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Tuesday, February 8, 2022

Parkinson’s Disease: Symptoms Causes Diagnosis Treatment Complications Nursing Assessment by Nurses Note

 Parkinson’s Disease 

Parkinson’s disease is a chronic, progressive neurologic disease affecting the brain centers responsible for the control and regulation of movement. It is characterized by tremor, bradykinesia, rigidity, and postural abnormalities. Parkinson’s can complicate the diagnosis, clinical course, and recovery from other illnesses. Approximately 1% of the total U.S. population older than age 60 is affected by idiopathic Parkinson’s disease, and it less commonly affects people of younger ages. It is the second most common neurodegenerative disease.

Pathophysiology and Etiology of  Parkinson’s Disease

1. A deficiency of dopamine, due to degenerative changes in the substantia nigra of the brain, is thought to be responsible for the symptoms of Parkinson’s disease.

2. Underlying etiology may be related to a virus; genetic susceptibility; toxicity from pesticides, herbicides, methyl-phenyltetrahydropyridine, or welding fumes; repeated head injuries; or other unknown causes.

3. The clinical diagnosis of Parkinson’s disease may be difficult because older patients may have other causes of rigidity, bradykinesia, and tremor.

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Clinical Manifestations of  Parkinson’s Disease

1. Bradykinesia (slowness of movement), loss of spontaneous movement, and delay in initiating movements.

2. Resting (“pill-rolling”) tremor of 4 to 5 Hz. The tremor may be worse on one side of the body, affecting the limbs and sometimes involving the head, neck, face, and jaw.

3. Rigidity in performance of all movements. Rigidity is always present but increases during movement. May lead to sensations of pain, especially in the arms and shoulders.

4. Poor balance when moving abruptly or suddenly changing body position. May lead to falls.

5. Autonomic disorders—sleeplessness, salivation, sweating, orthostatic hypotension, dizziness. 

6. Depression, dementia.

7. mask-like facies secondary to rigidity.

8. Gait difficulties characterized by a decreased or nonexistent arm swing; short, shuffling steps (festination); difficulty in negotiating turns; and sudden freezing spells (inability to take the next step).

9. Verbal fluency may be impaired.

10. Finger-tapping responses are slowed.

11. Micrographia (change in handwriting, with the script becoming smaller).

12. Problems with speech, breathing, swallowing, and sexual function.

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Diagnostic Evaluation of  Parkinson’s Disease

1. Observation of clinical symptoms; may perform imaging studies to rule out other disorders.

2. Physical examination of upper-extremity elbow flexion/extension reveals rigidity on extension.

3. Sensorimotor assessment of grip reveals abnormally high grip forces and longer than normal to complete object lift, particularly with lighter loads.

4. Favorable response to a single dose of levodopa or apomorphine helps confirm the diagnosis. 

Management of  Parkinson’s Disease


1. Anticholinergics, including trihexyphenidyl, benztropine, and procyclidine, to reduce transmission of cholinergic pathways, which are thought to be overactive when dopamine is deficient. These medications are most effective in controlling tremor, but are known to cause confusion and hallucinations.

2. Amantadine, originally an antiflu medication, blocks the reuptake of dopamine or increases the release of dopamine by neurons in the brain, thereby increasing the supply of dopamine in the synapses. Widely used as an early monotherapy, its effect may be augmented by drug-free days.

3. Levodopa, a dopamine precursor, combined with carbidopa, a decarboxylase inhibitor, to inhibit the destruction of L-dopa in the bloodstream, making more available to the brain.

4. The combination of levodopa−carbidopa is usually used. The addition of carbidopa prevents levodopa from being metabolized in the gut, liver, and other tissues and allows more to get to the brain. Therefore, a smaller dose of levodopa is required to treat symptoms and the unpleasant adverse effects are greatly reduced.

5. Bromocriptine, pramipexole, and ropinirole are dopaminergic agonists that activate dopamine receptors in the brain. Can be taken alone or in combination with levodopa-carbidopa.

6. Use of the monoamine oxidase inhibitor selegiline or Deprenyl boosts the effect of levodopa−carbidopa when levodopa becomes less effective.

7. Tolcapone and entacapone are in a new drug class (catechol-O-methyltransferase inhibitors) for adjunct treatment. They prolong the duration of symptom relief by blocking the action of an enzyme that breaks down levodopa before it reaches the brain. Must be taken with levodopa.


1. New surgical treatments for Parkinson’s disease and essential tremors are promising.

2. Medial pallidotomy (electrode destroys cells in the globus pallidus) often improves long-standing symptoms, such as dyskinesia, akinesia, rigidity, and tremor, and for patients who have developed dyskinetic movements in reaction to their medications.

3. Deep brain stimulation of the thalamus decreases tremors and uncontrollable movements unresponsive to medication. Electrodes are implanted in the thalamus or globus pallidus and connected to a pacemaker-like device, which the patient can switch on or off as symptoms dictate.

