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NSR390 Alex Case Study Assessment 2 Answer

NSR390 Alex Case Study Assessment 2 Answer

Complex Clinical Case Study  

Charles Sturt University


Mr. Alexander (Alex) Richards is a 78-year-old male with a 5-year history of Parkinson’s disease and a 15-year history of Chronic Obstructive Airway Disease, who has been admitted to the medical ward you are working on a registered nurse. Alex has a three-day history of increasing shortness of breath and a productive cough and has been commenced on intravenous antibiotics for exacerbation of COPD.  Alex is accompanied by his wife Sally and Son Michael. 

Medical Background 

Alex is a retired train driver and continues to maintain steam trains with the local historical society. Alex lives with his wife, Sally in their own home. Sally assists Alex as much as possible. 

Alex was diagnosed with COPD 15 years ago and was a smoker of 20- 30 cigarettes per day. Despite much encouragement, Alex continues to smoke 5-10 cigarettes per day, which he attributes to helping him cope with his current conditions.

To add to the complexity of Alex’s conditions, he was diagnosed 5 years ago with Parkinson’s disease, following a short period of worsening tremors is his right (dominant) hand, predominately at rest, as well as bradykinesia in the fingers of both hands, making daily activities such as turning switches to drive the train difficult. 

Recently Alex has developed a shuffled gait which is impacting on his ability to ambulate safely. Alex manages short distances at home, however, prefers to use a wheelchair when leaving the house. 

Alex remains continent of urine and faeces, however, wears an incontinent aid when away from home. Alex is easily fatigued and breathless, and sleeps when he can as he reports not being able to sleep at night for longer than 4 hours at a time and since the episode of COVID (2 months ago) becomes breathless quickly and finds it easier to sleep in a recliner. 

•Provide responses to following questions 
•Introduction ( 150 words) 

       identify to the reader what the paper will discuss. Who, what

       how.Does not need references. 

  E.G. Mr Alex Richards is 78, an ex train driver who has a 5 yr history of Parkinson’s disease and a 15 yr History of COPD. This assessment will discuss the pathophysiology of these two conditions, discuss advanced care planning and discussion and the roles these decisions have in the patients well being and acollaborative team member that could be included in his care in regards to sorting his medications. 

 Underlying pathophysiology 

Discuss the pathophysiology of Parkinson’s Disease and Chronic Obstructive Pulmonary Disease (COPD). 

Identify and describe the pathophysiology (at a systemic level) of two clinical manifestations that are common to both Parkinson’s Disease and COPD. 

Nursing management 

Identify what an advanced care directive is and describe its purpose.  Describe how instigating advance care planning discussions can assist the patients and their families who are living with complex conditions. 

Collaborative management

Polypharmacy is a risk factor for the older person. Define the term polypharmacy, identify one collaborative care team member ( for example Physiotherapist, or Occupational therapist) and justify their role  in the care of the patient regarding medication management and complex conditions. 


Title: Health Challenges 4: Complex Care


In this study, the focus will be given to a medical issue of an individual named Mr. Alexander Richards, a 78-year-old male with a 5-year history of Parkinson’s disease and a 15-year history of Chronic Obstructive Airway (COPD) disease. Based on two diagnosed clinical conditions of the patient, in this study, the author will discuss the pathophysiology of both Parkinson’s disease and COPD. Two clinical manifestations of Parkinson’s disease and COPD in the case of Mr. Alexander will also be highlighted in this study along with the role and relevance of Advanced Care Directory and Advanced Care Planning in the case of the patient. Lastly, the author will also discuss about the polypharmacy-associated risks of the patient and the role of an occupational therapist to manage the risks associated with the identified issue through an active collaboration with the patient, family members, and other healthcare professionals. 

