Week 3: Exemplar: Parkinson's disease

what is Parkinson’s disease?

a progressive, degenerative neurologic disorder that primarily affects movement

How would PD be characterized?

loss of dopaminergic neurons; connection between DA and ACh isn’t working

what is the etiology for PD?

• exact cause unknown

• likely combination of genetic susceptibility and exposure to environmental factors

what are the risk factors for PD?

• risk increases with age

• men at higher risk

• living in rural area

• certain occupations

how to diagnose PD?

• no specific test

• medical history, discussion of symptoms

• rule out any other causes of symptoms (head injury, etc)

what are ways to prevent PD?

• no definitive way to prevent

• healthy diet and nutritional supplements

what are some motor clinical manifestations for PD?

• tremor

  • +/- pill rolling

• rigidity

  • ex. cogwheel rigidity

• bradykinesia

  • can manifest with speech/swallowing/chewing issues such as drooling , hypophonia, etc.

• postural instability

  • shuffling steps, retropulsion, freezing of gait

what are some non-motor clinical manifestations for PD?

• cognitive deficits

  • slow thinking, memory loss

• emotional changes

  • depression, fear, anxiety

• sleep problems

  • insomnia, restless leg syndrome

what is freezing of gait?

an abnormal gait pattern that can accompany Parkinson’s disease as well as other parkinsonian disorders

what is Parkinsonism?

• individuals with motor symptoms commonly seen in PD are said to have “Parkinsonism”

• not everyone who has Parkinsonism has PD

• can be caused by medications, head trauma, etc

• said to have it if their symptoms do not resolve with PD medications like dopaminergic drugs

what are the nursing assessment goals for PD?

• prevent injury

• optimize mobility

• promote independence

what are non-pharmacologic interventions for PD?

• enhancing self-care activities

• improving bowel elimination

• improving nutrition

• enhancing swallowing

• encouraging use of assistive devices

• improving communication

• supporting coping abilities

• daily exercise

what kind of exercise would not be recommended for someone with PD?

• taking the stairs unless with someone

• driving

• running

• swimming

• anything with balance

what are the drugs for PD?

• dopamine replacement

• dopamine agonists

• MAO-B inhibitors

• Anticholinergics

what is the prototype for dopamine replacement?

levodopa/carbidopa(keeps it in brain and prevents brain from breaking it down)

what is the mechanism of action for levodopa/carbidopa?

• increases dopamine levels in the brain or mimics dopamine activity to improve motor control

• reduce symptoms of PD

what does levodopa/carbidopa do?

• decreases muscle stiffness

• decrease tremors

• decrease spasms

• increase muscle control

what are the adverse outcomes for PD?

• dyskinesia, dystonia

• orthostatic hypotension

• sleep disturbances, insomnia, fatigue

• nausea, vomiting, anorexia

• confusion, agitation

• headache

What to monitor and respond for dyskinesia and dystonia?

monitor:

• abnormal, involuntary movements, on-off effects

respond:

• hold and notify provider

What to monitor and respond for orthostatic hypertension?

monitor:

• BP with position change

Response:

• instruct pt to use call light

• assistance with transfer/repositioning as needed

• fall risk precautions

What to monitor and respond for sleep disturbances, insomnia, and fatigue?

monitor:

• patient report of sx

Response:

• sleep hygiene

• supplements

• notify provider

What to monitor and respond for nausea, vomiting, and anorexia?

monitor:

• patient report

response:

• encourage to take with or after meal;

• try ginger candy or ginger capsules

• notify provider esp with repeated vomiting

What to monitor and respond for confusion and agitation?

monitor:

• disorientation

• cognitive changes

• mood

response

• ensure safety

• reorient

• consistent day-night routine

• notify provider

What to monitor and respond for headaches?

monitor:

• patient report of sx

response:

• PRN pain meds or non-pharm techniques

• notify provider if disruptive

what to be caution when it comes to dopamine replacement?

MOAI (HTN crisis)

what is dopamine agonists?

help with minor symptoms; less effected compared to sinamet; used early by itself or used later with levadopa for adverse disease

what is the prototype drug for dopamine agonists?

pramipexole

what is the mechanism of action pramipexole is?

mimics dopamine activity to improve motor control and reduce symptoms

what does pramipexole do?

