Parkinson's Disease p.1387-1395

Clinical Manifestations - Describe the onset and progression of PD. (text p. 1387)

The onset of PD is gradual and insidious, with an ongoing progression. Only one side of the body may be involved initially.

______(drug) is typically prescribed for patients with advanced PD with evidence of intense motor fluctuations; for patients with end-of-dose wearing off. (text p. 1390)

A combination of carbidopa, levodopa, and entacapone (Stalevo) is available for patients with end-of-dose wearing off. It is typically prescribed for patients with advanced PD with evidence of intense motor fluctuations.

The nurse is told that the result of a serum carbamazepine level for a client who is receiving the medication for the control of seizures is 13 mcg/mL (55.03 mmol/L). Based on this laboratory result, the nurse anticipates that the health care provider (HCP) will document which prescription?

A decrease of the dosage of the medication -- When carbamazepine is administered, blood levels need to be monitored periodically to check for the child's absorption of the medication. The amount of the medication prescribed is based on the blood level achieved. The therapeutic serum range of carbamazepine is 8 to 12 mcg/mL (34 to 51). The nurse would anticipate that the HCP will decrease the dosage of the medication.

Transplantation of fetal neural tissue into the basal ganglia is designed to _____. Research and clinical trials of this form of therapy are ongoing. (text p. 1391)

Transplantation of fetal neural tissue into the basal ganglia is designed to provide DA-producing cells in the brains of patients with PD. Research and clinical trials of this form of therapy are ongoing.

Describe "tremor" in PD. (text p. 1388)

Tremor is often the first sign and may be minimal initially, so the patient is the only one who notices it. This tremor can affect handwriting, causing it to trail off, particularly toward the ends of words. Parkinsonian tremor is more prominent at rest and is aggravated by emotional stress or increased concentration. The hand tremor is described as "pill rolling" because the thumb and forefinger appear to move in a rotary fashion as if rolling a pill, coin, or other small object. Tremor can also involve the diaphragm, tongue, lips, and jaw but rarely causes shaking of the head.

A client is taking trihexyphenidyl hydrochloride. The nurse should assess for which side or adverse effect of this medication?

Trihexyphenidyl is an anticholinergic medication used for the treatment of Parkinson's disease. Therefore, it can cause urinary hesitancy and retention, constipation, dry mouth, and decreased sweating.

What is "essential tremor"? (text p. 1388)

Unfortunately, in many people a benign essential tremor is mistakenly diagnosed as PD. Essential tremor occurs during voluntary movement, has a more rapid frequency than parkinsonian tremor, and is often familial. *PD tremor occurs at rest.

Clinical Manifestations - Does PD affect a client's speech? (text p. 1387)

Up to 90% of patients also experience speech abnormalities (hypokinetic dysarthria) that can affect communication and quality of life

A patient with Parkinson's disease discusses with the nurse experiencing insomnia recently. The patient asks the nurse, "Can I take my old prescription of benzodiazepine that is prescribed to treat my insomnia?" What does the nurse know about the use of benzodiazepines in patients taking levodopa (Larodopa)? [Lilley]

Use of benzodiazepines decreases the therapeutic effect of the levodopa and may result in an increase in the symptoms of Parkinson's disease. Benzodiazepines interact with levodopa to cause reduced levodopa effects and an increase in the symptoms of Parkinson's disease.

A client has a prescription to receive valproic acid daily. To ensure the client's safety, when is the best time for the nurse to schedule the administration of this medication?

Valproic acid is an anticonvulsant that causes central nervous system (CNS) depression. For this reason, the side effects include sedation, dizziness, ataxia, and confusion. When the client is taking this medication as a single daily dose, administering it at bedtime negates the risk of injury from sedation and enhances client safety. The medication also should be administered at the same time each day.

