NURSING CARE

MANAGEMENT OF
CLIENTS WITH
PARKINSON’S DISEASE
NCM 0116 RELATED LEARNING EXPERIENCE
2ND SEMESTER A.Y. 2020-2021
As a Third-year nursing student, you are
assigned for your clinical exposure at the
Medical-Surgical ward of a tertiary
hospital in Pampanga. But before you
meet your patient, your clinical instructor
will give you an ungraded pre-test about
Parkinson’s disease. This is to see how
familiar you are with the topic.
Parkinson’s disease is a degenerative
brain disorder that leads to shaking,
stiffness, and difficulty with walking,
balance, and coordination.
Parkinson’s disease is a degenerative
brain disorder that leads to shaking,
stiffness, and difficulty with walking,
balance, and coordination.
Aging affects many cellular
processes that predispose to
neurodegeneration,
and age-related changes in
cellular function predispose
to the pathogenesis of
Parkinson’s disease.
Aging affects many cellular
processes that predispose to
neurodegeneration,
and age-related changes in
cellular function predispose
to the pathogenesis of
Parkinson’s disease.
 Reduced Folate and estrogen levels
may increase a person’s susceptibility
to Parkinson’s disease.
 Reduced Folate and estrogen levels
may increase a person’s susceptibility
to Parkinson’s disease.
Mental deterioration is
often the first sign of
Parkinson’s disease.
Rationale: Tremor is often
the first sign of
Parkinson’s disease.
Bilateral resting “pill-rolling” tremors
are cardinal features of patients with
Parkinson’s disease.
 Rationale: UNILATERAL resting “pill-
rolling” tremors are cardinal features of
patients with Parkinson’s disease.
The onset of Parkinson’s
disease is gradual, with
an ongoing progression.
 The onset of
Parkinson’s disease is
gradual, with an
ongoing progression.
The treatment of Parkinson’s disease is directed
toward controlling symptoms, maintaining
functional independence and prevent disease
progression.
 Rationale: Treatment is directed at
controlling symptoms and maintaining
functional independence because there are
no medical or surgical
approaches that prevent disease
progression.
 Levodopa is the gold
standard drug therapy
for Parkinson’s disease.
 Levodopa is the gold
standard drug therapy
for Parkinson’s disease.
 Parkinson's crisis is a rare but life-threatening
complication of Parkinson's disease, with a sudden
worsening of motor symptoms and severe akinesia.
 Parkinson's crisis is a rare but life-threatening
complication of Parkinson's disease, with a sudden
worsening of motor symptoms and severe akinesia.
 Anticholinergic like
Selegiline may help
control tremors in early
stages of Parkinson’s
Disease.
 Rationale:
Selegiline is a Monoamine oxidase inhibitor.
Anticholinergic (Congentin) may help control
tremors in early stages of Parkinson’s
Disease.
 For today’s clinical exposure, your
clinical instructor assigned you to Mr.
Jose Cruz, a 75 years old male patient
who has been suffering from Parkinson’s
disease for the past 10 years.
Curious about your patient’s case and
disease condition, during your pre-
conference for the day, you asked your
clinical instructor about Parkinson’s
disease. Your group engaged in a
discussion regarding the disease
condition. Your clinical instructor gave
you an interactive handout as you
discussed Parkinson's disease.
 PARKINSON’S DISEASE
(___________________/Shaking palsy)

slow, progressive disorder of the brain when Named after James Parkinson, a British
dopamine-producing cells that help control Doctor who identified the ailment’s unique
muscle movement begin to degenerate. symptoms in 1817

voluntary and involuntary movement  An estimated seven to 10 million people

person loses ability to execute smooth,
controlled movement
Mental deterioration occurs late in the disease
worldwide have Parkinson’s disease.
Incidence of PD increases with age, though
4% of people with PD are diagnosed before
age 50 years.
 Acetylcholine VS. Dopamine
BALANCE between:
Acetylcholine (excitatory)
Dopamine (inhibitory)

↓Dopamine = ↑ Acetylcholine

Leads to overstimulation of neurons = rigidity, tremors, etc.

