Parkinsons Disease

A progressively degenerative neurological disorder

affecting the brain centers (substantia nigra and basal
ganglia) responsible for control & regulation of
movement
Occurs in 1% of pop. Over 50, affects men > women
Pathophysiology: depletion of dopamine levels in the
basal ganglia of the mid brain, which is where
dopamine is produced & stored.
Dopamine promotes smooth, purposeful movements of
motor function
Dopamine depletion impairment of the extrapyramidal
tracts w loss of movement coordination
Parkinsons Disease
Cause: unknown
Some heredity causes
Secondary iatrogenic PD is drug or chemical related
Dopamine depleting drugs: reserpine. Phenothiazine,
metoclopromide, butyrophenones (droperidol & haloperidol)
Clinical manifestations: 3 cardinal signs
Bradykinesia / akinesia slowness of movement or
complete or partial loss of movement; difficulty w balance
involuntary tremors course, rest tremor of the fingers &
thumb ( pill-rolling movement) of one hand, occurs during
rest, & intensifies w stress, fatigue, cold, disappears during
sleep, the tremor can occur in tongue, lip, jaw, chin;
eventually spreads to the foot on the same side
Parkinsons Disease
Progressive muscle rigidity to antagonistic muscle groups,
causing resistance to both extension & flexion
Flexion contractures develop in the neck, trunk, elbows, knees & hip
Face expressionless, mask-like appearance, drooling & tearing
ability
Propulsive gait
Speech: high-pitched monotone voice & parroting the
speech of others
Hypothalmic dysfunction: or perspiration, heat
intolerance, seborrhea, & oil production
Psychosocial : PD does not affect intellectual ability
20% of pts will end up having dementia (Alzheimers ds)



Parkinsons Disease
Diagnostic Evaluation: no specific dx tests
History: progresses thru stages
Mild unilateral dysfunction
Mild bilateral dysfunction, expressionless face &
gait changes
dysfunction w walking, initiating movements, and
maintaining equilibrium
Severe disability- difficulty in walking, & maintaining
balance & steady propulsion, rigidity
Invalid bed rest

Question
Which of the following is not a cardinal sign
of Parkinsons disease?
a. Tremor
b. Dementia
c. Bradykinesia
d. Rigidity
Parkinsons Disease
Drug therapy
Goal is to enhance dopamine transmission
Dopaminergics
Levodopa is to provide dopamine to the basal ganglia,
is a synthetic metabolic precursor to dopamine. Dopamine
itself can not be used because it can not cross the blood
brain barrier. Given in combination w Sinemet (carbidopa)
to allow more levodopa to reach the brain and it prevents
peripheral metabolism of levodopa; beneficial first few
years; on & off reactions;
Sinemet
most common drug (carbidopa-levodopa)
SE = Orthostatic hypotension, nausea, hallucinations, dyskinesia
Nsg considerations: monitor B/P, use TED hose to venous return,
monitor for urinary retention.
PD drug therapy
Dopaminergics
Symmetrel (amantadine)
Action causes release of dopamine in CNS
Indications rigidity, bradykinesia
SE dizziness, ataxia, insomnia, leg edema
Nsg considerations monitor for postural hypotension,
do not administer at bed time
PD - drug therapy
Anticholinergic to block the release of
acetylcholine (balance between dopamine &
acetylcholine) and to block the excitatory effects
of the cholinergic system
Artane (trihexphenidyl)
Cogentin (benztropine)
Parsidol (ethopropazine)
Indications: tremor, rigidity, drooling
SE: dry mouth, constipation, blurred vision, confusion,
hallucinations
Nursing Indications: usually contraindicated in acute-angle
glaucoma, & tachycardia, monitor pulse & B/P during dosage
adjustments, administer w meals, do not withdraw meds sudden