_____ disorders produce parkinsonism. (text p. 1387)

FIG. 58-6 Nigrostriatal disorders produce parkinsonism. Left-sided view of the human brain showing the substantia nigra and the corpus striatum (shaded area) lying deep within the cerebral hemisphere. Nerve fibers extend upward from the substantia nigra, divide into many branches, and carry dopamine to all regions of the corpus striatum.

In Parkinson's disease there is a deficit in dopamine which creates an imbalance between dopamine and the excitatory neurotransmitter acetylcholine. (Fig. 58-7). In a healthy person, what does dopamine released from neurons originating in the substantia nigra do? (text p. 1387)

FIG. 58-7 In a healthy person, dopamine released from neurons originating in the substantia nigra inhibits the firing of neurons in the striatum that release γ-aminobutyric acid (GABA). Conversely, neurons located within the striatum, which release acetylcholine (ACh), excite the GABAergic neurons. Under normal conditions, inhibitory actions of DA are balanced by excitatory actions of ACh, and controlled movement results.

What symptoms does dopamine deficit illicit? (text p. 1387)

FIG. 58-7-B, In Parkinson's disease, neurons in the substantia nigra that supply DA to the striatum degenerate. When a deficit of DA occurs, excitatory effects of ACh go unopposed and disturbed movements (tremor, rigidity) result.

What diagnostic is commonly used to assess for PD? (text p. 1387)

FIG. 58-8 In Parkinson's disease, positron emission tomography (PET) scan showing reduced fluorodopa uptake in the basal ganglia (right) compared with a normal control.

The nurse preparing to administer carbamazepine notices a number of items on the client's breakfast tray. Which item should be a cause for concern and should be removed from the tray?

Grapefruit juice -- Grapefruit juice can increase peak and trough levels of carbamazepine. Accordingly, clients taking the medication should be advised to avoid grapefruit juice.

A client has a prescription for valproic acid. To maximize the client's safety, the nurse should plan to monitor for which potential complications of this medication? Select all that apply.

Valproic acid is an anticonvulsant that causes central nervous system depression. Although rare, this medication has caused pancreatitis and hepatoxicity. The nurse should monitor for these complications.

A client is taking benztropine mesylate orally daily. In monitoring this client for medication side effects, the nurse should plan to focus the assessment on which item?

Voiding pattern -- Benztropine mesylate is an anticholinergic. Because urinary retention is a side effect of benztropine mesylate, the nurse must assess for dysuria, distended abdomen, infrequent voiding in small amounts, and overflow incontinence. Monitoring of the other options is not necessary with this medication.

A patient who has been taking antiparkinson medications for years begins to have increased symptoms on a constant basis. In documenting these symptoms, what term will the nurse use? [Lilley]

Wearing-off phenomenon The wearing-off phenomenon occurs when anti-Parkinson's disease medications begin to lose their effectiveness, despite maximal dosing, as the disease progresses. The symptoms return and continue on a constant basis despite treatment and medications.

A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication?

White blood cell count, 3000 mm3 (3.0 × 109/L) -- Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, and leukopenia; cardiovascular disturbances, including thrombophlebitis and dysrhythmias; and dermatological effects. The low white blood cell count reflects agranulocytosis.

Within 3 to 5 years of standard Parkinson's drug treatments, many patients experience ____. (text p. 1390)

Within 3 to 5 years of standard Parkinson's drug treatments, many patients experience episodes of hypomobility (e.g., inability to rise from chair, speak, or walk; also called off episodes). The episodes can occur toward the end of a dosing interval with standard medications (so-called end-of-dose wearing off) or at unpredictable times (spontaneous "on/off").

