Nursing Diagnoses related to Parkinson's Disease

Proper nursing assessment and appropriate interventions are essential for the health and well being of individuals with Parkinson’s disease. Because there are commonalities amongst all people with Parkinson’s disease, we can make nursing diagnoses that address these common issues and help to focus our care.

Here are five common nursing diagnoses that apply to most people with PD.

1. Impaired physical mobility related to stiffness and muscle weakness

2. Imbalanced nutrition: less than body requirements related to PD, as evidenced by weight loss. 

3. Impaired bowel elimination as evidenced by constipation related to slowed movement/peristalsis

4. Impaired verbal communication related to facial muscle stiffness

5. Self care deficit related to neuromuscular weakness, decline in strength, loss of muscle control/coordination

So what do we do now that we have a diagnosis? Here is an example of how a nurse would process a diagnosis, what he/she would designate as a plan or expected outcome and how to intervene to achieve the expected outcome. 

Actual/Potential Diagnosis	Related to…	Plan/Outcome	Nursing Intervention
Impaired physical mobility	Stiffness and muscle weakness secondary to PD	Plan: Client will engage in neuromotor exercise for 20-30 minutes per day (balance, coordination, gait) Outcome: improve and   maintain physical function and reduce falls	- Observe and assess current mobility -Assist with range of motion exercises -Encourage mobilization, support with walk-assist devices if needed - practice strength and balance exercise

Nursing care of individuals with Parkinson’s Disease can be very systematic and organized if one follows a care plan tailored to each individual patient. It is important to prioritize safety (risk of falls, impaired swallowing) and the goals of the patient. The job of the nurse is to maintain safety and improve the quality of life of the patient living with PD. Because there is no cure, symptom management is key and nursing can play a big role by working with the family to cultivate a plan that can be successful.

In case you're a visual learner, here is a cute little video that quickly summarizes some key nursing interventions for people with PD. 

Links for more information on nursing diagnoses (specific to Parkinson’s Disease):

1. http://careplannursing.blogspot.com/2012/03/parkinsons-disease-nursing-care-plan.html

2. http://nandanursingdiagnoses.blogspot.com/2012/08/7-nanda-nursing-diagnosis-for.html

3. http://nursingfile.com/nursing-care-plan/nursing-interventions/nursing-interventions-for-  parkinson%E2%80%99s-disease.html

4. http://ncpnanda.blogspot.com/2012/08/parkinsons-disease-nanda-nursing-care.html

References: 

Ackley, B.J., Ladwig, G.B. (2014). Nursing Diagnosis Handbook. Mosby/Elsevier

Nursing Care of Individuals with Parkinson's Disease

Nurses care for patients with Parkinson’s disease in many ways and in several different settings.  If a patient is hospitalized, care is round-the-clock. Nurses must monitor and administer medications, assist with mobilization and stabilization so that the patient can return home as soon as possible. Because most patients with PD are not in the hospital and they are living with their symptoms at home, this is what we’ll focus on.

A person who has PD has a lot of different symptoms that must be managed in their home environment to maintain a good quality of life and keep them out of the hospital. The nurse can help with the symptom management and care coordination between many other care professions- physical therapists, speech therapists, mental health counselors, etc. He or she may coordinate care from a doctor’s office or from a hospital, make house calls or oversee nursing assistant care on a daily basis. Nursing care of people with PD involves a great deal of patient/family education. It also requires astute assessment of the patient: complex medical and social history, progression of the disease, current state including gait assessment, cranial nerve assessment, motor function and more!

Assessment is a huge part of nursing but beyond that skill, there are many ways that nurses can help with the daily lives of those with PD. Check out this table for a summary of some of the most common nursing actions (aside from assessment) for people living with PD.

Symptom/Aspect of Care	Nursing Responsibilities
Bradykinesia/Rigidity	Physical exercises Medication education Teach how to get in and out of chair/bed Speech exercises
Diet	Guidelines of what to eat and when to eat Texture of diet (soft foods to prevent choking) Swallow evaluation Educate about high calorie, high fiber to help with constipation and weight loss Educate about avoiding caffeine and alcohol
Medication	Plan schedule and reminders Ensure patient understands purpose and routine for each medication Teach timing for each medication and whether or not to take it with food Use pill box if needed Monitor for side effects and balance therapeutic value with side effects Screen for drug interactions and contraindications
Sleep	Teach about proper sleep hygiene Ensure quiet environment Manage medication
ADLs (activities of daily living)	Teach patient how to use assistive devices, encourage independence Assist patient with ADLs if needed- feeding, dressing, teeth brushing
Fall prevention	Teach patient how to get in and out of a chair/bed Encourage mobilization Teach how to use walk-assist devices if needed
Mental Health	Assess mental health- depression and anxiety is common Provide emotional support Provide resources to mental health professionals

