Download Chapter_059_Parkinsons_Disease

Focus on
Parkinson’s Disease

(Relates to Chapter 59,
“Nursing Management:
Chronic Neurologic Problems,”
in the textbook)
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Parkinson’s Disease (PD)
 Disease of basal ganglia
characterized by
 Slowing down in the initiation and
execution of movement
 ↑ muscle tone
 Tremor at rest
 Gait disturbance
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Etiology and Pathophysiology
 Diagnosis increases with age, with
peak onset in the seventh decade.
 More common in men, ratio of 3:2
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Etiology and Pathophysiology
 Other causes of parkinsonism
 Encephalitis lethargica (type A
encephalitis) has been associated with
onset.

Incidence has dwindled since 1920s.
 Symptoms have occurred after
intoxication with a variety of chemicals.
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Etiology and Pathophysiology
 Other causes (cont’d)
 Can also be seen after use of illicit drugs,
including amphetamines and
methamphetamines
 Hydrocephalus, hypoxia, infections,
stroke, tumor, and trauma
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Etiology and Pathophysiology
 Pathologic process of PD involves
degeneration of dopamine-producing
neurons in substantia nigra of the
midbrain.
 Disrupts dopamine-acetylcholine
balance in basal ganglia
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Parkinsonism
Fig. 59-6. Nigrostriatal disorders produce parkinsonism. Left-sided view of the human brain showing
the substantia nigra and the corpus striatum (shaded area) lying deep within the cerebral hemisphere.
Nerve fibers extend upward from the substantia nigra, divide into many branches, and carry dopamine
to all regions of the corpus striatum.
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Synaptic Activity
eFig. 59-1. Dopaminergic synaptic activity is mediated by dopamine. Cholinergic synaptic activity is
mediated by acetylcholine. A balance between the two kinds of activity produces normal motor
function. A relative excess of cholinergic activity produces akinesia and rigidity. A relative excess of
dopaminergic activity produces involuntary movements. Neurons in the caudate nucleus contain
ã-aminobutyric acid (GABA) and possibly control dopaminergic neurons in the substantia nigra
through a feedback pathway.
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Clinical Manifestations
 Onset is gradual and insidious.
 Classic triad of PD
 Tremor
 Rigidity
 Bradykinesia
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Clinical Manifestations
 Beginning stages may involve only
mild tremor, slight limp, or ↓ arm
swing.
 Later stages may have shuffling,
propulsive gait with arms flexed, and
loss of postural reflexes.
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Clinical Manifestations
 Tremor
 So minimal initially that only the patient
may notice it
 More prominent at rest and is aggravated
by emotional stress or ↑ concentration
 Described as pill rolling because thumb
and forefinger appear to move in rotary
fashion
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Clinical Manifestations
 Tremor (cont’d)
 Benign essential tremor, which occurs
during voluntary movement, has been
misdiagnosed as Parkinson’s disease
(PD).
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Clinical Manifestations
 Rigidity
 Increased resistance to passive motion
when limbs are moved through ROM
 Rigidity is typified by a jerky quality when
the joint is moved.
 Rigidity is similar to intermittent catches
in the movement of a cogwheel.
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Clinical Manifestations
 Rigidity (cont’d)
 Caused by sustained muscle contraction
and consequently elicits the following
Complaint of soreness
 Feeling tired and achy
 Pain in the head, upper body, spine, or legs

 Inhibits the alternating contraction and
relaxation in opposite muscle groups,
thus slowing movement
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Clinical Manifestations
 Bradykinesia
 Slowing down in initiation and execution
of movement
 Evident in loss of autonomic movements
Blinking
 Swinging of arms while walking
 Swallowing of saliva
 Self-expression with facial movements

