Parkinsonism is a clinical condition that is characterized by the following: gradual slowing of voluntary movement (bradykinesia); muscular rigidity; stooped posture; distinctive gait with short, accelerating steps; diminished facial expression; and resting tremor. Parkinson’s disease occurs with progressive parkinsonism in the absence of a toxic or known etiology and is a progressively degenerative disease of the substantia nigra and basal ganglia. Parkinson’s disease is also called paralysis agitans. Degeneration of the substantia nigra in the basal ganglia of the midbrain leads to depletion of the neurotransmitter dopamine, which is normally produced and stored in this location. Dopamine promotes smooth, purposeful movements and modulation of motor function. Depletion of dopamine leads to impairment of the extrapyramidal tracts and consequent loss of movement coordination. Complications include injuries from falls, skin breakdown from immobility, and urinary tract infections. Death is usually caused by aspiration pneumonia or other infection.
The majority of all cases of classic Parkinson’s disease are primary, or idiopathic, Parkinson’s disease (IPD). The cause is unknown; a few cases suggest a hereditary pattern. Secondary, or iatrogenic, Parkinson’s disease is drug- or chemical-related. Dopamine-depleting drugs such as reserpine, phenothiazine, metoclopramide, tetrabenazine, and the butyrophenones (droperidol and haloperidol) can lead to secondary Parkinson’s disease.
Nursing care plan assessment and physical examination
Obtain a family, medication, and occupational history. Parkinson’s disease progresses through the following stages: (1) mild unilateral dysfunction; (2) mild bilateral dysfunction, as evidenced by expressionless face and gait changes; (3) increasing dysfunction, with difficulties in walking, initiating movements, and maintaining equilibrium; (4) severe disability, including difficulties in walking and maintaining balance and steady propulsion, rigidity, and slowed movement; and (5) invalidism, which requires total care. Note the timing of progression of all symptoms.
The three cardinal signs of Parkinson’s disease are involuntary tremors, akinesia, and progressive muscle rigidity. The first symptom of Parkinson’s disease is a coarse, rest tremor of the fingers and thumb (pill-rolling movement) of one hand. It occurs during rest and intensifies with stress, fatigue, cold, or excitation. This tremor disappears during sleep or purposeful movement. The tremor can occur in the tongue, lip, jaw, chin, and closed eyelids. Eventually, the tremor can spread to the foot on the same side and then to the limbs on the other side of the body.
The diagnosis of Parkinson’s disease is made on the basis of two out of the four important symptoms: resting tremor, bradykinesia (slowing down or loss of voluntary muscle movement), cogwheel rigidity (rigidity of a muscle that gives way in a series of little jerks when passive stretching occurs), and postural instability; one of the two symptoms must be resting tremor or bradykinesia.
Assess the patient for signs of bradykinesia. Perform a passive range-of-motion examination, assessing for rigidity. Rigidity of the antagonistic muscles, which causes resistance to both extension and flexion, is a cardinal sign of Parkinson’s disease. Flexion contractures develop in the neck, trunk, elbows, knees, and hips. Note alterations in the respiratory status because rigidity of the intercostal muscles may decrease breath sounds or cause labored respirations. Observe the patient’s posture, noting if he or she is stooped, and assess gait dysfunction. Note involuntary movements, slowed movements, decreased movements, loss of muscle movement, repetitive muscle spasms, an inability to sit down, and difficulty in swallowing.
Observe the patient’s face, noting an expressionless, masklike appearance, drooling, and decreased tearing ability; note eyeballs fixed in an upward direction or eyelids completely closed, which are rare complications of Parkinson’s disease. Assess for defective speech, a highpitched monotone voice, and parroting the speech of others. Autonomic disorders that are manifested in Parkinson’s disease include hypothalamic dysfunction, so assess for decreased or Parkinson’s perspiration, heat intolerance, seborrhea, and excess oil production. Observe the patient for orthostatic hypotension, which manifests in fainting or dizziness. Note constipation or bladder dysfunction (urgency, frequency, retention).
