Parkinson s disease is a disease of the basal ganglia characterized by slowing down in the the initiation and execution of movement(bradykinesia),increased muscle tone(rigidity),tremor at rest,and impaired postural reflexes
ETIOLOGY
- The cause of most of the cases is unknown,
- Genetics,atherosclerosis,excessive accumulation of oxygen free radicals,viral infection,head trauma,chronic use of antipsychotic medications and some environmental factors.
PATHOPHYSIOLOGY (Steps)
1. Due to the etiological factors2. Destruction of dopaminergic neuronal cells in the substancia niagra in the basal ganglia.
3. Depletion of the dopamine stores
4. Degeneration of the dopaminergic nigrostriatal pathway
5. Imbalance of excitatory(acetylcholine)and inhibiting(dopamine)neurotransmitters in the in the corpus leuteum
6. Impairment of extrapyramidal tracts controlling complex body movements tremcausing tremors,rigidity,bradykinesia and postural changes
CLINICAL MANIFESTATIONS
- TREMORS
- RIGIDITY
- BRADYKINESIA
- POSTURAL INSTABILITY
OTHER MANIFESTATIONS
- Excessive and uncontrolled sweating,paroxysmal flushing,orthostatic hypotension,gastric and urinary retension,constipation and sexual dysfunction
- Depression dementia
- Sleep disturbances and hallucination.
- Mental changes in the form of cognitive deficits,perceptual and memory deficits
- Psychiatric manifestations like personality changes,psychosis,dementia and acute confusion
- Adverse effect of medications.
- Hypokinesia(abnormally diminished movement)
- Micrographia(Small handwriting)
- Mask like expressionless face and the blinking declines.
- Dysphonia(short,slurred,low pitched and less audible speech)
- Incoordination of the muscles responsible for speech
- Dysphagia,drooling and risk of choking and aspirations.
COMPLICATIONS
- Disorders of movement
- Respiratory and urinary tract infection,skin breakdown and injuries from falls.
- Medication side effects like dyskinesia or orthostatic hypotension
ASSESSMENT AND DIAGNOSTIC FINDINGS
- History collection and physical examination
- PET &SPECT
- Assess for cardinal signs like tremors,rigidity,bradykinesia,and postural changes.
- Medical history,physical examination,presenting symptoms,neurological examination and response to pharmacological agents should be evaluated.
MEDICAL MANAGEMENT
- Treatment is directed towards controlling the symptoms and attaining personal independence.
- Care is individualized for each patients on presenting symptoms and social,occupational and emotional needs
- Patients are cared at home and is hospitalized only if complications of the treatment occurs.
PHARMACOLOGICAL THERAPY
Anti parkinsonian medications acts by increasing the striatal dopaminergic activity,reducing the excessive influence of excitatory cholinergic neurones on the extrapyramidal tract,thereby balancing the dopaminergic and cholinergic activity,It acts on the neurotransmitter pathways other than the dopaminergic pathway.
ANTIPARKINSONIAN MEDICATIONS
- Levodopa(Larodopa) is used for treatment.Levodopa is believed to precipitate oxidation but there is a question whether this further damagesthe substancia niagra and speeds disease progression. Levodopa is converted to dopamine in the basal ganglia producing symptom relief.Confusion,hallucination,depression and sleep alterations are associated with prolonged use
- Levodopa is usually associated with carbidopa which maximizes the beneficial effects of levodopa by preventing the breakdown outside the brain and reduces the side effects.
- Within 5-10 effects most patients develops a response to the medication characterized by dyskinesia(abnormal involuntary muvements)including facial grimacing,rhythmic jerking movements of the hands,head bobbnig,chewing and jerking movements,and involuntary movements of the trunk and extremities.Te patient may experience on an doff syndromein which sudden periods of immobility (off effect)followed by sudden return of the effectiveness of the medication(on effect).
- Another potential complication of the long term dopaminergic medication is neuroleptic malignant syndrome which is characterized by severe rigidity,stupor and hyperthermia.
- Anticholinergic therapy
- Antiviral therapy
- Dopamine agonists
- Monoamine oxidase inhibitors
- Catechol-o-methyltransferase inhibitors
- Antidepressants
- Antihistamines
SURGICAL MANAGEMENT
- NEURAL TRANSPLANTATION
- DEEP BRAIN STIMUALTION
NURSING PROCESS
ASSESSMENT
During the assessment the nurse assesses the patient for patient for quality of speech,loss of facial expression,swallowing deficits(drooling,poor head control,coughing)tremors,slowness of movement,weakness,forward posture,rigidity,evidence of mental slowness and confusion
NURSING DIAGNOSIS
- Impaired physical mobility related to muscle rigidity and motor weakness.
- Self care deficits(feeding,dressing,hygiene and toileting)related to tremor and motor disturbance.
- Constipation related to medication and reduced activity.
- Imbalanced nutrition less than body requirement 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 the facial muscles.
- Ineffective coping related to depression and dysfunction due to disease progression.
PLANNING AND GOALS
The goals for the patient may include improving functional mobility,maintaining the ADL,achieving adequate bowel elimination,attaining and maintaining adequate nutritional status,achieving effective communication and developing positive coping mechanisms.
NURSING INTERVENTIONS
- IMPROVING MOBILITY
- ENHANCING SELF CARE ACTIVITIES
- IMPROVING BOWEL ELIMINATION
- IMPROVING NUTRITION
- ENHANCING SWALLOWING
- ENCOURAGING THE USE OF ASSISTIVE DEVICES
- IMPROVING COMMUNICATION
EXPECTED PATIENT OUTCOMES
- The patients mobility will be improved.
- The patient progresses towards self care.
- Patient maintains the bowel function
- Attains improved nutritional status.
- Achieves a method of communication
- Copes up with the effects of Parkinson’s disease.
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