Parkinson’s Disease NCLEX Review

This NCLEX review will discuss Parkinson’s disease.

As a nursing student, you must be familiar with this neuro disease along with how to provide care to a patient experiencing this condition.

Don’t forget to take the parkinson’s disease quiz.

You will learn the following from this NCLEX review:

• Definition of parkinson’s disease
• Pathophysiology
• Signs and Symptoms
• Nursing Interventions
• Medications
• Treatments

Parkinson’s Disease NCLEX Lecture

Parkinson’s Disease NCLEX Review

What is Parkinson’s Disease? It’s a neuro disease that gradually starts to affect movement.

What is happening in Parkinson’s disease to cause movement to become affected? The dopaminergic neurons in the part of the brain called substantia nigra have started to die.

Significance of this area? This area is part of the basal ganglia which is part of the midbrain that controls movements.

What is the role of these dopaminergic neurons? They release the neurotransmitter dopamine, which allows us to have accuracy with movement. Therefore, if they are dying this will lower the amounts of dopamine available to our body for normal movement.

Why is there the signs and symptoms of tremors, rigidity etc.? Normally in the nervous system there is a balance between acetylcholine (an excitatory neurotransmitter) and dopamine (an inhibitory neurotransmitter).

Therefore, the loss of dopamine leads to more acetylcholine being able to produce more excitatory affects to the neurons in the basal ganglia and this leads to overstimulation…..tremors, rigidity (increased cholinergic activity) etc.

Key Points about Parkinson’s Disease

• The disease tends to occur in older age 60+ (however it can affect younger people…example: Michael J. Fox was diagnosed with PD at the age of 29).
• There is currently no cure (there are medications to relieve signs and symptoms).
• Signs and symptoms are subtle (some patients don’t notice them at first) and they will become worse overtime.
• Signs and symptoms may present on one side or one extremity and progress to the others overtime.

Signs and Symptoms of Parkinson’s Disease

Mainly motor symptoms: affects how the patient is able to move

• Tremors at rest (most common): hands, arms, legs (even lips and tongue)… improves with movement
  • Pill-rolling: tremors of the hands and fingers….looks like the patient is rolling a pill between fingers and hands.
• Stiffness of extremities (arms DON’T swing with gait)…. akinesia: inability to move the muscles voluntarily….”freeze up”
  • Shuffling of gait (extremities can freeze while walking)
  • Cogwheel rigidity: when moving the patient’s arms passively toward the body they jerk or push back slightly
  • Bradykinesia: movements are slow, difficulty swallowing (drooling), Face mask-like: expressionless
• Coordination issues…..so the patient will stoop to compensate.
• Issues with the muscles used for chewing food, swallowing, and speaking: soft or slurred speech, problems swallowing (aspiration)

Other signs and symptoms that are non-motor:

• Depression
• Constipation: digestion slows down
• Loss of smell

Nursing Interventions for Parkinson’s Disease

What is going on?

• Safety issues (balance coordination, swallowing, freezing episodes can lead to falls)
• Psychosocial issues (low self-esteem, loses ability to care for self, depression, isolation)
• Digestion issues/nutrition issues
• Side effects and teaching with medications

Safety Issues:

Patient needs to wear low heel shoes and avoid rubber soles (they tend to stick to the floor and can cause tripping). The soles should be smooth (not slick).

For balance: move slowly when changing positions…rubber tip cane that is single point can help.

Education on how to deal with freezing episodes (some patients have them and they can occur randomly). For example, it can occur in the legs, and it feels like the shoes suddenly become stuck to the ground and they can’t move.

• Try to change direction of movement….rather then continue going to the side go forward.
• Use cane or walker with a laser…it provides a laser line on the floor that will help the patient find a landmark for when freezing episode happens and helps the patient coordinate their next step.
• Consciously lift the legs (as in marching) with each step or pretend they are walking over an object.
• DON’T push through the freeze up.

