Parkinsons Disease
Parkinsons disease is a slowly progressive degenerative
neurologic disorder affecting the brain centers that are
responsible for control and regulation of movement. The
degenerative or idiopathic form of Parkinsons disease is the
most common; there is also a secondary form with a known or
suspected cause. The cause of the disease is mostly unknown
but research suggests several causative factors (eg, genetics,
atherosclerosis, viral infections, head trauma). The disease
usually first appears in the fifth decade of life and is the fourth
most common neurodegenerative disease.
Pathophysiology
Parkinsons disease is associated with decreased levels of
dopamine resulting from destruction of pigmented neuronal cells
in the substantia nigra in the basal ganglia region of the brain.
The loss of dopamine stores in this area of the brain results in
more excitatory neurotransmitters than inhibitory neuro-
transmitters, leading to an imbalance that affects voluntary
movement. Cellular degeneration causes impairment of the
extrapyramidal tracts that control semiautomatic functions and
coordinated movements; motor cells of the motor cortex and the
pyramidal tracts are not affected.
Clinical Manifestations
The cardinal signs of Parkinsons disease are tremor, rigidity,
bradykinesia (abnormally slow movements), and postural
instability.
Resting tremors: a slow, unilateral turning of the forearm and
hand and a pill-rolling motion of the thumb against the
fingers; tremor at rest and increasing with concentration and
anxiety.
Resistance to passive limb movement characterizes muscle
rigidity; passive movement may cause the limb to move in
jerky increments (lead-pipe or cog-wheel movements);
stiffness of the arms, legs, face, and posture are common;
involuntary stiffness of passive extremity increases when
another extremity is engaged in voluntary active movement.
Impaired movement: Bradykinesia includes difficulty in
initiating, maintaining, and performing motor activities.
Loss of postural reflexes, shuffling gait, loss of balance
(difficulty pivoting); postural and gait problems place the
patient at increased risk for falls.
Other Characteristics
Autonomic symptoms that include excessive and
uncontrolled sweating, paroxysmal flushing, orthostatic
hypotension, gastric and urinary retention, constipation, and
sexual dysfunction.
Psychiatric changes may include depression, dementia,
delirium, and hallucinations; psychiatric manifestations may
include personality changes, psychosis, and acute
confusion.
Auditory and visual hallucinations may occur.
Hypokinesia (abnormally diminished movement) is common.
As dexterity declines, micrographia (small handwriting)
develops.
Masklike facial expression.
Dysphonia (soft, slurred, low-pitched, and less audible
speech).
Stages of Parkinsons Disease
I. Unilateral flexion of upper extremities
II. Shuffling gait
III. Progressive difficulty in ambulating
IV. Progressive weakness
V. Disability = last stage
Assessment and Diagnostic Methods
Patients history and presence of two of the four cardinal
manifestations: tremor, rigidity, bradykinesia, and postural
changes.
Positron emission tomography (PET) and single photon
emission computed tomography (SPECT) scanning have
been helpful in understanding the disease and advancing
treatment.
Medical history, presenting symptoms, neurologic
examination, and response to pharmacologic management
are carefully evaluated when making the diagnosis.
Medical Management
Goal of treatment is to control symptoms and maintain functional
independence; no approach prevents disease progression.
Pharmacologic Therapy
Levodopa (Larodopa) is the most effective agent and the
mainstay of treatment.
Anticholinergic agents (eg, trihexyphenidyl HCl [Artane],
benztropine mesylate [Cogentin]) to control tremor and
rigidity.
Amantadine hydrochloride (Symmetrel), an antiviral agent, to
reduce rigidity, tremor, and bradykinesia.
Dopamine agonists (eg, pergolide [Permax], bromocriptine
mesylate [Parlodel]), ropinirole, and pramipexole are used to
postpone the initiation of carbidopa and levodopa therapy.
Monoamine oxidase inhibitors (MAOIs) (eg, selegiline
[Eldepryl], rasagiline [Azilect]) to inhibit dopamine
breakdown.
Catechol-O-methyltransferase (COMT) inhibitors (eg,
entacapone [Comtan], tolcapone [Tasmar]) to reduce motor
fluctuation.
Antidepressant drugs (eg, amitriptyline HCl [Elavil]).
Antihistamine drugs (eg, diphenhydramine [Benadryl]) to
allay tremors.
Surgical Management
Surgery to destroy a part of the thalamus (stereotactic
thalamotomy and pallidotomy) to interrupt nerve pathways
and alleviate tremor or rigidity.
Transplantation of neural cells from fetal tissue of human or
animal source to reestablish normal dopamine release.
Deep brain stimulation with pacemakerlike brain implants to
block nerve pathways in the brain that cause tremors.
Nursing Diagnoses
Impaired physical mobility related to muscle rigidity and
motor weakness
Self-care deficits (eating, drinking, dressing, hygiene, and
toileting) related to tremor and motor disturbance
Constipation related to medication and reduced activity
Imbalanced nutrition: less than body requirements related to
tremor, slowness in eating, difficulty in chewing and
swallowing
Impaired verbal communication related to decreased speech
volume, slowness of speech, inability to move facial muscles
Ineffective coping related to depression and dysfunction due
to disease progression
Other nursing diagnoses may include sleep pattern
disturbances, deficient knowledge, risk for injury, risk for activity
intolerance, disturbed thought processes, and compromised
family coping.
Nursing Interventions Provide continuous encouragement and reassurance.
Assist and encourage patient to set achievable goals.
Improving Mobility Encourage patient to carry out daily tasks to retain
Help patient plan progressive program of daily exercise to independence.
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. Prepared by:
Encourage postural exercises to counter the tendency of the
head and neck to be drawn forward and down. Teach patient ERICSON C. MITRA
to walk erect, watch the horizon, use a wide-based gait, BSN IV Student
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.

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.

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.

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 patients weight on a weekly basis.
Provide supplementary feeding and, as disease progresses,
tube feedings.
Consult a dietitian regarding patients nutritional needs.

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.

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.

Supporting Coping Abilities

Encourage faithful adherence to exercise and walking
program; point out activities that are being maintained
through active participation.