 Unknown; predominantly idiopathic

othe cause of cellular degeneration is unknown.

odisease is characterized by degenerative changes in the SUBSTANTIA NIGRA,
which produces dopamine, a chemical substance that enables people to move
normally and smoothly.
ocellular loss of about 80% or dopamine loss of 60% from normal amount leads
to manifestation due to an imbalance with AcH levels.
opresence of _____________________: concentric, eosinophilic, cytoplasmic
inclusions with peripheral halos and dense cores. Indicates abnormal protein
accumulation which damages cells.
oAge – main risk factor (1% of population older than
60 years)

oMen are 1.5 times more likely to have PD than

women.

oGenetic/Hereditary – first-degree relative of people

with PD (parent, sibling or child) are at 3x greater
risk of developing the disease regardless of age.
• Reduced estrogen levels – menopausal women who receive little or
no HRT and those who have hysterectomies may be at higher risk

• Estrogen enhances presynaptic and postsynaptic signal transmission

thru increased production of neurotransmitter

• Reduced Folate levels – may increase susceptibility to PD

• Associated with elevated homocysteine levels which damages

vascular endothelium and are neurotoxic especially to dopaminergic
neurons. (HYPERHOMOCYTENEMIA)
• Environmental – exposure to herbicides and pesticides
are 3x more likely to develop PD than other people
with no exposure (no conclusive evidence yet)

• Trauma to the head, neck, or upper cervical spine -

several studies have shown a link between head
trauma and an increase in a person’s risk of
developing the disease

• Exposure to high levels of manganese and iron which

are known toxic to nerve cells
• Medications – Haloperidol, chlorpromazine,
metoclopramide, depacon (epilepsy drug)
may cause some features of PD especially
severe tremors

• Anti-psychotic: blocks dopamine receptors

and dopamine output by cells of the
substantia nigra

• Toxins – manganese dust or the chemical

MPTP, a by product of Heroin production can
lead to parkinsonism (rare)
 Before visiting your patient to conduct
your assessment, you with your clinical Case Scenario
instructor received the handover from the
staff nurse on duty assigned to the patient.
Based on the handover, you find out that Mr.
Cruz has been admitted yesterday with a
diagnosis of Parkinsonian Crisis.

•
After reviewing the patient’s chart, you
visited the patient with your clinical
instructor. When you entered the room,
Case Scenario
Mr. Cruz is having his breakfast with
the assistance of his daughter. You
have observed that he is unable to eat
on his own due to his persistent
bilateral hand tremors. He has a
stooped posture as he sat on the bed.
He looked at you with a deadpan
expression on his face as you greeted
him and introduced yourself. His
speech is monotonous and slow as he
answered your questions.
 While in an effective nurse-patient interaction, you have
gathered essential information about the patient’s case.
o a retired professional boxer who has won 2 gold medals for the country in the Southeast Asian Games.
o After retiring from boxing at the age of 35 years old, he became an owner of a pesticide factory.
o He is married with 3 adult children. He is currently living with his youngest son.
o When he was younger, he used to smoke a pack of cigarettes per day. He stopped smoking 20 years ago.
o Diabetes Mellitus Type 2 and on regular insulin 3 times a day.
o His younger brother was diagnosed with Parkinson’s disease at the age of 33 years old.
o He is currently taking Sinemet 25mg/100mg tablet 1 tablet orally three times a day
o His symptoms include bilateral hand tremors and a shuffling gait.
o He used to use a walker for ambulation but prefers the wheelchair for the past few months since walking
has become a struggle for him.
 According to Mr. Cruz, he had an argument with
his eldest son yesterday when he started experiencing
severe tremors, body rigidity and difficulty of breathing.
This event led to his sons to rush him to the emergency
room for immediate treatment. He verbalized that when
he is anxious and angry, he notices his symptoms
become worse.

