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