Question 1: Underlying Pathophysiology

Parkinson’s disease (PD) is considered a chronic and as well as progressive neurodegenerative illness that usually negatively influences the performance of dopaminergic neurons located in the substantia nigra pars compacta of the basal ganglia and this further leads to damage and loss of cells that are responsible for producing and secreting dopamine. According to Franco, Reyes-Resina & Navarro, (2021), dopamine acts as a neurotransmitter that has a significant role in the control of movement and coordination of motor activities. The pathophysiology of the disease is considered to have a significant association with the alpha-synuclein protein’s accumulation within the dopaminergic neurons in the form of Lewy bodies and the gradual decay or loss of neurons that produce dopamine is considered to be associated with the accumulation of Lewy bodies within it. Due to the above-mentioned issue, individuals with Parkinson’s disease often experience a significant alteration in their mood as according to Canesi et al., (2020), fluctuation in the level of dopamine significantly affects the emotions and moods of people.  According to Masato et al., (2019), the gradual decrease and loss of dopamine ultimately affects basal ganglia, and over time, it fails to regulate motor activities substantially. This incidence in further results into several clinical motor symptoms, for example, rigidity, tremors, postural instability and bradykinesia. Despite multiple research and molecular investigations, the exact molecular mechanism of Parkinson’s disease is not clearly known. However, the pathophysiology of the disease is considered to involve a complicated interplay of several environmental and as well as genetic factors. While several incidences of the disease are mostly due to unknown events, in some cases, researchers have found a significant association with the progression of the disease with some genetic mutations in some genes for example, PINK1, SNCA, Parkin, and LRRK2 (Lunati, Lesage & Brice, 2018). Apart from the motor symptoms mentioned above, the progression of the disease is often identified with some non-motor symptoms for example, anxiety, depression, autonomic dysfunction, cognitive instability, and anxiety. All the above-mentioned symptoms are considered an outcome of the involvement of different regions of the brain and a gradual accumulation of another protein named alpha-synuclein, for example, the autonomic nervous system (ANS) and cortex. 

On the other hand, Chronic Obstructive Pulmonary Disease, or COPD is considered as a chronic and as well as progressive respiratory illness. The disease is initially developed due to exposure to pollutants, for example, occupational dust, cigarette smoke, chemicals, and air dust. However, in the given case study of the patient, cigarette smoke is found as a pollutant or a major trigger for COPD. The pathophysiology of the disease involves both mechanisms of two chronic conditions called chronic bronchitis and emphysema. The exposure to cigarette smoke in the case of the patient is considered to trigger the inflammatory response of the body that further narrowed the airways. According to Agustí & Hogg, (2019), the narrowing of airways during the progression of COPD eventually leads to a persistent cough and the production of mucus. This condition is often considered as chronic bronchitis. Moreover, emphysema, another prevalent condition associated with COPD is facilitated by the gradual destruction of respiratory air sacs or alveoli (Hikichi et al., 2019). The gradual disruption of respiratory air sacs due to exposure to the above-mentioned pollutants is further considered to result in an impaired exchange of gases. Such a condition is considered to be exhibited with different clinical signs and symptoms, for example, breathing difficulties, persistent cough, and a reduction in the oxygen saturation level. According to Russel et al., (2019), both the above-mentioned events, for example, chronic inflammation and narrowing of the airways in patients with COPD are considered to enhance airway resistance. Hyperinflation due to air trapping is also common due to impaired gas exchange in COPD patients. 

Some clinical manifestations have been identified in the given case study that is similar in both COPD and Parkinson’s illness. In this section of the study, the author is to focus on these two clinical manifestations. The first clinical manifestation which is identified as common both in COPD and Parkinson’s disease is called Fatigue. According to Herlofson & Kluger, (2017), fatigue is a very common occurrence in Parkinson’s disease where it usually results from alterations in dopamine levels as the said neurotransmitter is involved in the process of regulating both motor activity and motivation. On the other hand, in the case of COPD, as suggested by Spruit et al., (2017), fatigue is associated with breathlessness and an increased effort to breathe, and the poor availability of oxygen in the body. To perform physical activity, oxygen is considered to have a very essential role in producing ATP. However, in COPD patients, fatigue is often shown due to the poor oxygen saturation level. Due to all the above-mentioned factors, Mr. Alexander might also experience fatigue due to his 15-year history of COPD and Parkinson’s disease which he was diagnosed with. Another clinical manifestation common in both COPD and Parkinson’s disease is called Dyspnoea or breathing shortness. Among individuals with Parkinson’s disease, dyspnoea or breathing shortage is usually appeared due to the impaired function of respiratory muscle, decreased expansion of the lung, and rigidity of the chest wall. On the other hand, the clinical manifestation is well prevalent in COPD patients mostly due to narrowed airways and enhanced resistance to airflow. As Mr. Alexander is found to suffer from both COPD and Parkinson’s disease, he would also experience Dyspnoea. 