Based on the records review that you have

performed earlier, when Mr. Cruz arrived at the
emergency department, he was having severe
exacerbation of tremors and body rigidity. He was also
tachypneic, tachycardic and hypertensive. This led to Mr.
Cruz’s hospital admission.
Your CI gathered the group and
asked about the clinical
manifestations of Parkinson’s
disease. Since you and your
group mates were not able to
give an answer, your CI asked
you to read more about the
condition as you answer this
interactive handout.
 Bradykinesia, Rigidity and
Tremors are cardinal features
of patients with Parkinson’s
disease.
 Bradykinesia, Rigidity and Tremors
are cardinal features of patients with
Parkinson’s disease.
3 Cardinal Features (2 out of 3 to make
diagnosis):

BRADYKINESIA, RIGIDITY, and

TREMORS

The onset of PD is gradual, with an

ongoing progression. Only 1 side of
the body may be involved at first
 Clinical Manifestations

oat rest on one side of the body.

ofirst manifestation in 70% of clients
(upper limbs)
ocoarse, ‘pill-rolling’ movement of
the thumb against the finger
ovoluntary movement stops or
reduces tremors but other patients
have intentional tremors
 Clinical Manifestations

ogeneral feeling
of stiffness along
with mild, diffuse
muscle pain
Clinical Manifestations

• abnormal slowness of movement

• fine movement becomes clumsy
• voluntary movements are difficult to execute. Severe manifestations can
lead to AKINESIA and clients are literally frozen on the spot.
• Severe manifestations of PD: akinesia, shuffling/ festinating gait; stooped
posture; stiff, mask-like face and without expression; microphonia;
micrographia; dysarthria; lack of spontaneous swallowing and chewing.
Clinical Manifestations

 Patients may describe being unable to stop

themselves from going forward (propulsion) or
backward (retropulsion).
Assessment of postural instability includes the
"pull test."
The examiner stands behind the patient and
gives a tug backward on the shoulder, causing
the patient to lose their balance and fall
backward.
Clinical Manifestations

oslight stiffness of one leg while walking and

ipsilateral arm may be flexed and
elbow/shoulder abducted
operson may drag one foot
owhen both sides are affected: __________________
with short steps may develop; feet barely leaving
the floor; no swinging of arms while walking.
Shuffling or festinating or propulsive
gait as if walking on tip-toes,
movement at a slow pace then
accelerates until the client is unable
to stop or until an obstruction is met.
Clinical Manifestations

ohead, shoulders and spine flexed forward.

o limited movement of facial muscles

 Clinical Manifestations

olow volume; monotonous; slow o15 to 20% of cases

o weak and infrequent swallowing

o saliva may flow involuntarily from the mouth

AUTONOMIC SYMPTOMS: decreased lacrimation and sexual

capacity ; constipation, incontinence; excessive perspiration and
heat intolerance.
 Clinical Manifestations

o due to emotional trauma or sudden withdrawal of drugs

o severe exacerbation of tremor, rigidity, bradykinesia
accompanied by acute anxiety, sweating, tachycardia,
and tachypnea
o MGMT: respi/cardiac support; quiet room; subdued
lighting; barbiturates may be given
 STAGES OF PARKINSON’S DISEASE
There are several different
rating scales that may be
used to assess the stage of
Parkinson’s disease (PD) in an
individual. One of the
commonly used rating scale
is the Hoehn and Yahr Scale.
Rates symptoms on a scale of 1 to 5.
On this scale:
o 1 and 2 represent early-stage
o2 and 3 mid-stage
o4 and 5 advanced-stage
Parkinson's
 Hoehn and Yahr Scale
STAGE I
During this initial stage, the
person has mild symptoms that
generally do not interfere with
daily activities.
Tremor and other movement
symptoms occur on one side of
the body only.
Changes in posture, walking and
facial expressions occur.
STAGE II
Symptoms start getting worse.
Tremor, rigidity and other
movement symptoms affect
both sides of the body.
Walking problems and poor
posture may be apparent.
The person is still able to live
alone, but daily tasks are more
difficult and lengthy.
 Hoehn and Yahr Scale
STAGE III
 Considered mid-stage, loss of balance
and slowness of movements are
hallmarks.
 Falls are more common.
 The person is still fully independent,
but symptoms significantly impair
actIvities such as dressing and eating.
STAGE IV
At this point, symptoms are severe
and limiting.
It’s possible to stand without
assistance, but movement may
require a walker.
The person needs help with
activities of daily living and is
unable to live alone.
 Hoehn and Yahr Scale
STAGE V

This is the most advanced and debilitating stage.