Some links for more information of nursing care of people with Parkinson’s Disease:

1. http://ncpnanda.blogspot.com/2012/08/parkinsons-disease-nanda-nursing-care.html

2. http://www.americannursetoday.com/caring-for-patients-with-parkinsons-disease/

3. http://ac.els-cdn.com.offcampus.lib.washington.edu/S0149763488800630/1-s2.0-S0149763488800630-main.pdf?_tid=43388e40-b23b-11e4-b069-00000aacb35f&acdnat=1423693012_fad282fe119c970b57ca07b72543d848

References:

Grosiran, B. (2012). Parkinson's Disease Nanda Nursing Care Plan. NCP Nanda

Accessed 2/12/15

Retrieved from http://ncpnanda.blogspot.com/2012/08/parkinsons-disease-nanda-nursing-care.html

Lynn, S. (2012). Caring for patients with Parkinson's disease. American Nurse Today. 7 (12). Retrieved from http://www.americannursetoday.com/caring-for-patients-with-parkinsons-disease/

Szigetti, E (1988). Nursing care of patients with Parkinson's disease. Neuroscience & Biobehavioral Reviews. 12: 307-309

Retrieved from

http://ac.els-cdn.com.offcampus.lib.washington.edu/S0149763488800630/1-s2.0-S0149763488800630-main.pdf?_tid=43388e40-b23b-11e4-b069-00000aacb35f&acdnat=1423693012_fad282fe119c970b57ca07b72543d848

Treatment Options

Because there is no cure for Parkinson’s Disease, treatment for the disorder is primarily symptom management. Treatment must figure in age, symptoms, stage of disease and level of physical activity. Treatment should be started when symptoms begin to interfere with daily life.

Remember that Parkinson’s Disease destroys the brain cells that produce dopamine and it is this reduction in dopamine that causes most of the (motor) symptoms of PD. So treatment is usually aimed at increasing the amount of dopamine circulating in the body. Dopamine cannot be given to a person directly because it cannot reach the brain. This is due to something called the blood brain barrier. The brain is very selective about what it allows to pass through it via the blood and dopamine is not allowed by itself. However, there is a drug that can pass the blood brain barrier and once it is in the brain it can be converted to dopamine and thus increase the levels in the brain – relieving symptoms! This medication is called Levodopa. We’ll focus on this medication for the treatment of PD because it is considered the most effective. Levodopa is given mostly in pill form but now there are trials of a gel form administered with a pump attached directly to the small intestine. It has to be administered with a drug called Carbidopa that keeps the drug intact until it reaches the brain so that it doesn’t get broken down by the body before it needs to be. These drugs are particularly effective for the symptom of bradykinesia (slowed movement) and rigidity.

Levodopa does have some side effects. The most common are nausea, sleepiness, dizziness and headache. Serious side effects include confusion, hallucinations and psychosis but if the person begins on a low does that is gradually increased, these side effects are rare. Levodopa is a quick acting drug and sometimes the effects wear off before a person with PD receives their next dose. This may cause some unpleasant motor symptoms such as jerking and muscle spasms. This is more likely to occur in individuals who have been taking Levodopa for long periods of time (upwards of 5 years). Also with long term use and progression of the disease, doses of Levodopa will have to be adjusted and slowly increased. Eventually sensitization may occur where the drug is no longer as effective. It is important to monitor symptoms and doses of the drug to ensure the best outcome.

The main objective in treatment of PD is to reduce the symptoms that interfere with daily life. If the medication that the person is taking has unpleasant side effects that also interfere with daily life, it is a judgment call on behalf of the patient, their family and the health professional whether or not to continue with the medications. There is a lot of trail and error when it comes to symptom management. 

Some other medications that can be used to help ease symptoms include:

•       Dopamine agonists- directly stimulate dopamine receptors in the brain
•       Monoamine oxidase inhibitors (MAOIs)- prevent dopamine from being broken down by blocking the effect of the enzymes that normally break it down.
•       Anticholiergic medications- reduce tremor symptoms
•       Treating Parkinson’s Disease requires symptom management and not just of the typical motor symptoms. Antidepressants, stool softeners and sleep medications may also be given.

Deep brain stimulation (DBS) is also a way to treat PD but it’s a little bit more invasive and usually used to treat later stages of the disease. It requires surgical placement of electrodes that send electrical pulses into the part of the brain involved in Parkinson’s Disease. It is thought that the stimulation reduces symptoms associated with PD by inactivating the parts of the brain that cause symptoms.  

