PARKINSONISM

PARKINSONISMEtiology and Risk Factors, Signs and Symptoms, Disease Stages, Pathophysiology, Diagnostic Evaluation, Nursing Management

Parkinson’s disease is a neurodegenerative disorder which leads to progressive deterioration of motor function due to loss of dopamine- producing brain cells and is characterized by progressive loss of muscle control, which leads to trembling of the limbs and head while at rest, stiffness, slowness, and impaired balance.

ETIOLOGY AND RISK FACTORS

  • Age is the largest risk factor for the development and progression of Parkinson’s disease. Most people who develop Parkinson’s disease are older than 60 years years of age.
  • Men are affected about 1.5 to 2 times more often than women.
  • A small number of individuals are at increased risk because of a family history of the disorder.
  • Head trauma, illness, or exposure to environmental toxins such as pesticides and herbicides maybe a risk factor.

SIGNS AND SYMPTOMS

  • Tremors: Trembling in fingers, hands, arms, feet, legs, jaw or head. Tremors most often occur while the individual is resting, but not while involved in a task. Tremors may worsen when an individual is excited, tired, or stressed.
  • Rigidity: Stiffness of the limbs and trunk, which may increase during movement. Rigidity may produce muscle aches and pain. Loss of fine hand movements can lead to cramped handwriting (micrographia) and may make eating difficult.
  • Bradykinesia: Slowness of voluntary movement. Over time, it may become difficult to initiate movement and to complete movement. Bradykinesia together with stiffness can also affect the facial muscles and result in an expressionless, ‘mask-like’ appearance.
  • Postural instability: Impaired or lost reflexes can make it difficult to adjust posture to maintain balance. Postural instability may lead to falls.
  • Parkinsonian gait: Individuals with more progressive Parkinson’s disease develop a distinctive shuffling walk with a stooped position and a diminished or absent arm swing. It may become difficult to start walking and to make turns. Individuals may freeze in mid-strike and appear to fall forward while walking.

SECONDARY SYMPTOMS OF PARKINSON’S DISEASE

While the main symptoms of Parkinson’s disease are movement- related, progressive loss of muscle control and continued damage to the brain can lead to secondary symptoms. Some of the secondary symptoms include:

  • Anxiety , insecurity and stress
  • Confusion , memory loss, and dementia
  • Constipation
  • Depression
  • Difficulty swallowing and excessive salivation
  • Diminished sense of smell
  • Increased sweating
  • Male erectile dysfunction
  • Skin problems
  • Slowed, quieter speech, and monotone voice
  • Urinary frequency/urgency
  • Slow blinking
  • Stooped position

PARKINSON’S DISEASE STAGES

  • Stage one: During this initial phase of the disease, a patient usually experiences mild symptoms. These symptoms may inconvenience the day- to-day tasks the patient would otherwise complete with ease. Typically these symptoms will include the presence of tremors or experiencing shaking in one of the limbs.
  • Stage two: In the second stage of Parkinson’s disease, the patient’s symptoms are bilateral, affecting both limbs and both sides of the body. The patient usually encounters problems walking or maintaining balance and the inability to complete normal physical tasks becomes more apparent.
  • Stage three: Stage three symptoms of Parkinson’s disease can be rather severe and include the inability to walk straight or to stand. There is a noticeable slowing of physical movements in stage three.
  • Stage four: This stage of the disease is accompanied by severe symptoms of Parkinson’s. Walking may still occur, but it is often limited and rigidity and bradykinesia are often visible. During this stage, most patients are unable to complete day-to-day tasks, and usually cannot live on their own. The tremors or shakiness that takes over during the earlier stages however, may lessen or become nonexistent for unknown reasons during this time.
  • Stage five: The last or final stage of Parkinson’s disease usually takes over the patients physical movements. The patient is usually unable to take care of himself or herself and may not be able to stand or walk during this stage. A patient at stage five usually requires constant one-on-one nursing care.

PATHOPHYSIOLOGY

  • A substance called dopamine acts as a messenger between two brain areas – the substantia nigra and the corpus striatum – to produce smooth, controlled movements.
  • Most of the movement related symptoms of Parkinson’s disease are caused by a lack of dopamine due to the loss of dopamine – producing cells in the substantia nigra.
  • When the amount of dopamine is too low, communication between the substantia nigra and corpus striatum becomes ineffective, and movement becomes impaired.
  • The greater the loss of dopamine, the worse the movement- related symptoms. Other cells in the brain also degenerate to some degree and may contribute to non-movement related symptoms of Parkinson’s disease.

DIAGNOSTIC EVALUATION

  • At least two of the three major symptoms are present (tremor at rest, muscle rigidity, and slowness).
  • The onset of symptoms started on one side of the body.
  • Symptoms are not due to secondary causes such as medication or strokes in the area controlling movement.
  • Symptoms are significantly improved with levodopa.

MANAGEMENT

  • Medical management
  • Levodopa, Sinemet, levodopa and Carbidopa
  • Pramipexole, Ropinirole, Bromocriptine
  • Selegiline, Rasagiline
  • Amantadine or anticholinergic medications to reduce early or mild tremors
  • Entacapone

Other medications may include

  • Memantine, rivastigmine, galantamine for cognitive difficulties
  • Antidepressants for mood disorders
  • Gabapentin, duloxetine for pain
  • Fludrocortisone, Midrodrine, Botox, Sidenafil for autonomic dysfunction
  • Armodafinil, clonazepam, Zolpidem for sleep disorders.

NURSING MANAGEMENT

Nursing Diagnosis

  • Impaired Physical Mobility related to stiffness and muscle weakness
  • Self-care deficits related to neuromuscular weakness, decreased strength, loss of muscle control/coordination
  • Impaired bowel elimination: Constipation related to medication and decreased activity
  • Imbalanced nutrition: Less than body requirements related to tremor, slowing the process of eating, difficulty chewing and swallowing
  • Impaired verbal communication related to the decrease in the volume of speech, delayed speech, inability to move facial muscles.
  • Ineffective individual coping related to depression and dysfunction due to disease progression.
  • Knowledge deficit related to information resources inadequate maintenance procedures.

Interventions

  • Examine existing mobility and observation of an increase in damage
  • Do exercise program increases muscle strength
  • Encourage bath and massage the muscle
  • Help clients perform ROM exercises, self-care according to tolerance
  • Collaboration physiotherapists for physical exercise
  • Assess the ability and the rate of decline and the scale of 0-4 to perform ADL
  • Avoid what not to do the client and help if needed
  • Collaborative provision of laxatives and consult a doctor of occupational therapy
  • Teach and support the client during the client’s activities
  • Environmental modifications
  • Refer to speech therapy
  • Teach clients to use facial exercises and breathing methods to correct the words, volume, and intonation
  • Breathe deeply before speaking to increase the volume and number of words in sentences of each breath

Practice speaking in short sentences, reading aloud in front of the glass or into a voice recorder (tape recorder) to monitor progress.

PARKINSONISM
PARKINSONISM

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