Stiffness in the legs may make it impossible to stand or walk.
The person requires a wheelchair or is bedridden.
Around-the-clock nursing care is required for all activities.
The person may experience hallucinations and delusions.
The Parkinson’s community acknowledges that there are many important
non-motor symptoms as well as motor symptoms.
 Shuffling gait is walking on tip-toe;
starting movement at a slow pace which
accelerates and client is unable to stop
until obstruction is met.
 Shuffling gait is walking on tip-toe;
starting movement at a slow pace which
accelerates and client is unable to stop
until obstruction is met.
 DIAGNOSTIC PROCEDURES

1. Clinical signs and symptoms and family history

2. Neurologic examination – evaluation of walking, coordination and
some simple tasks of dexterity
3. Medical History – medications taken
4. CT Scan or MRI to rule out other neurologic disease
5. ______________: abnormal pattern of glucose metabolism. Provides
information on dopamine uptake and integrity of receptor sites
 MEDICAL MANAGEMENT

1. Levodopa – converted into Dopamine by nerve cells in the brain; gold

standard drug therapy

2. ___________________ cannot be given directly because it can’t cross BBB

3. Carbidopa-Levodopa (Sinemet)
Carbidopa prevents peripheral metabolism of levodopa, allowing it to reach
the brain. Also, it decreases nausea and vomiting.
 Nursing Responsibilities for
Carbidopa/Levidopa (Sinemet)
Monitor for signs of dyskinesia.
Monitor for short-term adverse effects of nausea, vomiting, and
light-headedness.
Stress that effects may be delayed for several weeks to months.
Teach patient or caregiver to report any uncontrolled movement
of face, eyelids, mouth, tongue, arms, hands, or legs; mental
changes; palpitations; and difficulty urinating.
Do not give levodopa with food because protein reduces
absorption.

4. Dopamine agonists Bromocriptine
(Parlodel), Pergolide (Permax),
Pramipexole (Mirapex)
o not changed to Dopamine but mimic the
effect of Dopamine in the brain and cause
neurons to react as though sufficient amount
of dopamine were present. It is used as
adjunct to levodopa therapy.
MEDICAL
MANAGEMENT
Nursing Responsibilities for
Pramipexole (Mirapex)
• Take the drug with food to
decrease nausea.
• Notify the HCP immediately if
uncontrollable urges, confusion,
muscle rigidity, excess urination,
shortness of breath, or vision
changes occur.
 MEDICAL MANAGEMENT

5. Selegiline (Eldepryl), Rasagiline (Azilect),

and Safinamide (Xadago)
• monoamine oxidase type B (MAO-B) inhibitors that may be used in
combination with Sinemet.
• By inhibiting MAO-B, the enzyme that degrades Dopamine, these agents
increase the levels of Dopamine and prolong the half-life of levodopa.
• Rasagiline can be used alone as therapy in early PD.
• However, MAO-B inhibitors are less effective at treating motor symptoms
than Dopamine receptor agonists.
 MEDICAL MANAGEMENT
6. Catechol-o-methyl transferase inhibitors
Entacapone (Comtan) and Tolcapone (Tasmar)
• prolong effect of levodopa (Sinemet) therapy and are used
only as adjuncts
• increases peripheral half-life of levodopa delivering more
levodopa to the brain
• They are often used when the patient’s response to levodopa is
wearing off at the end of the dosing interval.
• Tolcapone is rarely prescribed because it is associated with
fatal hepatotoxicity.
 MEDICAL MANAGEMENT

7. ___________________
• main treatment for PD before the introduction of
levodopa; help control tremors in the early stages of
the disease.
• Benztropine mesylate (Cogentin)
• blocks release of AcH, creating a better balance
between dopamine and acetylcholine
 MEDICAL MANAGEMENT