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Appearance of Patient With PD
Fig. 59-8. Characteristic appearance of a patient with Parkinson’s disease.
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Complications
 Nonmotor symptoms
 Depression
 Anxiety
 Apathy
 Fatigue
 Pain
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Complications
 Nonmotor symptoms (cont’d)
 Constipation
 Impotence
 Short-term memory impairment
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Complications
 As disease progresses, complications
increase
 Motor symptoms
 Weakness
 Akinesia
 Neurologic problems
 Neuropsychiatric problems
 Dementia occurs in 40% of patients.
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Complications
 Dysphagia may result in malnutrition
and aspiration.
 General debilitation may lead to
pneumonia, UTIs, and skin
breakdown.
 Orthostatic hypotension may occur.
 Could result in falls and injuries
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Complications
 Sleep disorders are common and
potentially severe.
 Effective management of sleep
disturbances can greatly improve quality
of life.
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Diagnostic Tests
 No specific tests
 Diagnosis based solely on history and
clinical features
 Firm diagnosis can be made when at least
two of three characteristics of the classic
triad (tremor, rigidity, and bradykinesia)
are present.
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Collaborative Care
Drug Therapy
 Aimed at correcting imbalances of
neurotransmitters within the CNS
 Antiparkinsonian drugs either
 Enhance or release supply of DA
 Antagonize or block the effects of
overactive cholinergic neurons in the
striatum
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Collaborative Care
Drug Therapy
 Levodopa with carbidopa (Sinemet) is
often the first drug used.
 Precursor of DA and crosses blood-brain
barrier
 Converted to DA in the basal ganglia
 Carbidopa inhibits an enzyme that breaks
down levodopa before it reaches the
brain.
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Collaborative Care
Drug Therapy
 Effectiveness of Sinemet could wear
off after a few years of therapy.
 Therefore, therapy is initiated with a DA
receptor agonist instead.
 Sinemet is added when moderate to
severe symptoms develop.
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Collaborative Care
Drug Therapy
 Anticholinergics are also used in
management.
 ↓ activity of acetylcholine
 Antihistamines with anticholinergic or βadrenergic blockers are used to manage
tremors.
 Antiviral agent amantadine is effective,
although exact mechanism is unknown.
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Collaborative Care
Drug Therapy
 MAO-B inhibitors, selegiline, and
rasagiline may be combined with
Sinemet.
 Entacapone and tolcapone block the
enzyme that breaks down levodopa in
the peripheral circulation.
 Prolong the effects of Sinemet
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Collaborative Care
Drug Therapy
 Initially, only one drug is typically
used.
 As disease progresses, combination
therapy is often required.
 Excessive dopaminergic drugs can lead
to paradoxical intoxication.
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Collaborative Care
Drug Therapy
 Within 3 to 5 years of treatment,
patients experience episodes of
hypomobility.
 Treated with apomorphine (Apokyn)

Needs to be taken with an antiemetic drug
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Collaborative Care
 Surgical therapy
 Procedures aimed at relieving symptoms
 Used in patients who are usually
unresponsive to drug therapy or have
developed severe motor complications
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Collaborative Care
 Ablation surgery
 Has been used to treat PD for over 50
years
 But has been recently replaced by deep
brain stimulation (DBS)
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Collaborative Care
 Deep brain stimulation
 Involves placing an electrode in the
thalamus, globus pallidus, or subthalamic
nucleus
 Connected to a generator placed in the
upper chest
 Device is programmed to deliver specific
current to targeted brain location.
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Collaborative Care
 Transplantation of fetal neural tissue
into the basal ganglia provides
DA-producing cells in the brains of
patients.
 Still in experimental stages
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Collaborative Care
 Nutritional therapy
 Malnutrition and constipation can be
serious consequences.
 Patients with dysphagia and bradykinesia
need food that is easily chewed and
swallowed.
 Adequate roughage
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Collaborative Care
 Nutritional therapy (cont’d)
 Food should be cut into bite-sized pieces.
 Several small meals should be taken to
prevent fatigue.
 Provide ample time to avoid frustration.
 Levodopa can be impaired by protein and
B6 ingestion.
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Nursing Management
Nursing Assessment
 Health history
 CNS trauma
 Cerebrovascular disorders
 Exposure to metals and CO2
 Encephalitis
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Nursing Management
Nursing Assessment
 Health history (cont’d)
 Medications
Tranquilizers
 Reserpine
 Methyldopa
 Amphetamines

