Parkinson’s Disease Nursing Care Plan & Management

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.

Assessment

1. Bradykinesia, abnormal slowness of movement, and sluggishness of physical and mental responses.
2. Akinesia
3. Monotonous speech
4. Handwriting that becomes progressively smaller
5. Tremors in hands and fingers at rest (pill rolling)
6. Tremors increasing when fatigued and decreasing with purposeful activity or sleep.
7. Rigidity with jerky interrupted movements
8. Restlessness and pacing
9. Blank facial expression-mask –like facies
10. Drooling
11. Difficulty swallowing and speaking
12. Loss of coordination and balance.
13. Shuffling steps, stooped position, and propulsive gait.

Primary Nursing Diagnosis

• Self-care deficit related to rigidity and tremors

Diagnostic Evaluation

• The diagnosis of Parkinson’s disease is usually made through clinical findings rather than diagnostic tests. The key to diagnosis is the patient’s response to levodopa (see Pharmacologic Highlights).
• Positron emission tomography (PET) and single photon emission computed tomography (SPECT) shows decrease dopamine uptake in the basal ganglia. Degeneration of substantia nigra in the basal ganglia of midbrain leads to depletion of dopamine

Medical Management

• 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.

Pharmacologic Highlights

• Antiparkinson drugs such as Levodopa (L-dopa); carbidopa-levodopa (Sinemet) is used to control tremors and rigidity; converted to dopamine in the basal ganglia.
• Antiviral agents such as Amantadine hydrochloride (Symmetrel) is used to control tremor and rigidity by increasing the release of dopamine to the basal ganglia.
• Synthetic anticholinergics such as Trihexyphenidyl (Artane); benztropine mesylate (Cogentin) is used to block acetylcholine stimulated nerves that lead to tremors.
• Other Drugs: Antihistamines are sometimes prescribed with the anticholinergics to inhibit dopamine uptake; bromocriptine mesylate, a dopamine antagonist, is ordered to stimulate dopaminergic receptors.

Nursing Interventions

1. Assess neurological status.
2. Assess ability to swallow and chew.
3. Provide high-calorie, high-protien, high-fiber soft diet with small, frequent feedings.
4. Increase fluid intake to 2000 mL/day.
5. Monitor for constipation.
6. Promote independence along with safety measures.
7. Avoid rushing the client with activities.
8. Assist with ambulation and provide assistive devices.
9. Instruct client to rock back and forth to initiate movement.
10. Instruct the client to wear low-heeled shoes.
11. Encourage the client to lift feet when walking and avoid prolonged sitting.
12. Provide a firm mattress, and position the client prone, without a pillow, to facilitate proper posture.
13. Instruct in proper posture by teaching the client to hold the hands behind the back to keep the spine and neck erect.
14. Promote physical therapy and rehabilitation.
15. Administer anticholinergic medications as prescribed to treat tremors and rigidity and to inhibit the action of acetylcholine.
16. Administer antiparkinsonian medications to increase the level of dopamine in the CNS.
17. Instruct the client to avoid foods high in vitamin B6 because they block the effects of antiparkinsonian medications.
18. Instruct the client to avoid monoamine oxidase inhibitors because they will precipitate hypertensive crisis.

Documentation Guidelines

• Ability to ambulate, perform the activities of daily living, progress in an exercise program
• Use of verbal and nonverbal communication
• Statements about body image and self-esteem
• Discomfort during activity

Discharge and Home Healthcare 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.