8. Amantadine (________________)
• antiviral drug prescribed in the latter stages of PD.
• augments release of dopamine and may block receptors for
acetylcholine
• It may be useful as a single therapy for early PD.
• It can be used later with levodopa.
• As a single treatment, amantadine often becomes less
effective after a few months.
• Withdrawal of amantadine even after extended therapy can
worsen dyskinesia.
MEDICAL MANAGEMENT

9. ____________________
• can slow down progression of
disease
• scavenger of free radicals/anti-
oxidants
 SURGICAL MANAGEMENT

• destruction of small
amounts of tissue in
the thalamus.
• To treat disabling
tremors.
 SURGICAL MANAGEMENT
Pallidotomy Electric current is used to destroy a small amount of tissue in
the pallidum (globus pallidus found in the basal ganglia), a part of the brain responsible for
the many symptoms of PD (rigidity, bradykinesia, intractable tremors).
 SURGICAL MANAGEMENT
Deep Brain
Stimulation
• consists of a deep brain
stimulator (brain implant device)
that can help control the
disabling shaking and trembling
caused by PD.
• uses electric current to ‘jam’ or
reset abnormal brain signals
 SURGICAL MANAGEMENT
Autologous
Transplantation
• still at the experimental stage
• cells that produce dopamine
are transplanted
Lifestyle Changes Nursing Management
a. Eat a healthy diet
a nutritionally balanced diet that contains plenty of fruits,
vegetables and whole grains contains natural antioxidants that
help protect against free radical damage; helps prevent
constipation.
2L of fluid/24 hours and increase fiber to avoid constipation.
Avoid __________________________ which increases s/sx
Lifestyle Changes
Nursing Management
b. Consider vitamins and supplements

• high doses of vitamin E could delay the onset of severe PD

symptoms.
• Vitamin E: ____________, an antioxidant. It stabilizes cell
membranes by preventing the oxidation of fatty acids.
• Source: eggs, butter, cereals
Lifestyle Changes Nursing Management
c. Eat slowly and carefully
Take small bites of food and chew each mouthful thoroughly. Chew
hard and move food around with the tongue
Swallow each mouthful before putting more food in the mouth. Finish
one bite before taking another.
Chop food in a food processor or blender to make it easier to eat.
Take time eating.
Eat in an upright chair.
 Lifestyle Changes Nursing Management

d. Exercise
• helps improve mobility, balance, ROM and even emotional well-being.
• In the morning when energy levels are highest. Provide extra time with
activities.
• Daily ROM to avoid rigidity and contractures
• Throw small objects in front like paper to practice fine motor movement
Lifestyle Changes Nursing Management
e. Walk with care
If the patient notices himself shuffling, tell him to
slow down and check his posture; stand up straight
with head over hips and feet 8-10 inches apart.
o Look up and not down

Buy a good pair of walking shoes

o avoid running shoes.
o use cane or walker if beneficial
Lifestyle Changes Nursing Management
e. Walk with care
• Practice taking long steps and exaggerate lifting his legs and swinging his
arms.
• maintain wide-based gait
• Consciously pick up feet to take steps
• If the patient becomes stuck in place (freezing), instruct him to rock
gently side to side or pretend he is stepping over an object on the floor.
• rocking back and forth especially when sitted/walking an imaginary line
• avoid soft, deep chairs and get out of the chair by bending over slowly so that the
head is over the toes.
Lifestyle Changes Nursing Management