Watch this video to see one man’s journey through DBS. It’s lengthy but very interesting.

                               

If video does not appear, please click on link to view it!

https://www.youtube.com/watch?v=MEBdXbZ5CDM

References:

Deep Brain Stimulation Surgery to treat Parkinson's Disease (2013). Youtube. Retrieved from https://www.youtube.com/watch?v=MEBdXbZ5CDM

Tarsy, D. (2015). Pharmacologic treatment of Parkinson disease. UptoDate. Retrieved from http://www-uptodate-com.offcampus.lib.washington.edu/contents/pharmacologic-treatment-of-parkinson-disease?source=search_result&search=treatment+of+parkinsons+disease&selectedTitle=1~150

Tarsy, D. (2014). Patient information: Parkinson disease treatment options — medications (Beyond the Basics). UptoDate

Retrieved from http://www-uptodate-com.offcampus.lib.washington.edu/contents/parkinson-disease-treatment-options-medications-beyond-the-basics?source=search_result&search=treatment+of+parkinsons+disease+beyond+basics&selectedTitle=2~150

Understanding Parkinson’s Disease- Diagnosis and Treatment (2015). WebMD. Retrieved from http://www.webmd.com/parkinsons-disease/guide/understanding-parkinsons-disease-treatment

Symptoms of PD and Disease Progression

We’ve talked a bit about the symptoms of Parkinson’s disease but this week we’ll break it down a little further. Let’s talk about the top 4 symptoms of the disease and from there discuss some other common symptoms, both motor and non-motor.

 The top four symptoms of Parkinson’s Disease that approximately 90% of all people with PD experience:

1.     Bradykinesia- slowness of movement all over the body

2.     Tremor- shaking that typically starts the hand and may spread as the disease progresses and affect the legs, lips, jaw and other body parts

3.     Rigidity- general stiffness

4.     Postural Instability- difficulty with balance

 Some common motor symptoms that are a bit less common than our top 4

•        Masked facial expression- harder to see the expression, or emotion, in the face
•        Stooped posture
•        Shuffling gait

      Non- Motor: 

•          Constipation
•         Difficulties with urination
•         Trouble swallowing (dysphagia)
•         Orthostatic Hypotension- drop in blood pressure when a person moves from lying position        to sitting/standing. It can cause dizziness and lightheadedness, even falls
•         Changes in/ difficulty with smell
•         Depression

Take a look at this image- it will give you a visual of a typical presentation of Parkinson’s Disease so you can have a better picture of what the disease affects.

Features of PD and Management of Symptoms:

The progression of PD is different for each individual- no doctor or nurse can predict exactly how the disease will unfold. Generally, a person who is diagnoses with Parkinson’s will live an average of 6-22 years after the diagnosis. The disease may progress from mild (symptoms are inconvenient but do not affect daily activities) to moderate (body slows down and motor symptoms may be present of both sides of the body) to advanced (needs assistance with all daily activities and person cannot live alone). Dementia occurs in approximately 40% of PD patients and the prevalence increases as the disease progresses. Generally, postural instability (one of our top four symptoms) occurs in later stages of the disease.

Symptom management, medication and access to care all influence a person’s quality life as they live with disease. It’s important to get the proper care and disease education to ensure the best quality of life possible.

References:

Chou, K (2014). Clinical manifestations of Parkinson’s disease. Retrieved from http://www-uptodate-com.offcampus.lib.washington.edu/contents/clinical-manifestations-of-parkinson-disease?source=machineLearning&search=symptoms+of+parkinson+disease&selectedTitle=1~150&sectionRank=1&anchor=H2#H2

Parkinson’s Disease Foundation (2015). Progression. Retrieved from http://www.pdf.org/en/progression_parkinsons

How does Parkinson’s Disease get diagnosed?

PD is a complicated disease and diagnosing it is very complex and sometimes challenging, especially in the early stages of the disease. There is not a specific blood test of biological marker that can be used to diagnose the disease. Researchers are working on this now and the hope is that one day there will be a diagnostic test! Stay tuned!

Because there is not a specific test we can use to diagnose the disease, diagnosis must be made by a trained clinician- usually a neurologist. The neurologist takes a thorough medical history and reviews the signs and symptoms to make a differential diagnosis. A differential diagnosis basically means the doctor rules out the possibility that the signs and symptoms could be explained by something else. The doctor rules out the possibility that the presenting symptoms are not caused by another disease process or even by medications a person is taking (it can happen!) Once other explanations are ruled out, the person can start a course of treatment for PD and see if it helps. If it helps, that’s a pretty reliable indicator that the person has PD.