• decrease tremor

• decrease rigidity

• decrease bradykinesia

• increase balance

what are the adverse outcomes with pramipexole?

• hallucinations (increases with age)

• dizziness

• orthostatic hypotension

• nausea

• drowsiness

what to monitor and respond for hallucinations?

monitor:

• disorientation

• cognitive changes

• mood

• patient sense of safety

Response:

• ensure safety of pt and staff

• reorient

• notify provider

what to monitor and respond for dizziness?

monitor:

• LOC

• neurochanges

Response:

• ensure safety

• fall risk precautions

• notify provider

what to monitor and respond for othostatic hypotension?

monitor:

• BP with position changes

Response:

• instruct pt to use call light

• assistance with transfer/repositioning as needed

• fall risk precautions.

what to monitor and response with nausea?

monitor:

• patient report

Response:

• encourage to take with or after meal

• try ginger candy or ginger capsules

• notify provider esp with repeated vomiting

what to monitor and respond for drowsiness?

monitor:

• LOC

• sleep hygiene

Response:

• ensure safety

• notify provider

what is MAO-B inhibitors?

adjunct to levodopa, normally when leaning off, and early PD signs and symptoms

what is prototype drug for MAO-B inhibitors?

selegiline

what is the mechanism of action of selegiline?

prevents the breakdown of dopamine = extend the action of dopamine

what does selegiline do?

• improve motor symptoms

  • decrease slowness, stiffness, and tremor

  • increase sleep quality

  • decrease reducing fatigue

what are the adverse outcomes of selegiline?

• nausea, vomiting

• orthostatic hypotension

• confusion, agitation

• dyskinesia, dystonia

what to monitor and respond for nausea and vomiting?

monitor:

• patient report

Response:

• encourage to take with or after meal

• try ginger candy or ginger capsules

• notify provider esp with repeated vomiting.

what to monitor and respond for orthostatic hypotension?

monitor:

• BP with position changes

Response:

• instruct pt to use call light

• assistance with transfer/repositioning as needed

• fall risk precautions..

what to monitor and respond for confusion and agitation?

monitor:

• disorientation

• cognitive changes

• mood

Response:

• ensure safety

• reorient

• consistent day-night routines

• notify provider.

what to monitor and respond for dyskinesia and dystonia?

monitor:

• abnormal, involuntary movements

• on-off effect

Response:

• hold and notify provider

what are anticholinerics?

works more with ACh; oldest antiparkinson drug and effective at reducing tremor

what is the prototype drug for anticholinergics?

benztropine

what is the mechanism of action for benztropine?

blocks the activity of acetylcholine therefore restoring the balance of acetylcholine and dopamine

what does benztropine do?

• decrease tremor

• decrease rigidity

• decrease mm contracture

• decrease salvation

• decrease sweating

what are the adverse outcomes for benztropine?

• blurred vision

• tachycardia, dysrhythmias

• constipation

• dry mouth, nose, throat

• urinary retention

• dizziness, confusion

what to monitor and respond for blurred vision?

monitor:

• patient report of visual disturbances

Response:

• advise this is temporary

• avoid activities requiring clear vision

• notify provider

what to monitor and respond for tachycardia and dysrhythmias?

monitor:

• increase HR

• EKG changes

Response:

• hold med and notify provider

what to monitor and respond for constipation?

monitor:

• BM frequency

• patient report of difficulty

Response:

• increase fluid and fiber

• notify provider

• anticipate stool softeners

what to monitor and respond for dry mouth, nose and throat?

monitor:

• patient report of dry mouth, oral examination

Response:

• provide sips of water

• sugar-free gum or lozenges

• humidified air

• notify provider if severe

what to monitor and respond for urinary retention

monitor:

• post-void residual

Response:

• anticipate order for catheterization

• notify provider

what to monitor and respond for dizziness and confusion?

monitor:

• LOC

• disorientation

• cognitive changes

Response:

• ensure safety

• consistent day-night routines

• notify provider

what are drugs that address non-motor symptoms?

antidepressants, anxiolytics, and antipsychotics