Evidence-based practice related to Parkinson's disease (Part 1) --Implications for Nursing Practice 1. What information will you provide to T.K. related to muscle atrophy and joint contractures and the importance of physical activity? (text p. 1389)

[National Institute of Neurological Disorders and Stroke] --Physical therapy, occupational therapy, and rehabilitation may help to improve posture, prevent joint immobility, and slow muscle weakness and atrophy. Stretching and strengthening exercises may help reduce contractures, increase range of motion, and keeps circulation flowing. --Nerve cells in the brain stem and spinal cord that control essential skeletal muscle activity such as speaking, walking, breathing, and swallowing, leading to muscle weakness and atrophy. Motor neurons control movement in the arms, legs, chest, face, throat, and tongue. When there are disruptions in the signals between motor neurons and muscles, the muscles gradually weaken, begin wasting away and develop twitching (called fasciculations).

The pathologic process of PD involves ____. (text p. 1387)

degeneration of the DA [dopamine]-producing neurons in the substantia nigra of the midbrain (Figs. 58-6 to 58-8), which in turn disrupts the normal balance between DA and acetylcholine (ACh) in the basal ganglia.

What are some "non-motor" symptoms of PD? (text p. 1389)

depression, anxiety, apathy, fatigue, pain, urinary retention and constipation, erectile dysfunction, and memory changes. Sleep problems are common and include difficulty staying asleep at night, restless sleep, nightmares, and drowsiness or sudden sleep onset during the day. In particular, rapid eye movement (REM) behavior disorder is a preparkinsonian state that occurs in about one third of patients with PD. It is characterized by violent dreams and potentially dangerous motor activity during REM sleep

bradykinesia

extreme slowness in movement

A hallmark of Parkinson's is movement problems, but the disease has many non-movement symptoms as well.

https://parkinsonsnewstoday.com/parkinsons-disease-treatments/non-motor-symptoms/

What is akinesia?

loss or impairment of the power of voluntary movement; inability to initiate movement

Cogwheel rigidity,

muscle tension that intermittently halts movement as an examiner attempts to manipulate a limb

The neurotransmitter DA [dopamine] is essential for _____. (text p. 1387)

normal functioning of the extrapyramidal motor system, including control of posture, support, and voluntary motion.

Genetic Link -Approximately 15% of patients with PD have a family history of PD. Many autosomal dominant and recessive genes have been linked to familial PD. The most common genetic contributor to PD is _____. (text p. 1387)

the LRRK2 gene. Mutations in this gene also appear to have a role in sporadic, or noninherited, cases of PD.

dysarthria

the inability to use speech that is distinct and connected because of a loss of muscle control after damage to the peripheral or central nervous system; slurred speech, difficulty forming words

What is the first sign that usually presents with PD? (text p. 1388)

tremor

Clonazepam is widely used as a treatment for epilepsy. In multiple sclerosis, clonazepam is sometimes used to treat ...

tremor. It is also occasionally used to manage pain or spasticity when other drugs have not been successful.

What are common therapies used to treat PD? (text p. 1389)

• Antiparkinsonian drugs (Table 58-16) • Surgical therapy • Deep brain stimulation • Ablation surgery • Physical therapy • Occupational therapy • Dietitian consult for nutritional therapy

What is include in the diagnostic assessment of PD? (text p. 1389)

• History and physical examination • TRAP (tremor, rigidity, akinesia and postural instability) • Positive response to antiparkinsonian drugs • MRI • Rule out side effects of phenothiazines, reserpine, benzodiazepines, haloperidol [Phenothiazines are used to treat serious mental and emotional disorders, including schizophrenia and other psychotic disorders. An example is chlorpromazine (brand name: Thorazine). Benzodiazepines are a class of drugs often referred to as tranquilizers and are primarily used for treating anxiety, insomnia, epilepsy, and alcohol dependence. Examples can include diazepam (Valium) and alprazolam (Xanax)

DRUG ALERT: Bromocriptine (parlodel) (text p. 1390)

• Patient may become dizzy or faint due to orthostatic hypotension, especially after the first dose. • Notify physician immediately if a severe headache develops that does not improve or continues to get worse.

Do the clinical manifestations diagnose PD? (text p. 1387)

None of the clinical manifestations alone is sufficient evidence for a diagnosis of the disease.