 So what are these signs and symptoms that the doctor uses to make his/her differential diagnosis? Well, remember how PD is largely movement related? So these signs and symptoms used for diagnosis are mostly movement related too. To get the diagnosis of Parkinson’s the person needs to meet a symptom criteria. They must have bradykinesia (slowed movement) and either tremor or rigidity or both. There are more signs and symptoms of PD that are NOT movement related and sometimes they show up before the movement problems. Often they are hard to detect though. This video will help you understand some of the non-movement related symptoms doctors use to diagnose PD:

10 key non-movement symptoms of Parkinson's that everybody ought to know about

Now you know the basics of how a diagnosis of PD is made. It is important to be aware of the subtle indicators and note movement related problems but also the non-movement ones because early detection of PD can help in the treatment course!

Check out more resources here:

http://www.parkinson.org/Parkinson-s-Disease/Diagnosis

http://www.pdf.org/en/diagnosis

http://www.mayoclinic.org/diseases-conditions/parkinsons-disease/basics/tests-diagnosis/con-20028488

References:

Chou, K. (2014). Diagnosis of parkinson's disease. UptoDate. Retrieved from http://www-uptodate-com.offcampus.lib.washington.edu/contents/diagnosis-of-parkinson-disease?source=search_result&search=diagnosis+parkinson%27s+disease&selectedTitle=1~150

Giuffre, K. (2010, December 31). 10 key non-movement symptoms of Parkinson's that everybody ought to know about. Youtube. Retrieved from https://www.youtube.com/watch?v=h78x80xAMEk

Parkinson's Disease- tests and diagnosis. The Mayo Clinic. Retrieved from http://www.mayoclinic.org/diseases-conditions/parkinsons-disease/basics/tests-diagnosis/con-20028488

What Causes Parkinson's Disease? How does it work?

We really don’t know. It’s super frustrating, I know. So let's focus on what we DO know: how the disease works and what causes the symptoms.

Remember most symptoms are movement related- shaking (tremors), stiffness (rigidity), poor balance and a general slowness of all movement. These symptoms gradually progress as the disease does. There are other non-motor symptoms that affect a person’s mood, sleep cycle and even use of the 5 senses. The thinking process can also be affected and may sometimes result in dementia.

Now on to how the disease works. It all stems from a reduction in the amount of the neurotransmitter dopamine. Dopamine is a brain chemical that is essential for many things, among them… you guessed it, movement. In PD, a decrease in dopamine causes the movement related difficulties. The neurons that release dopamine hang out the in basal ganglia of the brain (it’s deep in the middle- check out this picture for help!)

The Basal Ganglia

A collection of small structures make up the basal ganglia but the one we care about the most is the substantia nigra. You can spot the substanta nigra because it is darker in color than the rest of brain tissue. This is because the cells there are pigmented. In a normally functioning brain the substantia nigra receives information from the rest of the body via the cerebral cortex. It processes that information and sends it back out to the cerbreal cortex (especially the motor cortex for our purposes). Once it sends the signal out, it influences the actions carried out by neurons in the motor cortex. Dopamine that is required for this signaling to be successful so as you can imagine, this is where problems arise. In Parkinson’s Disease, the cells of the substantia nigra die and they can no longer produce dopamine. This decrease produces the symptoms that contribute to a diagnosis of PD.

It’s super complicated, right? But wait, there’s more. The cells of the substantia nigra don’t just die and disappear. They actually stay in the brain and end up with these abnormal structures made of protein inside. These structures are called lewy bodies. The protein clumps together inside the neuron and this, as you can imagine, causes many problems.

Lewy bodies exist outside the substantia nigra, too. They can clump inside cells all over the brain and cause even more widespread damage. A lot of cognitive problems come along with this and the problem even has it’s own name. Lewy Body Dementia.  

Parkinson’s disease itself is not fatal. People with PD may be susceptible to other conditions that lead to premature death. Among the most common, dementia and pneumonia. It is important to remember that with proper symptom management and precautions, people with PD can live long and productive lives. The best way to help is to educate yourself and those around you!

Check out this video for a visual summary of the pathophysiology of PD!