Parkinson’s disease does not usually affect intellectual ability, but 20% of patients with Parkinson’s disease develop dementia similar to that of Alzheimer’s disease. The Parkinson’s disease patient commonly develops depression later in the disease process, and this is characterized by withdrawal, sadness, loss of appetite, and sleep disturbance. Patients may also demonstrate problems with social isolation, ineffective coping, potential for injury, and sleep pattern disturbance.
Nursing care plan primary nursing diagnosis: Self-care deficit related to rigidity and tremors.
Nursing care plan intervention and physical examination
To control tremor and rigidity, pharmacologic management is the treatment of choice. Longterm levodopa therapy can result in drug tolerance or drug toxicity. Symptoms of drug toxicity are confusion, hallucinations, and decreased drug effectiveness. Treatment for drug tolerance and toxicity is either a change in drug dosage or a drug holiday. Autologous transplantation of small portions of the adrenal gland into the brain’s caudate nucleus of Parkinson’s disease patients is offered on an experimental basis in some medical centers as a palliative treatment. In addition, if medications are ineffective, a thalamotomy or stereotaxic neurosurgery may be done to treat intractable tremor.
Physical and occupational therapy consultation is helpful to plan a program to reduce flexion contractures and to maximize functions for the activities of daily living. To prevent impaired physical mobility, perform passive and active range-of-motion exercises and muscle-stretching exercises. In addition, include exercises for muscles of the face and tongue to facilitate speech and swallowing. Use of a cane or walker promotes ambulation and prevents falls.
Promote independence in the patient. Encourage maximum participation in self-care activities. Allow sufficient time to perform activities, and schedule outings in late morning or in the afternoon to avoid rushing the patient. Reinforce occupational and physical therapy recommendations. Use adaptive devices as needed. If painful muscle cramps threaten to limit the patient’s mobility, consider warm baths or muscle massage.
To facilitate communication, encourage the Parkinson’s disease patient to speak slowly and to pause for a breath at appropriate intervals in each sentence. Teach deep-breathing exercises to promote chest expansion and adequate air exchange. Be alert to nonverbal clues, and supplement interactions with a communication board, mechanical voice synthesizer, computer, or electric typewriter.
To maintain nutritional status, monitor the patient’s ability to chew and swallow. Monitor weight, intake, and output. Position the patient in the upright position for eating to facilitate swallowing. Offer small, frequent meals; soft foods; and thick, cold fluids. Supplemental puddings or nutritional shakes may be given throughout the day to maintain weight.
Help the patient maintain a positive self-image by emphasizing her or his abilities and by reinforcing success. Encourage the patient to verbalize feelings and to write in a journal. Help the patient maintain a clean, attractive appearance. Caregivers may need a great deal of emotional support. Explore strategies for long-term care with the patient and significant others.
Nursing care plan discharge and home health care guidelines
Be sure the patient or caregiver understands all medications, including the dosage, route, action, and adverse reactions. Avoid the use of alcohol, reserpine, pyridoxine, and phenothiazine while taking levodopa. In general, recommend massage and relaxation techniques, and reinforce exercises recommended by the physical therapist. Several techniques facilitate mobility and enhance safety in Parkinson’s disease patients. Instruct the patient to try the following strategies: (1) To assist in maintaining balance, concentrate on taking larger steps with feet apart, keeping back straight and swinging the arms; (2) to overcome akinesia, tape the “frozen” leg to initiate movement; (3) to reduce tremors, hold objects (coins, keys, or purse) in the hand; (4) to obtain partial control of tremors when seated, grasp chair arms; (5) to reduce rigidity before exercise, take a warm bath; (6) to initiate movement, rock back and forth; (7) to prevent spine flexion, periodically lie prone and avoid using a neck pillow; and (8) teach the patient to eliminate loose carpeting, install grab bars, and elevate the toilet seat. Use of chair lifts can also be beneficial.