NUR 331 Adult Health I: Alteration in Neural Functioning – Part 2

Parkinson's Disease

Slow, progressive neurologic movement disorder associated with decreased levels of dopamine

Parkinson's Disease Cardinal Manifestations

- tremor

- rigidity

- bradykinesia

- akinesia

- postural instability

Parkinson's Disease Autonomic Manifestations

- sweating

- drooling

- flushing

- orthostatic hypotension

- gastric and urinary retention

- dysphagia

Parkinson's Disease Psychiatric Manifestations

- depression

- anxiety

- dementia

- delirium

- hallucinations

Parkinson's Gait Example

- stooped posture

- rigidity

- flexed elbows & wrists

- trembling of extremities

- shuffling, short-stepped gait

- slight flexed hips & knees

- forward tilt of trunk

- masked facial expression

Pathophysiology of Parkinson Disease

Parkinson's Disease Motor Manifestations: Resting Tremor

- Pill-rolling tremor

- often unilateral

- decreases with movement

Parkinson's Disease Motor Manifestations: Rigidity

- Muscle stiffness

- cogwheel rigidity

Parkinson's Disease Motor Manifestations: Bradykinesia

- Slow movements

- difficulty initiating movement

- masked face

Parkinson's Disease Motor Manifestations: Postural Instability

- Stooped posture

- impaired balance

- fall risk

Parkinson's Disease Motor Manifestations: Gait Changes

- Shuffling gait

- reduced arm swing

- freezing

- festination

Parkinson's Disease Motor Manifestations: Other Motor Changes

- Micrographia

- soft monotone speech

- dysphagia

Parkinson's Disease Nonmotor Manifestations: Autonomic

- Orthostatic hypotension

- constipation

- urinary urgency

- sweating

Parkinson's Disease Nonmotor Manifestations: Cognitive

- Slowed thinking

- memory impairment

- possible dementia

Parkinson's Disease Nonmotor Manifestations: Psychological

- Depression

- anxiety

- apathy

Parkinson's Disease Nonmotor Manifestations: Sleep

- Insomnia

- daytime sleepiness

- REM sleep behavior disorder

Parkinson's Disease Nonmotor Manifestations: Sensory

Decreased sense of smell (hyposmia)

Parkinson's Disease Nonmotor Manifestations: Other

- Fatigue

- drooling

- swallowing difficulties

Medical Management of Parkinson's Disease

- Treatment directed toward controlling symptoms and maintaining functional independence

- Pharmacologic treatment: Levadopa

- Surgical procedures

- Stereotactic Procedures

- thalamotomy

- pallidotomy

- Neural transplantation: ongoing research

Surgical Management of Parkinson Disease

- Considered for disabling tremor, rigidity, or severe dyskinesia

Surgical Management of Parkinson Disease: Deep brain stimulation (DBS)

- Most effective interventional therapy

- Involves surgical implantation of an electrode into the brain

Surgical Management of Parkinson Disease: Magnetic resonance-guided high-intensity focused ultrasound (MRgFUS)

- Approved for tremors

- Creates tissue damage at specific targets in the brain

Assessment of the Patient with Parkinson's Disease

- Focus on the degree of disability and functional changes that occur throughout the day, such as responses to medication

- Almost every patient with a movement disorder has some functional alteration and may have some type of behavioral dysfunction

- Quality of speech, loss of facial expression, swallowing deficits (drooling, poor head control, coughing), tremors, slowness of movement, weakness, forward posture, rigidity, evidence of mental slowness, and confusion