For you information:

Easier reads:

http://www-uptodate-com.offcampus.lib.washington.edu/contents/parkinson-disease-the-basics?source=see_link

http://www-uptodate-com.offcampus.lib.washington.edu/contents/parkinson-disease-symptoms-and-diagnosis-beyond-the-basics?source=see_link

Super complex and in-depth:

http://www-uptodate-com.offcampus.lib.washington.edu/contents/etiology-and-pathogenesis-of-parkinson-disease?source=search_result&search=parkinson%27s+disease&selectedTitle=4~150

References:

Bergman, H. Deuschl, G.(2002). Pathophysiology of Parkinson's Disease: from clinical neurology to basic neuroscience and back. Movement Disorders. Vol 17 (3). 

Retrieved from

http://onlinelibrary.wiley.com.offcampus.lib.washington.edu/store/10.1002/mds.10140/asset/10140_ftp.pdf?v=1&t=i54h1xns&s=0431b8dfd982d82cfa7f4cc0cc5b7e780c584f24

Jankovic, J. (2014). Etiology and pathogenesis of Parkinson disease. UptoDate.

Retreived on from

http://www-uptodate-com.offcampus.lib.washington.edu/contents/etiology-and-pathogenesis-of-parkinson-disease?source=search_result&search=parkinson%27s+disease&selectedTitle=4~150

Epidemiology of Parkinson's Disease

So who is Mr. Parkinson? James Parkinson was an English doctor who published the first essay about the symptoms of what we now call Parkinson’s Disease. He published this work in 1817 and ever since there has been extensive research and discovery about the disease. Since the days of James Parkinson, there have been an increasing number of cases of PD.

Right now approximately 1% of people over the age of 60 in industrialized countries is living with Parkinson’s disease (de Lau & Breteler, 2006). It is rare for the disease to emerge before the age of 50 and as a person ages, risk of the getting the disease goes up. In fact, for people aged 60-69, approximately 1 in 200 people has PD but for people aged 70-79, 1 in 100 people have PD. And over 80 years old, 1 in 35 people have PD (Tanner, Brandabur & Dorsey, 2008). Parkinson’s is slightly more common in men than women (Lai & Tsui, 2001). It is also more prevalent in developed countries but trends are starting to change. Check out this graph that shows us the prevalence of PD in 2005 by country and then a projected estimate for the prevalence in 2030 (Tanner, Brandabur & Dorsey, 2008).

Distribution of Individuals with Parkinson’s Disease by Country, 2005 and 2030*

Because Parkinson’s affects the lives of so many, we have to ask what causes the disease? Unfortunately there is no simple answer to that question. There is not one particular cause for the disease and many of the influencing factors are poorly understood at this time. Research is going on as I type and that’s pretty exciting! Right now, here is a list of what the experts are investigating:

·      Parkinson’s is likely caused by a complicated interaction of genes and environment that is currently under research (de Lau & Breteler, 2006).

·      Exposure to environmental toxins (pesticides) is a potential cause that is currently undergoing a lot of research with some success in liking these chemicals to an increased risk of developing Parkinson’s (de Lau & Breteler, 2006).

·      Inheritability is being studied. 10-15% of PD cases are familial, meaning the disease runs in their family and may demonstrate a genetic component (Lai & Tsui, 2001).

·      Diet is under investigation as well as drinking habits (both alcohol and caffeine) (Lai & Tsui, 2001).

A diagnosis of Parkinson’s Disease is not a death sentence. People live with the disease for many years with proper symptom management. PD itself is not fatal but life-expectancy may be reduced. This is likely because many patients (25-40%) with PD will develop dementia. Pneumonia is the most common cause of death for someone with PD. This is because a person might have difficulty swallowing and food or liquid may accidentally settle in their lungs instead of their stomach. This can cause an infection in the lungs and a person will develop Pneumonia (Lai & Tsui, 2001).

Research is continuously going on. My hope is that we will learn more about the causes of the disease in the near future so that we can develop more effective care and screening tools to treat and prevent PD.

References:

deLau, L.M.L, Breteler, M.M.B. (2006). Epidemiology of Parkinson's Disease. The

Lancet Neurology 5 (6). Retrieved from http://www.sciencedirect.com.offcampus.lib.washington.edu/science/article/pii/S1474442206704719

Lai, B.C.L., & Tsui, J.K.C. (2001). Epidemiology of Parkinson's Disease. BC

Medical Journal, 43 (3). Retrieved from  http://www.bcmj.org/article/epidemiology-parkinson%E2%80%99s-disease

Tanner, C.M., Brandabur, M., Dorsey, E.R. (2008). Parkinson Disease: A Global View.

Research Reports. Retrieved from http://www.parkinson.org/NationalParkinsonFoundation/files/84/84233ed6-196b-4f80-85dd-77a5720c0f5a.pdf