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Nursing Management
Nursing Assessment
 Health history (cont’d)
 Excessive salivation
 Dysphagia
 Weight loss
 Difficulty initiating movements, falls, loss
of dexterity
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Nursing Management
Nursing Assessment
 Health history (cont’d)
 Constipation
 Incontinence
 Diffuse pain in head, shoulders, neck,
back, legs, and hips
 Depression
 Mood swings
 Hallucinations
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Nursing Management
Nursing Assessment
 Objective data
 Blank faces, infrequent blinking
 Seborrhea
 Dandruff
 Ankle edema
 Postural hypotension
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Nursing Management
Nursing Assessment
 Objective data (cont’d)
 Tremor at rest
 “Pill rolling”
 Poor coordination
 Subtle dementia
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Nursing Management
Nursing Assessment
 Objective data (cont’d)
 Cogwheel rigidity
 Dysarthria
 Bradykinesia
 Contractures
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Nursing Management
Nursing Diagnoses
 Impaired physical mobility
 Imbalanced nutrition: less than body
requirements
 Impaired verbal communication
 Deficient diversional activity
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Nursing Management
Planning
 Maximize neurologic function.
 Maintain independence in activities of
daily living (ADLs) for as long as
possible.
 Optimize psychosocial well-being.
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Nursing Management
Nursing Implementation
 Promote physical exercise and
a well-balanced diet.
 Limit the consequences from decreased
mobility
 Specific exercises to strengthen muscles
involved with speaking and swallowing
 Teach maintenance of good health,
independence, and avoidance of
complications.
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Nursing Management
Nursing Implementation
 Problems secondary to bradykinesia
can be alleviated by
 Consciously thinking about stepping over
a line on the floor
 Lifting toes when stepping
 One step back and . . .
 Two steps forward
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Nursing Management
Nursing Implementation
 Get out of a chair by using arms and
placing the back legs on small blocks.
 Remove rugs and excess furniture.
 Simplify clothing from buttons and
hooks.
 Use elevated toilet seats.
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Nursing Management
Nursing Implementation
 Assist patients as they make
adjustments to their lifestyle to
accommodate symptoms.
 Caregivers may also experience stress
associated with disease progression
(i.e., dementia).
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Audience Response Question
The nurse admits a patient with advanced Parkinson’s
disease at the outpatient clinic with a cough and fever.
During assessment of the patient, the nurse would expect to
find:
1. Slurred speech, visual disturbances, and ataxia.
2. Muscle atrophy, spasticity, and speech difficulties.
3. Muscle weakness, double vision, and reports of fatigue.
4. Drooling, stooped posture, tremors, and a propulsive gait.
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Audience Response Question
An appropriate nursing diagnosis for a patient with
advanced Parkinson’s disease is
1. Risk for injury related to limited vision.
2. Risk for aspiration related to impaired swallowing.
3. Urge incontinence related to effects of drug therapy.
4. Ineffective breathing pattern related to diaphragm
fatigue.
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Case Study
52
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Case Study
 67-year-old man presents to clinic with
a tremor in his hands that is interfering
with writing.
 He also complains of muscle aches and
excessive drooling saliva that he
cannot swallow.
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Case Study
 He doesn’t remember when all this
began—says it was “a while ago.”
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Case Study
 Physical examination reveals
 Rigidity in limbs
 Shuffling gait
 Blank expression
 Pill rolling in both hands
 He is diagnosed with Parkinson’s
disease.
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Discussion Questions
1. He is anxious and worries that his
tremors will never stop. What can you
tell him?
2. What other emotional issues may
arise for him?
3. What can you tell him about
treatment options?
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Discussion Questions
4. What changes may he need to make
to his home?
5. What other teaching should you
perform?
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Discussion Questions
6. What monitoring should be done for
him?
7. What changes should be made in the
home environment?
8. How might the disease progress?
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