Use handrails in bathroom and shower, elevated toilet seat, non-slip shoes and socks, removes rugs and make sure pets are away from feet etc.

Psychosocial Issues: autonomy very important!

Help them with locating utensils for eating, cooking etc….. there are special types of cookware for PD like spoons, forks, bowls, knives to maintain autonomy

isolation:

• local support groups with other people who have PD
• exercise

Don’t stress patient about activities or hurry them…stress increases symptoms….wait for medication to peak so the most dopamine will be the most available.

Dress patient in shirts without buttons or zippers…easy to put on…replace articles of clothing with Velcro and shoes that don’t have to be tied.

Digestion/Nutrition:

Avoid taking antiparkinson’s medication (Carbidopa/Levodopa) with a high protein meal (meats, eggs, dairy, beans) because they interfere with how the body can absorb the medication (makes medication less effective).

At risk for weight loss because of the struggle with swallowing, chewing, depression, and hard to feed self due to rigidity

Needs foods that are soft, easy to swallow, and chew…speech therapy to evaluate…recommend consistency of fluids

Prevent constipation: drink plenty of fluids 2 L per day (unless contraindicated) with high fiber foods….example fresh fruits and vegetable and stool softner per MD order

Assess last bowel movement and bowel sounds along with palpation of abdomen.

Medications for Parkinson’s Disease (side effects and teaching)

NO cure but medications can help make signs and symptoms more manageable

Carbidopa/Levodopa (combination)….most common “Sinemet”: adds more dopamine to the brain

Carbidopa helps to prevent levodopa from being broken down in the blood before it enters the brain (hence more enters the brain) and lessens the side effect of nausea and when levodopa enters the brain it turns into dopamine

Education:

• takes up to 3 weeks to notice a decrease in symptoms when beginning treatment
• don’t be alarm if body fluids turn a dark color
• after long term usage the drug may wear off before next dose and cause signs and symptoms
  • Entacapone “Comtan”: a COMT can be prescribed to help decrease this from happening
• Don’t take with MAO inhibitors….hypertensive crisis!!
• Don’t take with high amounts of food or supplements with Vitamin B6: decreases effectiveness
• Avoid taking with high protein foods like cheese, milk, meat etc…decreases the amount of drug absorbed (competes with protein in the small intestines)

Side effects: nausea, involuntary movements

Ropinirole “Requip”: stimulates dopamine receptors ….dopamine agonists: helps with improving movement

Side effects: drowsiness major side effect (educate NOT to take when about to drive, cook, or operative machinery etc.)

Amantadine (antiviral: prevents influenza A…antiparkison as well): helps with symptoms by stimulating dopaminergic activity in the CNS

Anticholinergic:

Remember acetylcholine (causes cholinergic activity) is exceeding dopamine, which is producing an excitatory affect on the neurons. Therefore, ANTIcholinergics can be prescribed to decrease these effects. These medications are usually for younger adults who have extreme tremors and avoided in older adults because for the side effects.

Benztropine “Cogentin”:  blocks acetylcholine by decreasing rigidity, saliva (drooling), improved movements

NOT for people with GLAUCOMA!!

Education: never abruptly stop taking (increases signs and symptoms seen in Parkinson disease), dry mouth (sugar less candy or gum), NO alcohol.

MAO Inhibitor Type B (Monoamine Oxidase Inhibitor Type B):

Rasagiline “Azilect”: increases dopamine by stopping the activity of MOA…improvement of symptoms

Educate about limiting foods with tyramine: hypertensive crisis

• aged cheese
• smoked or cured meats (pepperoni, bacon, hot dogs)
• fermented food
• beer

COMT Inhibitors

Entacapone “Comtan” (catechol-O-methyltransferase inhibitors) used with levodopa/carbidopa to prevent the “wearing off” of the drug before the next dose is due….blocks COMT enzyme that will break down the levodopa in the blood to allow it to last longer.

References: