Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis?
A. Imbalanced nutrition: Less than body requirements
B. Ineffective airway clearance
C. Impaired urinary elimination
D. Risk for injury
Correct Answer: B. Ineffective airway clearance
In Parkinson’s crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of Ineffective airway clearance takes highest priority. Although the other options also are appropriate, they aren’t immediately life-threatening.
Option A: Assess the patient’s ability to eat. To provide information regarding factors associated with reduced intake of nutrients. Weigh the patient daily, on the same scale and same time if possible. Provides information about weight loss or gain. Provide an unhurried environment during meal time. Patients with PD may have difficulty maintaining their weight as eating becomes a very slow process, requiring concentration due to a dry mouth from medications and difficulty chewing and swallowing.
Option C: Teach patient to sit in chairs with backs and armrests; use elevated toilet seats or sidebars in the bathroom. Help with rising from a sitting position and prevent falls. Provide warm baths and massages. Helps relax muscles and relieve painful muscle spasms that accompany rigidity.
Option D: Assess ambulation and movement. Instruct the patient to swing arms and lift heels during ambulation. These actions assist gait and prevent falls. Teach the patient to turn in wide arcs. To prevent the crossing of one leg over the other, which could cause a fall. Remind the patient to maintain an upright posture and look up when walking. Stooped posture may cause the patient to collide with objects.
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