Question 2: Nursing Management

An Advanced Care Directive or ACD is considered a legal document that frames the wishes of an individual or more specifically a patient regarding their preferences of clinical or end-of-life clinical care when they will not be able to make their own clinical decisions. According to Meehan et al., (2022), the ACD is considered a disciplinary way for patients to communicate about their clinical choices and preferences to ensure an appropriate fulfillment of their wishes in a dignified and respectful manner. As suggested by Meehan et al., (2022), the key purpose of an ACD is to deliver sufficient guidance to healthcare staff for example, physicians and nurses, family members and care providers in making clinical decisions on behalf of the patient who is currently under end-of-life care or will go through this path in near future. According to Jimenez et al., (2022), ACD in clinical facilities and mostly in palliative care facilities allows patients to have regulation over their clinical care and assures the fulfillment of their wishes or preferences with proper respect and dignity, even if they are not in a homeostatic or stable condition to communicate about the wishes or preferences directly with healthcare professionals. According to Jimenez et al., (2022), starting an advanced care planning communication can help patients in EOL care as well as their family members and caregivers in multiple manners. For example, it helps patients to experience honest and as well as transparent communication with family members and healthcare professionals about their clinical status, preferences, and values. This further helps in mitigating the risk of emotional and psychological disbalances of them and the development of stress and anxiety. Moreover, according to Beck et al., (2017), ACP also helps in maintaining autonomy in practice and hence, is considered to have an ethical standpoint where patients and family members get opportunities to make informed decisions about their clinical care. It also assures a scope for patients and their family members and caregivers to consider both the advantages and risks of available therapeutic options. As per the standards and guidelines of ACD in Australia, patients can further take their clinical decisions considering the benefits and risks associated with it. Last but not least, ACD in clinical care facilities, is also considered to assure emotional homeostasis of patients as well as their family members and care providers as through the ACP they come to know about the respectful and dignified manner to address their clinical preferences and wishes. It helps in reducing the risks of uncertainties among patients in terms of their clinical decision-making and also the risk of forced and unethical clinical decision-making. 

Question 3: Collaborative Management

Polypharmacy is considered as the utilisation of multiple medicines by a patient in order to manage progression of multiple chronic or acute illnesses. According to Mehta et al., (2021), polypharmacy is considered one of the major risk factors among adult peoples mostly due to associated risks for example, complex drug interactions, added healthcare expenditure, poor adherence to medication regimes and an increased risk of poor drug reactions. Different healthcare professionals can further manage the risks associated with polypharmacy. However, in case of Mr. Alexander, an occupational therapist or OT is anticipated to have a significant role in reducing the polypharmacy associated risk for the patient. As per current evidence, clinical standard and clinical understanding, an OT can work in a collaborative manner with Mr. Alexander and as well as his family members and other healthcare professionals to assess the medication regimen of the patient to identify potential or adverse drug interactions and also to develop evidence-based strategies to assist the patient to increase his adherence to an appropriate medication regime (Sluggett et al., 2017). The OT in this order can also provide necessary assistance to Mr. Alexander to recognize potential barriers associated with his adherence to medication and can also develop necessary solutions to address the identified barriers. For instance, due to having Parkinson’s disease, Mr. Alexander can experience difficulties in opening the packaging of medicines because of hand tremors. In this circumstance, if appears, the OT can suggest Mr. Alexander to have adaptive equipment such as pill splitters to ease the problem for the patient to have timely medication. Moreover, OT can also provide the necessary education to Mr. Alexander for enhancing or improving his medication adherence. According to Molokhia & Majeed, (2017), providing necessary education about potential risks and side-effects associated with polypharmacy is considered to increase awareness of both aged patients and as well as their family members. Collaborative action planning further may empower the OT, family members, and other health professionals to develop a safe and comprehensive medication management plan that also includes the use of assistive devices and strategies to develop the confidence of the patient to take medicines. As a whole, it can be stated that OT can significantly assist the patient with complex clinical conditions through an active collaboration with the patient, family members and healthcare professionals to manage the risks of polypharmacy. 


In this study the author has collected cues from the given case scenario of Mr. Alexander. As per the information shared in the case scenario, Mr. Alexander is currently suffering from Parkinson’s disease and COPD. Two clinical manifestations that may raise further include fatigue and Dyspnoea. Based on his advanced progression of both COPD and Parkinson’s disease, the role and relevance of ACD and ACP has also been discussed where it is identified that healthcare professionals can assure his emotional and psychological wellbeing and security in terms of the fulfilment of end-of-life wishes and clinical preferences through the ACP. Due to significant risks of polypharmacy in case of the patient, in this study it has also been stated that an OT can mitigate the potential risks of polypharmacy through an active collaboration with healthcare professionals, the patient and his family members and evidence-based strategy and education to empower the patient and family members to enhance his adherence with medicine regimen. 

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