Surgical procedures for PD fall into three categories. What are these 3 categories? (text p. 1390)

Surgical procedures fall into three categories: deep brain stimulation (DBS), ablation (destruction), and transplantation.

The nurse has given medication instructions to a client receiving phenytoin. Which statement indicates that the client has an adequate understanding of the instructions?

"Good oral hygiene is needed, including brushing and flossing." -- Typical antiseizure medication instructions include taking the prescribed daily dosage to keep the blood level of the medication constant and having a sample drawn for serum medication level determination before taking the morning dose. The client is taught not to stop the medication abruptly, to avoid alcohol, to check with a health care provider before taking over-the-counter medications, to avoid activities in which alertness and coordination are required until medication effects are known, to provide good oral hygiene, and to obtain regular dental care. The client should also wear a MedicAlert bracelet.

A client has been started on zolpidem. After instructing the client in how to obtain the maximal effect of zolpidem, the nurse determines that the client demonstrates understanding of correct administration of the medication by which statement?

"I need to swallow the medication whole with a full glass of water." -- Zolpidem is a hypnotic. The client should be instructed to take the medication at bedtime and to swallow the medication whole with a full glass of water. For faster onset of sleep, the client should be instructed not to take the medication with food or immediately after a meal. Antacids affect the absorption of the medication.

A client with a diagnosis of trigeminal neuralgia is started on a regimen of carbamazepine. The nurse provides instructions to the client about the side and adverse effects of the medication. Which client statement indicates an understanding of the side and adverse effects of the medication?

"I will report a fever or sore throat to my health care provider." -- Agranulocytosis is an adverse effect of carbamazepine and places the client at risk for infection. If a fever or a sore throat develops, the health care provider should be notified.

Benztropine mesylate is prescribed for a client. What statement by the client indicates that the client needs further teaching about the medication?

"I will sit in the sun for an hour a day to enhance medication effectiveness." -- Benztropine mesylate is an anticholinergic that may be prescribed to treat Parkinson's disease. The client taking benztropine mesylate may have decreased tolerance to heat as a result of diminished ability to sweat and should plan rest periods in cool places during the day. The client is instructed to avoid driving or operating hazardous equipment if drowsy or dizzy. The client is also instructed to monitor urinary output and watch for signs of constipation. The client should be instructed to contact the health care provider if difficulty swallowing or speaking develops, vomiting occurs, or central nervous system effects occur. In addition, the use of anticholinergic medications should be avoided in older adults because they can cause confusion, urinary retention, constipation, dry mouth, and blurred vision.

Phenytoin 100 mg to be given orally 3 times daily has been prescribed to a client. The home health nurse visits the client and provides instructions regarding the medication. Which statement, if made by the client, would indicate an understanding of the instructions?

"I will use a soft toothbrush to brush my teeth." -- Phenytoin is an anticonvulsant used to treat seizure disorders. Gingival hyperplasia, bleeding, swelling, and tenderness of the gums can occur with the use of this medication. The client needs to be taught good oral hygiene, gum massage, and the need for regular dentist visits. Capsules should not be chewed or broken. The client should not skip medication doses because inadequate blood levels could precipitate a seizure. The client needs to be instructed to report a sore throat, fever, glandular swelling, or any skin reaction because such findings may indicate hematological toxicity.

The nurse has given medication instructions to a client beginning carbamazepine. The nurse determines that the client understands the use of the medication if he makes which statement?

"I will use sunscreen when outdoors." -- Carbamazepine is an anticonvulsant. The client should use protective clothing and sunscreen to avoid photosensitivity reactions. Carbamazepine acts by depressing synaptic transmission in the central nervous system (CNS). Because of this, the client should avoid driving at any time or doing other activities that require mental alertness until the effect of the medication on the client is known. The medication may cause dry mouth, and the client should be instructed to provide good oral hygiene and use sugarless candy or gum as needed. The medication should not be abruptly discontinued because this could lead to return of seizures or status epilepticus. Fever and sore throat (leukopenia) should be reported to the health care provider.