- Fall risk assessment

Planning and Goals for the Patient with Parkinson's Disease

- Improving functional mobility

- Maintaining independence in ADLs

- Achieving adequate bowel elimination

- Attaining and maintaining acceptable nutritional status

- Achieving effective communication

- Developing positive coping skills

Parkinson's Disease Nursing Interventions: Promote Mobility

- Encourage exercise

- ROM

- physical therapy to maintain strength and flexibility

Parkinson's Disease Nursing Interventions: Prevent Falls

- Assist with ambulation

- remove hazards

- use assistive devices

Parkinson's Disease Nursing Interventions: Improve Gait

- Encourage upright posture

- deliberate steps

- visual cues to overcome freezing

Parkinson's Disease Nursing Interventions: Promote Independence

- Allow extra time for ADLs

- provide adaptive equipment

Parkinson's Disease Nursing Interventions: Administer Medications on Time

- Maintain symptom control

- prevent worsening of motor symptoms

Parkinson's Disease Nursing Interventions: Manage Orthostatic Hypotension

- Monitor BP

- encourage slow position changes to prevent dizziness and falls

Parkinson's Disease Nursing Interventions: Prevent Aspiration

- Assess swallowing

- position upright during meals

- consult speech therapy

Parkinson's Disease Nursing Interventions: Promote Nutrition

- Offer small, frequent meals

- monitor weight

- allow extra time to eat

Parkinson's Disease Nursing Interventions: Improve Communication

- Encourage slow, deliberate speech

- allow time for responses

Parkinson's Disease Nursing Interventions: Manage Constipation

Encourage fluids, fiber, and activity as tolerated

Parkinson's Disease Nursing Interventions: Support Sleep

- Promote consistent sleep routines

- minimize nighttime disturbances

Parkinson's Disease Nursing Interventions: Provide Emotional Support

- Assess for depression and anxiety

- encourage support systems

Parkinson's Nursing Priorities

- Parkinson's disease involves both motor and nonmotor manifestations.

- Bradykinesia is a defining motor feature, while dysphagia, postural instability, and autonomic dysfunction contribute to important nursing safety concerns.

- Fall prevention, aspiration precautions, maintaining mobility and independence, and administering antiparkinsonian medications at their prescribed times.

Myasthenia Gravis

- Autoimmune disorder affecting the neuromuscular junction

- Characterized by varying degrees of muscle weakness

- Estimated 14 to 40 per 100,000 people in the U.S.

- More common in females aged 20-30 and males older than 60

Myasthenia Gravis Pathophysiology

- Acetylcholine release and muscle contraction

- Antibodies block acetylcholine receptor sites

- Resulting muscle weakness with continued activity

- Thymus gland involvement in antibody production

Myasthenia Gravis CM

- Ocular and generalized types

- Diplopia and ptosis in ocular form

- Bulbar symptoms

- limb weakness

- respiratory failure in a generalized form

- Risk of myasthenic crisis

Myasthenia Gravis Assessment and Diagnostic Findings

- Tensilon test and ice test

- Blood tests for acetylcholine

- Repetitive nerve stimulation (RNS) and single-fiber electromyography (EMG)

- CT or MRI scan for thymus gland enlargement

Myasthenia Gravis Medical Management

- Improving function and reducing circulating antibodies

- Anticholinesterase medications

- immunosuppressive therapy

- IVIG

- therapeutic plasma exchange

- thymectomy

Amyotrophic Lateral Sclerosis (ALS)

- Unknown cause

- Loss of motor neurons

- Neuronal degeneration in upper and lower motor neurons

- Will lead to full paralysis including respirator paralysis

Amyotrophic Lateral Sclerosis (ALS): Clinical manifestations

- Fatigue

- Progressive muscle weakness

- Cramps

- Fasciculations (twitching)

- Lack of coordination

Amyotrophic Lateral Sclerosis (ALS): Assessment and diagnosis

- Electromyography (EMG) and muscle biopsies

- Diagnosed based on signs/symptoms

Amyotrophic Lateral Sclerosis (ALS): Management

- Progressive, debilitating, incurable

- Symptom management

- Provide emotional support

ALS Risk Fctors

- Age

- Autoimmune disease

- Environmental exposure to toxins

- Excessive alcohol consumptions

- Family history

- Genetics

- Low body mass index

- Smoking

- Viral Infections

Huntingdon's Chorea Disease

- Progressive, inherited neurodegenerative disorder affecting movement, cognition, and behavior

- Autosomal dominant inheritance

- Progressive degeneration of neurons, particularly in the basal ganglia Loss of inhibitory motor control contributes to involuntary movements (chorea)

- Symptoms typically begin in adulthood and progressively worsen

HD CM: Motor Manifestations

- Chorea: involuntary, rapid, jerky movements

- Impaired coordination, balance, and gait

- Dysarthria (difficulty speaking)

- dysphagia (difficulty swallowing)

- Progressive rigidity and difficulty initiating movement in later stages

HD CM: Cognitive and Psychiatric Manifestations

- Impaired memory, judgment, and concentration

- Progressive cognitive decline and dementia

- Depression, anxiety, irritability, and impulsivity

- Personality and behavioral changes

HD CM: Others

- Weight loss

- increased fall risk

- aspiration risk

HD Nursing Interventions: Safety and Mobility

- Implement fall precautions

- assist with ambulation and ADLs

- Encourage physical and occupational therapy

HD Nursing Interventions: Nutrition and Aspiration Prevention

- Assess swallowing and monitor for aspiration

- Provide high-calorie meals as indicated

- monitor weight

- Position upright during meals

- consult speech-language pathology

HD Nursing Interventions: Psychosocial Support and Medications

- Assess for depression and suicide risk

- Provide patient and caregiver support

- refer for genetic counseling

- Administer prescribed medications to manage chorea and psychiatric symptoms

HD Nursing Interventions: Priority nursing concerns

- Injury prevention

- aspiration

- inadequate nutrition

- psychosocial well-being.