PD drug therapy
Antihistamines:
Benadryl
Indications: tremor, rigidity, insomnia
SE: dry mouth, lethargy, confusion
Nsg considerations: use w caution in pts w seizures,
hypertension, hyperthyroidism, renal ds, diabetes, administer w
meals or antacids.
Dopamine agonists
Parlodel (bromocriptine)
Action: activates dopamine receptor in the CNS, helpful
for tx of on-off reactions
Indications: fluctuation of manifestations, dyskinesia,
dystonia
SE: Hallucinations, mental fogginess, orthostatic
hypotension, confusion
Nsg considerations: monitor B/P & mental status
PD drug therapy
COMT inhibitors [catechol-O-methyltransferase}
Tolcapone
Action: enhance effect of dopamine
Indications: adjuvant treatment
SE: diarrhea, liver enzymes
Nsg: monitor LE
MAO inhibators
Deprenyl (selegiline)
Action: inhibitmonoamine oxidase B, an enzyme that converts
chemical byproducts in the brain into neurotoxins that prevent
substantia nigra cell death
Indications: adjuvant tx
SE: nausea, dizziness, confusion, hallucinations, dry mouth
Nsg: monitor for levodopa SE, Selegiline may effects of levodopa
Antidepressants

Parkinsonian Crisis
Sudden or inadvertent withdrawal of anti-PK
drugs or emotional trauma, pts experiencing
severe exacerbation of tremor, rigidity and
bradykinesia, along w acute anxiety,
sweating, tachycardia.
Interventions: respiratory & cardiac support,
subdued lighting, mild barbiturates, anti PK
drugs
PD nursing management
Improve mobility
Exercise & stretch regularly (first thing in morning)
Encourage daily ROM to avoid rigidity & contractures
Enhance walking walk erect, watch horizon, wide-based
gait, heel-toe gait, long strides.
Use cane or walker prevent falls
Improve hydration & nutrition
Maintain fluid intake 2 L/24 hrs
Monitor weight & ability to chew & swallow
Upright position to chew & swallow, offer small freq. meals, soft foods
& thick cold foods supplemental puddings
Prevent aspiration think thru the steps of swallowing, keep lips
closed, keep teeth together, chew, finish one bite before another
PD nursing management
Improve bowel elimination
Stool softners, mild laxatives, regular routine, fiber,
raised toilet seat
Enhance self-care
Extra time needed to perform ADLs, use of side
rails, overhead trapeze.
Reinforce occupational & physical therapy
Sleep on firm mattress, prevent neck contractures
Improve communication
Speech therapy speak slowly, use board,
mechanical voice synthesizer
PD nursing management
Support coping abilities
Feel embarrassed, depressed, lonely, bored
Pd progresses, more rigidity & unresponsive to verbal
stimuli, treat w dignity, do not ignore clients
Client to be active participant in EO
Explore feelings
Education
Services: American Parkinsons Disease
Foundation
Myasthenia Gravis
Autoimmune disorder affecting the myoneural
junction
Antibodies directed at acetylcholine at the
myoneural junction impair transmission of
impulses
Manifestations
Myasthenia gravis is a motor disorder
Initially, symptoms involve ocular muscles, causing
conditions such as diplopia and ptosis
Weakness of facial muscles, swallowing and voice
impairment (dysphonia), generalized weakness
Myasthenia Gravis (cont.)
ACh receptor site in myasthenia
gravis
Normal ACh
receptor site
Medical Management
Pharmacologic therapy
Cholinesterase inhibitor: pyrostigmine
bromide (Mestinon)
See Chart 64-4
Immunomodulating therapy
Plasmapheresis
Thymectomy

Cholinergic
Crisis
Result of disease
exacerbation or a
precipitating event,
most commonly a
respiratory infection
Severe generalized
muscle weakness with
respiratory and bulbar
weakness
Patient may develop
respiratory compromise
failure
Caused by
overmedication with
cholinesterase
inhibitors
Severe muscle
weakness with
respiratory and bulbar
weakness
Patent may develop
respiratory compromise
and failure
Myasthenic
Crisis
Management of Myasthenic
Crisis
Patient instruction in signs and symptoms of
myasthenic crisis and cholinergic crisis
Ensuring adequate ventilation; intubation and
mechanical ventilation may be needed
Assessment and supportive measures include:
Ensure airway and respiratory support
Take ABGs, serum electrolytes, I&O, and daily weight
If patient cannot swallow, nasogastric feeding may be
required
Avoid sedatives and tranquilizers
MG - management
No cure
Drug therapy: two groups of medications
Short-acting anticholinesterase compounds
Mestinon (pyridostigmine)
Prostigmin (neostigmine)
Corticosteriods
Prednisone = assists in reducing the levels of serum
Ach receptor antibodies, steroids may temporary
worsen the symptoms followed by improvement
Immunosuppressive therapy: the level of
circulating Ach receptor antibodies
Imuran (azaathioprine)
Sandimmune (cycloporine)