f. Avoid falls
• Ask the doctor/PT about exercises that improve
balance especially TAI CHI – relaxes and strengthens
muscles and joints.
• Wear rubber-soled shoes – less likely to slip than
those with leather soles.
Lifestyle Changes Nursing Management
f. Avoid falls
• Remove all area rugs from home and make
sure carpeting is secured firmly on the
floor. Proper lighting.
• Install handrails, especially among
stairways.
• Keep electrical and telephone cords out of
the way.
• Install grab bars around the tub and beside
the toilet.
Lifestyle Changes Nursing Management
f. Avoid falls
• Make sure the patient can reach the
telephone from the bed and carry a phone
with him during the day.
• Arrange items so that they are within
reach
• Elevated toilet seat; avoid carrying hot
liquids especially if with tremors
Lifestyle Changes Nursing Management
g. Dressing
• Allow plenty of time so the patient does not feel rushed.
• Lay clothes nearby.
• Choose clothes that the patient can slip on easily.
• Look for clothes and shoes with Velcro fasteners or replace
buttons on clothes with Velcro.
• Dress and undress in front of a mirror
Lifestyle Changes Nursing Management
h. Speaking
• Face the person he is talking to and deliberately talk louder than what he thinks is
necessary. Exaggerate pronunciation
• Practice reading or reciting out loud, focusing on breathing and on having a strong
voice.
• Tell the client to speak for himself – don’t let others speak for him.
• Consult a speech language pathologist who is trained to treat people with PD.
• Pause between every few words
• Express ideas in short, concise phrases
Lifestyle Changes Nursing Management
i. Sleeping
•Use a firm mattress
•Avoid using soft pillow to limit flexion of spine
•Sleep on side with tremors
Lifestyle Changes Nursing Management

j. To reduce tremors
• Grasp coins in their pockets
• Grip the arms of a chair
• Squeeze a rubber ball
• Use both hands to accomplish tasks
Lifestyle Changes Nursing Management

j. To reduce tremors
• Grasp coins in their pockets
• Grip the arms of a chair
• Squeeze a rubber ball
• Use both hands to accomplish tasks
 Dr. Lewis, Mr. Cruz’s primary physician,
Case Scenario
arrived for his daily rounds. With your clinical
instructor, you followed the staff nurse as
she accompanied Dr. Lewis to the patient’s
room. Dr. Lewis ordered to encourage
ambulation and mobilize the patient to the
chair at least twice per shift. According to Dr.
Lewis, Mr. Cruz will be discharged tomorrow
if he will be stable for the next 24 hours.

•
 Your clinical instructor facilitated a viewing activity
regarding safety patient handling and transfer with/without
the use of assistive devices.

1. Transferring patient from bed to chair (2.26minutes)

https://youtu.be/CSxT88saN94

2. 2. Use of Hoyer (hydraulic) Lift: Patient transfer from bed to chair (12.26 minutes) and chair to bed
(6.19minutes)
https://youtu.be/MI1CMip07tA
https://youtu.be/OzouYWmAJSk

3. Lateral transfer of a patient using a sliding board (3.46minutes)

https://youtu.be/IFHriQpQB50
 For your post-conference, your clinical
instructor instructed the group to accomplish
the following tasks:

1. Viewing Activity
• You will be watching an instructional video entitled, “Deep Brain Stimulation: How It
Works?” (1.50seconds)
https://youtu.be/kaThzeghWnM

• You will be watching a documentary of Mr. Tim Barth’s Deep Brain Stimulation Surgery.
(6.32 seconds)
https://youtu.be/3SW2jzaVGho
 For your post-conference, your clinical
instructor instructed the group to accomplish
the following tasks:

2. Asynchronous Learning Task: Case based Learning (Creating a Case Scenario

and Nursing Care Plan)
• You will be tasked to create a case scenario highlighting two priority
problems to facilitate learning and application of the concepts learned during
the discussion regarding Parkinson’s disease. A list of nursing problems
related to Parkinson’s disease will be provided. Two nursing care plans should
be formulated based on the case scenario.
 DISCUSSION BOARD

As a nurse in the family, relatives would usually ask for your opinion and views
regarding matters about health and illness. A family member told you that he
has been recently diagnosed with early stages of Parkinson’s disease. He is
devastated and worried about his diagnosis. “My life is over now! What will
happen to me now?” he asked.

What will be your best response?

Why should emotional and mental health be included in the management of

clients with degenerative diseases like Parkinson’s disease?
Thank you for your
participation!
Prepared by:
NCM 0116 RLE Instructors
2nd semester A.Y. 2020-2021