Nursing Process Assessment

Nursing Process
Assessment:
For a client with Parkinson’s disease, it is important to perform a thorough head to toe
assessment, so that the nurse will be able to provide effective care without any consequences. As
a nurse, the first step in my assessment would be to perform a thorough head to toe assessment to
see if there are any physiological changes that have deviated from the previous assessments. If
there are any changes, I must make note of them, as they could possibly worsen the client’s
condition if left unattended. For the client with Parkinson’s, I need to assess their motor strength,
as it is the area affected by this disease. Next, I need to check their cognitive function to see if
the disease has progressed. This assessment is vital, because it is stated in my research that 45
percent of clients with Parkinson’s are likely to have some cognitive impairment. I would have to
assess these clients during the start of my shift, before and after any procedure and prior to
finishing the shift.
Planning:
As I have stated in this research that this disease is both chronic and progressive, it is highly
unlikely that this patient with Parkinson’s is going to recover fully. Despite that, I plan on
improving this client’s health, so that they may be able to manage this debilitating illness. It is
important this I have a plan prior to carrying out my interventions, so that I may be able to
anticipate any changes while carrying out the interventions.
Implementation:
For a client with Parkinson’s disease, their motor functions are the epicentre of this disease. As
such, I will need to assure that their environment is free of any obstacles, to prevent them from
falling, which could lead to further complications. Because they are prone to tripping due to their
gait imbalance, I may need to provide some device that will keep them ambulatory, such as a
walker, or a cane. Because of their symptoms, I will need to assist them with ROM exercises if
they are not capable, to prevent atrophy of the muscles. I will also assist them in eating as they
could suffer from tremors, which prevents them from keeping their hand stable, thus spilling the
contents from the eating utensils. I may need to assist them with their ADLs if they can’t perform
them, because this disease will continue to progress, thus hindering them from doing this
activities with full capacity. I will also need to administer medications as ordered from the
physician to temporarily control their symptoms. I should also educate them on this disease;
client teaching is a huge part in caring for our clients, therefore, it is imperative that the client be
educated on their diagnosis, so that they will be prepared in living with this condition as they are
discharged from the hospital.
Evaluation:
It is important to evaluate, to determine whether or not your interventions are improving the
client's condition. If it is not aiding the client, then changes must be made to the care plan
immediately, so that, the client’s condition will not continue to worsen. It is important to check
the effectiveness of you interventions on a daily basis, so that the caregiver may be able to
determine a more appropriate intervention, if the current actions are not working. I need to
evaluate their motor function to see if they are capable of ambulating themselves; if they are not
able to move, despite the interventions that were carried, then I must revise the care plan in a
manner that will help them with motor functions. For all the other interventions, I must act
accordingly to each one if they are not effective in helping the clients conditions improve.
Nursing Assessment
A history of signs and symptoms related to UTI is obtained from the patient with a suspected
UTI.
• Assess changes in urinary pattern such as frequency, urgency, or hesitancy.
• Assess the patient’s knowledge about antimicrobials and preventive health care measures.
• Assess the characteristics of the patient’s urine such as the color, concentration, odor,
volume, and cloudiness.
Nursing Diagnosis
Based on the assessment data, the nursing diagnoses may include the following:
• Acute pain related to infection within the urinary tract.
• Deficient knowledge related to lack of information regarding predisposing factors and

prevention of the disease.
Nursing Care Planning & Goals
Major goals for the patient may include:
• Relief of pain and discomfort.
• Increased knowledge of preventive measures and treatment modalities.
• Absence of complications.
Nursing Assessment
A history of signs and symptoms related to Parkinson's Disease is obtained from the patient with
a suspected Parkinson's Disease.
DIAGNOSIS
Based on the assessment data, the nursing diagnoses may include the following:
 Ineffective Airway Clearance related to

 Disturbed Thought Process
 Impaired Verbal Communication
 Impaired Physical Mobility
 Imbalanced Nutrition: Less Than Body Requirements
 Impaired Swallowing
 Risk for Injury
 Ineffective Coping
 Deficient Knowledge

Nursing Process Assessment

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Nursing Process

finishing the shift.

anticipate any changes while carrying out the interventions.

discharged from the hospital.

• Assess changes in urinary pattern such as frequency, urgency, or hesitancy.

• Acute pain related to infection within the urinary tract.

• Deficient knowledge related to lack of information regarding predisposing factors and

Nursing Care Planning & Goals

Major goals for the patient may include:

• Relief of pain and discomfort.

• Increased knowledge of preventive measures and treatment modalities.

 Ineffective Airway Clearance related to

 Impaired Verbal Communication

 Impaired Physical Mobility

 Imbalanced Nutrition: Less Than Body Requirements

 Risk for Injury

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