1. Focus on Parkinson’s Disease  (Relates to Chapter 59, “Nursing Management: Chronic Neurologic Problems,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

2. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 2

3. Etiology and Pathophysiology  Diagnosis increases with age, with peak onset in the seventh decade.  More common in men, ratio of 3:2 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 3

4. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 4

5. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 5

6. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 6

7. Parkinsonism Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 7 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.

8. Synaptic Activity Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 8 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.

9. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 9

10. Clinical Manifestations  Onset is gradual and insidious.  Classic triad of PD  Tremor  Rigidity  Bradykinesia Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 10

11. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 11

12. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 12

13. Clinical Manifestations  Tremor (cont’d)  Benign essential tremor, which occurs during voluntary movement, has been misdiagnosed as Parkinson’s disease (PD). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 13

14. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 14

15. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 15

16. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 16

17. Appearance of Patient With PD Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 17 Fig. 59-8. Characteristic appearance of a patient with Parkinson’s disease.

18. Complications  Nonmotor symptoms  Depression  Anxiety  Apathy  Fatigue  Pain Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 18

19. Complications  Nonmotor symptoms (cont’d)  Constipation  Impotence  Short-term memory impairment Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 19

20. Complications  As disease progresses, complications increase  Motor symptoms  Weakness  Akinesia  Neurologic problems  Neuropsychiatric problems  Dementia occurs in 40% of patients. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 20

21. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 21

22. Complications  Sleep disorders are common and potentially severe.  Effective management of sleep disturbances can greatly improve quality of life. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 22

23. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 23

24. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 24

25. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 25

26. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 26

27. Collaborative Care Drug Therapy  Anticholinergics are also used in management.  ↓ activity of acetylcholine  Antihistamines with anticholinergic or β- adrenergic blockers are used to manage tremors.  Antiviral agent amantadine is effective, although exact mechanism is unknown. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 27

28. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 28

29. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 29

30. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 30

31. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 31

32. Collaborative Care  Ablation surgery  Has been used to treat PD for over 50 years  But has been recently replaced by deep brain stimulation (DBS) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 32

33. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 33

34. Collaborative Care  Transplantation of fetal neural tissue into the basal ganglia provides DA-producing cells in the brains of patients.  Still in experimental stages Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 34

35. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 35

36. 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 B 6 ingestion. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 36

37. Nursing Management Nursing Assessment  Health history  CNS trauma  Cerebrovascular disorders  Exposure to metals and CO 2  Encephalitis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 37

38. Nursing Management Nursing Assessment  Health history (cont’d)  Medications  Tranquilizers  Reserpine  Methyldopa  Amphetamines Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 38

39. Nursing Management Nursing Assessment  Health history (cont’d)  Excessive salivation  Dysphagia  Weight loss  Difficulty initiating movements, falls, loss of dexterity Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 39

40. Nursing Management Nursing Assessment  Health history (cont’d)  Constipation  Incontinence  Diffuse pain in head, shoulders, neck, back, legs, and hips  Depression  Mood swings  Hallucinations Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 40

41. Nursing Management Nursing Assessment  Objective data  Blank faces, infrequent blinking  Seborrhea  Dandruff  Ankle edema  Postural hypotension Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 41

42. Nursing Management Nursing Assessment  Objective data (cont’d)  Tremor at rest  “Pill rolling”  Poor coordination  Subtle dementia Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 42

43. Nursing Management Nursing Assessment  Objective data (cont’d)  Cogwheel rigidity  Dysarthria  Bradykinesia  Contractures Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 43

44. Nursing Management Nursing Diagnoses  Impaired physical mobility  Imbalanced nutrition: less than body requirements  Impaired verbal communication  Deficient diversional activity Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 44

45. Nursing Management Planning  Maximize neurologic function.  Maintain independence in activities of daily living (ADLs) for as long as possible.  Optimize psychosocial well-being. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 45

46. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 46

47. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 47

48. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 48

49. 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). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 49

50. 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. Audience Response Question Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 50

51. 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. Audience Response Question Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 51

52. Case Study Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 52

53. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 53

54. Case Study  He doesn’t remember when all this began—says it was “a while ago.” Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 54

55. Case Study  Physical examination reveals  Rigidity in limbs  Shuffling gait  Blank expression  Pill rolling in both hands  He is diagnosed with Parkinson’s disease. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 55

56. 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? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 56

57. Discussion Questions 4. What changes may he need to make to his home? 5. What other teaching should you perform? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 57

58. 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? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 58