A home care nurse visits a client at home. Clonazepam has been prescribed for the client, and the nurse teaches the client about the medication. Which client statement indicates that further teaching is necessary?

"If I experience slurred speech, this problem will disappear in about 8 weeks." -- Clients who are experiencing signs and symptoms of toxicity with the administration of clonazepam exhibit slurred speech, sedation, confusion, respiratory depression, hypotension, and eventually coma. The medication may be taken with food to decrease gastrointestinal irritation. Some drowsiness may occur but will decrease with continued use.

The nurse is providing instructions to an adolescent prescribed phenytoin for the control of seizures. Which statement by the adolescent indicates a need for further teaching regarding the medication?

"If my gums become sore and swollen, I need to stop the medication." -- The adolescent should not stop taking antiseizure medications suddenly or without discussing it with a health care provider (HCP) or nurse. Acne or oily skin may be a problem for the adolescent, and the adolescent is advised to call a HCP for skin problems. Alcohol will lower the seizure threshold, and it is best to avoid its use. Birth control pills may be less effective when the client is taking antiseizure medication.

The patient asks the nurse to explain the difference between carbidopa-levodopa (Sinemet) and ropinirole (Requip). How will the nurse respond? [Lilley]

"Ropinirole is a dopamine agonist that has fewer adverse effects than carbidopa-levodopa." Ropinirole stimulates specific dopamine receptors in the brain. It is more specific for the receptors associated with parkinsonian symptoms, the D2 subfamily of dopamine receptors. This in turn may have more specific antiparkinson effects, with fewer adverse effects associated with generalized dopaminergic stimulation.

A patient with Parkinson's disease who has been positively responding to carbidopa-levodopa (Sinemet) asks the nurse, "Why have I suddenly developed a relapse of my symptoms." Which explanation by the nurse is appropriate? [Lilley]

"This is called the "on-off phenomenon." Your health care provider can change your medication regimen to help manage this effect." Patients who have been taking levodopa for a period of time may experience periods of symptom return. Changing to Sinemet controlled release or adding another medication can help reduce the on-off phenomenon. [Lilley]

The nurse teaches the wife of a client who is receiving levodopa/carbidopa to avoid pyridoxine medications. Which statement by the wife indicates an understanding of the instructions?

"Vitamin B6 reverses the effectiveness of the medication, meaning a higher dose is needed." -- Pyridoxine (vitamin B6) reverses the therapeutic effects of levodopa. Dietary restrictions are not necessary, but ingredients of multivitamins should be assessed. Many multivitamins contain pyridoxine and should be avoided. Careful reading of over-the-counter vitamin labeling is necessary to avoid increasing pyridoxine in the diet.

What are changes found in the brains of people with PD that may play a role in development of the disease? (text p. 1387)

(1) lack of dopamine (DA), (2) structural changes in the brain [showed gray matter volume decreases in hippocampus, thalamus, and anterior cingulate regions

S/S of heart attack

(can vary depending on amount of heart damage). Severe, painful pressure under breastbone (sternum) w/ pain radiating to shoulders, arms, neck, and jaw=common symptom. Usually intense SOB. The skin, especially near lips and nail beds, becomes pale or cyanotic (bluish). Weak but also anxious and apprehensive. Nausea, vomiting, diaphoresis, and loss of consciousness may occur.

What drugs can cause a Parkinson-like syndrome?

-- "Cogwheel rigidity of ARM." 1. Antipsychotics, 2. Reserpine, 3. Metoclopramide. -- -- Haldol, major tranquilizers -- drugs that end in -azine

How does DBS work for PD? (text p. 1390)

-- DBS procedures reduce the increased neuronal activity produced by DA depletion. It has been shown to improve motor function and reduce dyskinesia and medication usage. DBS is most effective when candidates are carefully selected and screened.

