Parkinson's Disease

1. Mr. HIREN GEHLOTH
JG COLLEGE OF NURSING

2. PARKINSON’S DISEASE
• Parkinson's disease is a slowly progressive
neurologic movement disorder that eventually leads
to disability.
• It is characterized by tremors, rigidity, bradykinesia,
Postural changes.

3. Parkinson's disease is a associated with
the decrease level of dopamine
resulting from degeneration of
dopamine storage cells in the
substance nigra in the basal ganglion
region of the brain.
Normally, Nerve cells use a dopamine which help to control muscle
movements.

4. CAUSES
• Causes of most cases is unknown.
• Genetic factors
• Family history
• Atherosclerosis
• Excessive accumulation of oxygen free radicals
• Viral infections
• Head trauma
• Chronic use of antipsychotic drug
• Deficiency of dopamine in substantia nigra of brain
• Environmental factors such as heavy metals and
pesticides

5. PATHOPHYSIOLOGY
Destruction of dopaminergic neuronal cells in the substantia nigra in the basal
ganglia
Depletion of dopamine stores
Loss of smooth, controlled muscle activity
Imbalance of excitatory and inhibitory
neurotransmitter in the carpus striatum
Impairment of extrapyramidal tracts
controlling complex body movements.
Tremors Postural Changes
Bradykinesia
Rigidity

6. Clinical Manifestation
Tremors: Although symptoms are variable, a slow, unilateral
resting tremor is present in the majority of patients at the time
of diagnosis.
Resting tremors characteristically disappears with purposeful
movements and during sleep but is evident when the
extremities are motionless or at rest.
Trembling in fingers, hands, arms, feet, legs, jaw or head.

7. Rigidity: Passive movement of an extremity may cause
the limb to move in jerky increments, referred to as lead-
pipe or cogwheel movements.
Involuntary stiffness of the passive extremity increases
when another extremity is engaged in voluntary active
movement.
Stiffness of the arms, legs, face, and posture are common.
Early in the disease, the patient my complain of shoulder
pain due to rigidity.

8. Bradykinesia: Slowness of voluntary
movements. Overtime it may become
difficult to initiate movement and to
complete movement. Bradykinesia together
with stiffness can also effect the facial
muscles and result in an expressionless,
MASK LIKE appearance.
Postural Instability: Impaired or lost
reflexes can make it difficult to adjust
posture to maintain balance. Postural
instability may lead to falls.

9. Parkinsonian gait: Individuals with more
progressive Parkinson’s disease developed a
distinctive SHUFFLING walk with a stopped
position and a diminished or absent arm swing.
It may become difficult to start walking and to make
turns, Individuals may freeze in mid-stride and appear
to fall forward while walking.

10. Other Manifestations :
• Excessive and uncontrolled sweating
• Paroxysmal flushing
• Orthostatic hypotension
• Urinary retention
• Sexual dysfunction
• Depression, Anxiety, Dementia, delirium, hallucination
• Hypokinesia (Abnormal diminished movement)
• Micrographia (Small handwriting )
• Dysphonia (voice impairment or altered voice
production)
• Dysphagia, Begins to drool, Choking and aspiration
MICROGRAPHIA

11. Assessment and Diagnostic finding:
 Medical history or present with two or more cardinal symptoms.
 Position emission tomographic (PET)
 Neurological examination
 Response to pharmacologic management. (Positive response to a levodopa)

12. Management
Pharmacologic Therapy:
Antiparkinsonian drug: Levodopa is the most effective agent and the
mainstay of treatment. Levodopa is converted to dopamine in the basal
ganglia, producing symptom relief.
Sometimes Levodopa + Carbidopa is administered to avoid the metabolism of
levodopa before it can reach the brain.
Anticholinergic: Trihexyphenidyl hydrochloride and Benztropine mesylate
(To control the tremors and rigidity.)
Antiviral agent: Amantadine (Reduce rigidity, tremors, bradykinesia, and
postural changes in early Parkinson's disease.)

13.  Dopamine agonists: (Bromocriptine mesylate) activates the dopamine receptors.
 Monoamine oxidase inhibitors: Selegiline, Rasagiline, (Prevent the dopamine
breakdown.)
 Catechol-o-Methyltransferase inhibitors: Increase the duration of levodopa[a or
carbidopa.
 Antidepressant: Bupropion hydrochloride
 Antihistamine : Diphenhydramine hydrochloride (May help in reduce the tremors.)

