health Service Standards (Australian Commission on Safety and Quality in
Health Care, 2016), where it is specified that patients must receive comprehensive
care. Health professionals must provide coordinated health care that is "aligned with
the patient's expressed goals of care and healthcare needs, considers the impact of
the patient's health issues on their life and wellbeing, and is clinically appropriate"
(p.36).
CONSIDER THE PATIENT’S SITUATION
Nathan is continuing to experience fluctuating symptoms of his Parkinson’s Disease
NRSG374 Mr Nathan Rollins AT2
that have recently caused increasing musculoskeletal and nervous system pain. The
Palliative Care Team have consulted during this admission providing useful advice
for not only pain interventions but also his fatigue and mild cognitive changes
including lack of concentration. It was decided in a family meeting that ongoing
eview from palliative services would be useful in supporting Nathan and Heather to
emain at home and support each other.
Nathan has also expressed feelings of apathy and disillusionment regarding his
prognosis and ongoing deterioration as he and Heather had always planned to travel
around Australia in their retirement having recently bought their dream Landcruiser
and Campervan. Nathan had been feeling well and energetic since his CABGS and
was looking forward to an active retirement with Heather once she had recovered
from her hip replacement.
Three weeks ago Nathan presented to the Emergency Department (ED) with an
exace
ation of neuropathic pain and a rapid decline in movement, he has spent up
until now admitted to the medical ward undergoing various tests that have revealed
the rapid deterioration of his disease process. It is becoming apparent to Nathan and
Heather that many of their plans would now need to change as he was no longer
able to drive. Heather, an only child was raised by her Aunt Kate after her parents
were killed in a car accident when she was only six years old, Nathan has one
other Scott who is older than him is ma
ied and has 3 children that are now grown
and also ma
ied with their own children. Nathan’s
other Scott lives in far north
Queensland, he and Heather were hoping to visit them as they travelled around
Australia. Scott and his wife are coming down to Melbourne to be with Nathan when
he is discharged home as they recognise that he will not be able to travel to their
NRSG374 Mr Nathan Rollins AT2
home in Queensland as he is deteriorating quite rapidly.
The purpose of a refe
al to community palliative care is to provide wholistic patient
centred care to Nathan and Heather as they navigate their way through this altered
journey of retirement that they had planned. They have been actively involved in the
local golf club and have a few friends that have been cooking meals for them and
helping to support them emotionally, however they are very private with their health
needs and do not want to rely on Nathan’s
other or friends for physical care.
Nathan and Heather have been contemplating several things lately, particularly their
quality of life and the future direction of their retirement. Nathan is concerned about
all components of his life not just the physical, as his Parkinson’s Disease is
displaying signs other than the physical such as:
• Anxiety about his health and is inability to support Heather
• Apathy
• Fatigue
• Difficulties sleeping
• Speech and swallowing issues
• Episodes of urinary Incontinence
• Alterations in vision
• Restless Leg Syndrome (RLS)
• Lower back and neck pain
• Weight loss
• Spiritual concerns
• Financial wo
ies and future considerations of his care
NRSG374 Mr Nathan Rollins AT2
COLLECT CUES AND INFORMATION
Observations
HR: 72bpm
RR: 23/min
BP: 126/74
Sao2: 98% R/A
• Kyphosis and forward head posture with lumbar lordosis upon
musculoskeletal assessment
• Increased difficulty with transfer from bed to chair and mobility within bed from
nursing, medical and allied health staff
• Decreased ability to perform ADL’s, assistance with hygiene and requirement
for over the toilet chair
Nathan’s Past Hx
• Tonsillectomy
• Past Smoker 1 pack/day for 33 years
• Laparoscopic Cholecystectomy – acute cholecystitis 1996
• STEMI CABGs (x4 arteries) – 10 years ago
Cu
ent Hx
• Recent Dx Rapidly Progressing Parkinson’s Disease
• Neuropathic Pain related to dystonia and disc compression of the spine
• Musculo-skeletal pain related to increasing rigidity
• High Falls Risk – shuffling gait
• Carer for wife – emotional and psychological concerns for her ongoing care
• Increasingly intermittent episodes of urinary incontinence
NRSG374 Mr Nathan Rollins AT2
Cu
ent Medication
• Levodopa/Ca
idopa (Sinemet) 250/25 1 tablet TDS
• Gabapentin 100mg BD (improvement of rigidity, tremor, restless legs, and
neuropathic pain – can cause leg oedema and increase sedation)
• Glycopy
olate 1-2g TDS (Drooling)
• Tolterodine 4mg nocte (Overactive Bladder)
• Targin 5mg BD
• Meloxicam 7.5mg PRN
• Endone 5-10mg PRN
Considerations for the palliative care refe
al
• Consider some of the assessments that you can undertake on Nathan, how
might this assist with your refe
al to community palliative care services?
• What key criteria do you believe