Dopaminergics commonly used to treat PD. (text p. 1390)

-- Dopamine Precursors -- Dopamine Receptor Agonists -- Dopamine Agonists -- Anticholinergics -- Antihistamines -- Monoamine Oxidase Inhibitors -- Catechol O-Methyltransferase (COMT) Inhibitors

contractures,

-- a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints. -- Shortening or contraction of a muscle. May be due to spasms or paralysis and may be permanent;

Dopamine Agonists commonly used to treat PD. (text p. 1390)

-- amantadine **locks NMDA-type glutamate receptors, increases dopamine release, and blocks dopamine reuptake --- apomorphine (Apokyn) *** Stimulates postsynaptic dopamine receptors

Dimenhydrinate (Dramamine)

-- an antihistamine, has anticholinergic properties, anticholinergic meds can cause urinary retention thus compounding urinary tract symptoms associated with prostatic hypertrophy, is contraindicated in patient with benign prostatic hypertrophy (BPH). -- is an antiemetic and antihistamine used to treat and prevent the signs and symptoms of dizziness, vertigo, and nausea and vomiting that accompany motion sickness.

Dopamine Receptor Agonists commonly used to treat PD. (text p. 1390)

-- bromocriptine (Parlodel) -- cabergoline pramipexole (Mirapex) -- ropinirole (Requip, Requip XL) -- rotigotine (Neupro [transdermal patch]) **Stimulate dopamine receptors

Antihistamines commonly used to treat PD. (text p. 1390)

-- diphenhydramine -- Has anticholinergic effect - Opposing the actions of the neurotransmitter acetylcholine. nervous system side effects, including sedation, drowsiness, somnolence, fatigue, cognitive decline, psychomotor effects, and loss of coordination. -- Anticholinergic drugs inhibit the transmission of parasympathetic nerve impulses, thereby reducing spasms of smooth muscles (for example, muscles in the bladder).

Catechol O-Methyltransferase (COMT) Inhibitors commonly used to treat PD. (text p. 1390)

-- entacapone (Comtan) -- tolcapone (Tasmar) ** Block COMT and slow the breakdown of levodopa, thus prolonging the action of levodopa

Dopamine Precursors commonly used to treat PD. (text p. 1390)

-- levodopa (L-dopa) -- levodopa/carbidopa (Sinemet) ** Converted to dopamine in basal ganglia

Monoamine Oxidase Inhibitors commonly used to treat PD. (text p. 1390)

-- selegiline (Eldepryl) -- rasagiline (Azilect) ** Block breakdown of dopamine

Anticholinergics commonly used to treat PD. (text p. 1390)

-- trihexyphenidyl benztropine (Cogentin) ** Block cholinergic receptors, thus helping to balance cholinergic and dopaminergic activity

S/S seizures

--Change in LOC, Involuntary movements, Posturing Changes in perception, behaviors, or sensations --some patients experience an aura or sensations that warns that a seizure is about to occur. Might be sounds, smells, visual

What drug is often prescribed early in the disease process of PD? Why do some doctors prefer to start therapy with a DA (dopaminergic) receptor agonist? (text p. 1389)

--Many patients are given Sinemet early in the disease course for the management of motor symptoms. However, some HCPs believe that, after a few years of therapy, the effectiveness of Sinemet wears off. Therefore they prefer to start therapy with a DA receptor agonist, a drug that directly stimulates DA receptors. -- [Four dopamine agonists are now Federal Drug Administration (FDA) approved and available for use in the United States to treat PD: Mirapex® (pramipexole), Requip® (ropinirole), Neupro® (rotigotine) and Apokyn® (apomorphine). -- apdaparkinson.org ]

DRUG ALERT: Carbidopa/Levodopa (Sinemet) (text p. 1389)

--monitor for dyskinesia, instruct to report uncontrolled movement of the face, eyelids, mouth, tongue, arms, hands or legs, mental changes, palpitations, severe N/V, difficulty urinating • Monitor for signs of dyskinesia. • Effects may be delayed for several weeks to months. • Instruct patient or caregiver to report any uncontrolled movement of face, eyelids, mouth, tongue, arms, hands, or legs; m

The nurse is observing a new nursing graduate who is preparing an intermittent intravenous (IV) infusion of phenytoin for a client with a diagnosis of seizures. Which solution used by the nursing graduate should indicate to the nurse an understanding of proper preparation of this medication?