4. Brain tissue transplants are still in the experimental stages but have produced encouraging results using stem cells and genetically engineered animal cells that can be made to produce dopamine.

Complications of  Parkinson’s Disease

1. Dementia.

2. Aspiration.

3. Injury from falls.

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Nursing Assessment of  Parkinson’s Disease

1. Obtain a history of symptoms and their effect on functioning. Mobility, feeding, communication, and self-care difficulties will have many nursing implications.

2. Assess CNs, cerebellar function (coordination), motor function.

3. Observe gait and performance of activities.

4. Assess speech for clarity and pace.

5. Assess for signs of depression.

6. Assess family dynamics, support systems, and access to social services.

Nursing Diagnoses of  Parkinson’s Disease

 Impaired Physical Mobility related to bradykinesia, rigidity, and tremor.

￾ Imbalanced Nutrition: Less Than Body Requirements related to motor difficulties with feeding, chewing, and swallowing.

￾ Impaired Verbal Communication is related to decreased speech volume and facial muscle involvement.

￾ Constipation is related to diminished motor function, inactivity, and medications.

￾ Ineffective Coping is related to physical limitations and loss of independence.

Nursing Interventions of  Parkinson’s Disease

Improving Mobility

1. Encourage the patient to participate in daily exercises, such as walking, riding a stationary bike, swimming, or gardening.

2. Advise the patient to do stretching and postural exercises as outlined by a physical therapist.

3. Encourage the patient to take warm baths and receive messages to help relax muscles.

4. Instruct the patient to take frequent rest periods to overcome fatigue and frustration.

5. Teach postural exercises and walking techniques to offset shuffling gait and tendency to lean forward.

 a. Instruct the patient to use a broad-based gait.

 b. Have the patient make a conscious effort to swing arms, raise the feet while walking, use a heel-toe gait, and increase the width of stride.

 c. Tell the patient to practice walking to marching music or the sound of a ticking metronome to provide sensory reinforcement. 

Optimizing Nutritional Status

1. Teach the patient to think through the sequence of swallowing—close lips with teeth together; lift tongue up with food on it; then move tongue back and swallow while tilting head forward.

2. Instruct the patient to chew deliberately and slowly, using both sides of the mouth.

3. Tell the patient to make a conscious effort to control the accumulation of saliva by holding the head upright and swallowing periodically.

4. Have the patient use secure, stabilized dishes and eating utensils.

5. Suggest smaller meals and additional snacks.

6. Monitor weight.

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Maximizing Communication Ability

1. Encourage compliance with medication regimen.

2. Suggest referral to the speech therapist.

3. Teach the patient facial exercises and breathing methods to obtain appropriate pronunciation, volume, and intonation.

 a. Take a deep breath before speaking to increase the volume of sound and number of words spoken with each breath.

 b. Exaggerate pronunciation and speak in short sentences; read aloud in front of a mirror or into a tape recorder to monitor progress.

 c. Exercise facial muscles by smiling, frowning, grimacing, and puckering.

Preventing Constipation

1. Encourage foods with moderate fiber content—whole grains, fruits, and vegetables.

2. Increase water intake.

3. Obtain a raised toilet seat to encourage normal position.

4. Encourage the patient to follow regular bowel regimen.

Strengthening Coping Ability

1. Help the patient establish realistic goals and outline ways to achieve goals.

2. Provide emotional support and encouragement.

3. Encourage the use of all resources, such as therapists, primary care providers, social workers, and social support networks.

4. Encourage open communication, discussion of feelings, and exchange of information about Parkinson’s disease.

5. Have the patient take an active role in activity planning and evaluation of the treatment plan.

6. Observe for changes in depression to determine if the patient is responding to antidepressants.

Community and Home Care Considerations

1. Recommend interdisciplinary home health care program. Requires skilled assessment of needs of the patient, professional nursing and therapeutic services, patient and family education, and case management to optimize patient outcomes.

2. Encourage the use of soothing music to reduce pain and depression.

3. Assess safety in the environment to reduce the risk of falls.

4. Utilize physical therapy services to encourage safe ambulation and reduce fear of falls.

5. Encourage use of social services, respite care and health visitors, mental health counselors, and support groups to prevent caregiver strain.

6. Use occupational therapy aids to ensure mobility and safety, such as grab rails in the tub or shower, raised toilet seat, handrails on both sides of the stairway, rope secured to foot of bed to achieve sitting position and straight-backed wooden chairs with armrests.

Patient Education and Health Maintenance

1. Instruct the patient to avoid sedatives, unless specifically prescribed, which have additive effects with other medications.

2. Instruct the patient in medication regimen, signs of toxicity, and adverse reactions, such as orthostatic hypotension, dry mouth, dystonia, muscle twitching, urine retention, impaired glucose tolerance, anemia, and elevated liver function tests.

3. Encourage follow-up and monitoring for diabetes, glaucoma, hepatotoxicity, and anemia while undergoing drug therapy. Increasing episodes of freezing should be reported.

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