Question
A patient is undergoing a Tensilon test to
diagnose myasthenia gravis. Which of the
following medications should be available
to control the side effects of Tensilon?
a. Lidocaine
b. Atropine
c. Mestinon
d. Copaxone
MG Nursing Management
Improve resp function
Increase physical mobility
Improve communication
Provide eye care
Prevent aspiration
Nursing ProcessThe Care of the
Patient With Myasthenia Gravis
Focus on patient and family teaching
Provide medication teaching and management
Implement energy conservation measures
Implement strategies to help with ocular
manifestations
Prevent and/or manage complications and avoid
crisis
Implement measures to reduce risk of aspiration
Avoid stress, infections, vigorous physical
activity, some medications, and high
environmental temperatures
Amyotrophic Lateral Sclerosis
(ALS)

Lou Gehrigs disease
Loss of motor neurons in the anterior horn of
the spinal cord and loss of motor nuclei in the
brain stem cause progressive weakness and
atrophy of the muscles of the extremities and
trunk; weakness of the bulbar muscles impairs
swallowing and talking; and respiratory
function is also impaired

Amyotrophic Lateral Sclerosis
(ALS)
Course of ds- death from pneumonia in 3-5 yrs.
Diagnosis: clinical s&s; EMG changes, muscle
biopsies, CSF analysis, CT, & MRI
Nursing Management is focused on the tx of
symptoms & rehabilitation measures

Nutrition:
Airway management:
Guillain-Barr Syndrome
Autoimmune disorder with acute attack of
peripheral nerve myelin
Rapid demyelination may produce respiratory
failure and autonomic nervous system
dysfunction with CV instability
Most often follows a viral infection
Manifestations are variable and include
weakness, paralysis, paresthesias, pain,
diminished or absent reflexes starting with the
lower extremities and progressing upward, bulbar
weakness, cranial nerve symptoms, tachycardia,
bradycardia, hypertension, or hypotension
Guillain Barre Syndrome
Also known as acute demyelinating
polyneuropathy or acute idiopathic polyneuritis,
results in a temporary, flaccid paralysis lasting
4-8 weeks
Medical emergency, 80% will recover
The syndrome is preceded by a resp. or GI,
viral infection 1 to 3 weeks prior to the onset of
paralysis.
Autoimmune hypothesis
Campylobacter jejuni is the organism most assoc.
Affects both men & women equally & of all
ages.
Guillain-Barr Syndrome (cont.)
Medical management
Requires intensive care management with
continuous monitoring and respiratory support
Plasmapheresis and IVIG are used to reduce
circulating antibodies
Recovery rates vary but most patients
recover completely

Nursing ProcessAssessment of the
Patient With Guillain-Barr Syndrome
Conduct ongoing assessment with
emphasis on early detection of life-
threatening complications of respiratory
failure, cardiac dysrhythmias, and deep
vein thrombosis
Monitor for changes in vital capacity and
negative inspiratory force
Assess VS frequently/continuously including
continuous monitoring of ECG
Encourage patient and family coping
Interventions
Enhance physical mobility and prevent DVT
Support limbs in a functional position
Perform passive ROM at least twice daily
Initiate position changes at least every 2 hours
Provide elastic compression hose and/or sequential
compression boots
Provide adequate hydration
Administer IV and parenteral nutrition as prescribed
Carefully assess swallowing and gag reflex and take measures to
prevent aspiration
Develop a plan for communication individualized to patient needs
Decrease fear and anxiety
Provide information and support
Provide referral to support group
Implement relaxation measures
Maintain positive attitude and atmosphere to promote a sense
of well-being
Implement diversional activities


Interventions (cont.)
Develop a plan for communication
individualized to patient needs
Decrease fear and anxiety
Provide information and support
Provide referral to support group
Implement relaxation measures
Maintain positive attitude and atmosphere to
promote a sense of well-being
Implement diversional activities