0.9% sodium chloride -- Intermittent IV infusion of phenytoin is administered by injection into a large vein, using normal saline solution. Dextrose solutions are avoided because the medication will precipitate in these solutions. Therefore, the options containing dextrose identify incorrect solutions for IV administration with this medication. In addition, lactated Ringer's solution contains electrolytes that can interfere with phenytoin administration

Benztropine mesylate is prescribed for a client. What statements by the client indicates that the client understands teaching about the medication?

1. "I will avoid driving if I get drowsy or dizzy." 2. "I will watch my urinary output and look for signs of constipation." 3. "I will call the health care provider if I have difficulty swallowing or if I start vomiting."

Nursing concepts related to PD

1. Cognition 2. Mobility 3. Sensory 4. Pain and coping / emotional changes 5. Speech, language 6. Elimination: Urinary 7.

You are working in a rehabilitation facility where one of your patients is a 78-yr-old man with Parkinson's disease. Six months ago he was also at your facility with a fractured hip after falling in his yard. The family has asked to talk with you about their fear of taking him for a walk in the hallways because he is so unstable. • What advice would you provide to the family?

1. With exercise and physical therapy, people with PD can improve their balance. 2. When people with PD experience freezing and fall, they can't adjust their balance automatically. Taking small steps to try and regain balance can make things worse, because it involves shifting weight with each step. The brain changes from PD inhibit their ability to take a big step to catch their balance and avoid a fall. For some, the drug levodopa (Sinemet) can help prevent freezing, but does not improve balance. 3. With exercise and physical therapy it is possible to cope better with freezing, turn and walk more normally and improve balance. Through practice and sessions, a physical therapist can help people with PD avoid tripping by helping them learn to take larger steps. Additionally, joining an exercise class tailored to people with PD can help. If you take levodopa, be sure to exercise while it is working — the drug helps your body learn and remember motor skills.

The nurse is assisting in the care of a client being discharged on phenytoin 100 mg three times daily. When providing client teaching about this medication, the nurse should be sure to include which points? Select all that apply. 1. Break the capsules so they are easier to swallow. 2.Use a soft toothbrush while taking this medication. 3.If a dose is missed, just wait until the next one is due. 4.The medication may turn the urine pink, red, or brown. 5.Alcohol should be avoided while taking this medication. 6.Sore throat is a common side effect of the medication and is nothing to worry about.

2.Use a soft toothbrush while taking this medication. 4.The medication may turn the urine pink, red, or brown. 5.Alcohol should be avoided while taking this medication. -- Phenytoin is an anticonvulsant that can cause gingival hyperplasia, as well as bleeding, swelling, and tenderness of the gums. The client should use good oral hygiene and gum massage and have regular dental checkups. Alcohol interferes with the absorption of phenytoin, so it should be avoided. Change in the color of the urine is a normal reaction. A sore throat, fever, glandular swelling, or any skin reaction indicates hematological toxicity and needs to be reported.

A client with myasthenia gravis has difficulty chewing and has received a prescription for pyridostigmine. The nurse should check to see that the client takes the medication at what time?

30 minutes before meals -- Pyridostigmine is a cholinergic medication used to increase muscle strength in the client with myasthenia gravis. For the client who has difficulty chewing, the medication should be administered 30 minutes before meals to enhance the client's ability to eat.