14. Surgical Management:
a. Stereotactic procedures:
 Thalamotomy and Pallidotomy are ablative procedures that
were formally used to relieve symptoms of disease. However,
these procedures permanently destroy brain tissue.
 Deep Brain Stimulator (DBS) involves the surgical
implantation of an electrodes into the brain either in pallidus
and subthalamic nucleus.
Stimulation of these areas may increase dopamine release or
anticholinergic release, there by improving the tremors and
rigidity.

15. b. Neural Transplantation:
Ongoing research is exploring transplantation of porcine neuronal cells,
human fetal cells, and stem cells to replace degenerated striatal cells.
Legal, ethical, and political concerns surrounding the use of fetal brain cells
and steam cells have limited the exploration of these procedures.

16. NURSING MANAGEMENT
ASSESSMENT:
• The nurse notes how the disease affects the patient’s activities of daily living
and functional abilities and also observes for degree of disability and
functional changes that occur throughout the day, such as responses to
medication.
• Observe the patient for quality of speech, loss of facial expression,
swallowing deficits (drooling, poor head control, coughing), tremors,
slowness of movement, weakness, forward posture, rigidity, evidence of
mental slowness, and confusion.

17. The following questions may facilitate observations:
• Do you have leg or arm stiffness?
• Have you experienced any irregular jerking of your arms or legs?
• Have you ever been “frozen” or rooted to the spot and unable to move?
• Does your mouth water excessively?
• Have you (or others) noticed yourself grimacing or making faces or chewing
movements?
• What specific activities do you have difficulty doing?

18. NURSING DIAGNOSIS
1. Impaired physical mobility related to muscle rigidity and postural impairment
2. Self care deficits(feeding, dressing, hygiene, and toileting,) related to tremors
and muscle rigidity.
3. constipation related to medication and reduced activity.
4. Impaired verbal communication related to decrease speech volume, slowness
of speech, inability to move facial muscles.
5. ineffective coping related to depression and dysfunction due to disease
progression.

19. Nursing Interventions
1. Improving Mobility
• Help patient plan progressive program of daily exercise to increase muscle strength,
improve coordination and dexterity, reduce muscular rigidity, and prevent
contractures.
• Encourage exercises for joint mobility (eg, stationary bike, walking).
• Instruct in stretching and range-of-motion exercises to increase joint flexibility.
• Encourage postural exercises to counter the tendency of the head and neck to be
drawn forward and down.
• Teach patient to walk erect, watch the horizon, use a wide-based gait, swing arms
with walking, walk heel-toe, and practice marching to music. Also encourage
breathing exercises while walking and frequent rest periods to prevent fatigue or
frustration.
• Advise patient that warm baths and massage help relax muscles.

20. 2. Enhancing Self-Care Activities
• Encourage, teach, and support patient during activities of daily living.
• Modify environment to compensate for functional disabilities; adaptive
devices may be useful.
• Enlist assistance of an occupational therapist as indicated.
3. Improving Bowel Elimination
• Establish a regular bowel routine.
• Increase fluid intake; eat foods with moderate fiber content.
• Provide raised toilet seat for easier toilet use.

21. 4. Improving Swallowing and Nutrition
• Promote swallowing and prevent aspiration by having patient sit in upright position
during meals.
• Provide semisolid diet with thick liquids that are easier to swallow.
• Teach patient to place the food on the tongue, close the lips and teeth, lift the tongue up
and then back, and swallow; encourage patient to chew first on one side of the mouth and
then on the other.
• Remind patient to hold head upright and to make a conscious effort to swallow to
control buildup of saliva.
• Monitor patient’s weight on a weekly basis.
• Provide supplementary feeding and, as disease progresses, tube feedings.
• Consult a dietitian regarding patient’s nutritional needs.

22. 5. Encouraging Use of Assistive Devices
• An occupational therapist can assist in identifying appropriate adaptive devices.
• Useful devices may include an electric warming tray that keeps food hot and
allows the patient to rest during the prolonged time that it may take to eat; special
utensils; a plate that is stabilized, a nonspill cup, and eating utensils.
6. Improving Communication
• Remind patient to face the listener, speak slowly and deliberately, and exaggerate
pronunciation of words; a
small electronic amplifier is helpful if the patient has difficulty being heard.
• Instruct patient to speak in short sentences and take a few breaths before speaking.
• Enlist a speech therapist to assist the patient.

23. 7. Supporting Coping Abilities
• Encourage faithful adherence to exercise and walking program; point out
activities that are being maintained through active participation.
• Provide continuous encouragement and reassurance.
• Assist and encourage patient to set achievable goals.
• Encourage patient to carry out daily tasks to retain independence.