A client with status epilepticus has been prescribed phenytoin to be given by the intravenous (IV) route. The nurse administering the medication is careful not to exceed which recommended infusion rate?

50 mg/min -- IV administration of phenytoin is performed slowly (no faster than 50 mg/min) because rapid administration can cause cardiovascular collapse. It should not be added to any existing IV infusion because this is likely to produce a precipitate in the solution. Solutions are highly alkaline and can cause local venous irritation.

Manifestations of PD [Parkinson's] do not occur until ____. (text p. 1387)

80% of neurons in the substantia nigra are lost.

A client receiving therapy with carbidopa/levodopa is upset and tells the home health nurse that his urine has turned a darker color since he started taking this medication. The client wants to discontinue its use. In formulating a response to the client's concerns, the nurse interprets that this change is indicative of which condition?

A harmless side effect of the medication -- With carbidopa/levodopa therapy, a darkening of the urine or sweat may occur. The client should be reassured that this is a harmless effect of the medication, and its use should be continued. Darkened urine is not indicative of carbidopa/levodopa toxicity.

A client with myasthenia gravis has become increasingly weaker. The health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis?

A temporary worsening of the condition -- An edrophonium injection makes the client in cholinergic crisis temporarily worse. An improvement in the weakness indicates myasthenia crisis.

Dantrolene sodium has been administered to a client with a spinal cord injury. The nurse determines that the client is experiencing a side or adverse effect of the medication if which is noted?

Abdominal pain -- Dantrium is hepatotoxic. The nurse observes for indications of liver dysfunction, which include jaundice, abdominal pain, and malaise. The nurse notifies the health care provider if these occur. The signs and symptoms in the remaining options are expected side effects due to the central nervous system-depressant effects of the medication: dizziness, light-headedness, drowsiness

Describe ablation surgery for PD. (text p. 1391)

Ablation surgery involves locating, targeting, and destroying an area of the brain affected by PD. The goal is to destroy tissue that produces abnormal chemical or electrical impulses leading to tremors or other symptoms. Typical targets of ablation are the thalamus (thalamotomy), globus pallidus (pallidotomy), and subthalamic nucleus (subthalamic nucleotomy).

Drug-induced parkinsonism usually disappears with discontinuance of the drug, except for the drug ______. (text p. 1387)

After stopping these drugs, symptoms of parkinsonism generally disappear; one notable exception is irreversible parkinsonism following MTPT exposure. MTPT is a street drug contaminant known to induce parkinsonism.

Describe "akinesia" as it relates to PD. (text p. 1388)

Akinesia is the absence or loss of control of voluntary muscle movements. In PD bradykinesia (slowness of movement) is particularly evident in the loss of automatic movements. This occurs because of the physical and chemical alteration of the basal ganglia and related structures in the extrapyramidal portion of the CNS. In the unaffected patient, automatic movements are involuntary and occur subconsciously. They include blinking of the eyelids, swinging of the arms while walking, swallowing of saliva, using facial and hand movements for self-expression, and making minor movements for postural adjustment.

A client began taking amantadine approximately 2 weeks ago. The nurse determines that the medication is having a therapeutic effect if the client exhibits which finding?

Amantadine is an antiparkinson agent that potentiates the action of dopamine in the central nervous system. The expected effect of therapy is a decrease in akinesia and rigidity. Urinary retention, hypotension, and leukopenia are adverse effects of the medication.

A client is suspected of having myasthenia gravis. Edrophonium is administered intravenously to determine the diagnosis. Which indicates that the client may have myasthenia gravis?

An increase in muscle strength within 30 to 60 seconds following administration of the medication -- Edrophonium is a short-acting acetylcholinesterase inhibitor used as a diagnostic agent. When a client has suspected myasthenia gravis, the health care provider will administer an edrophonium test. When a dose is administered intravenously, an increase in muscle strength should be seen in 30 to 60 seconds. If no response occurs, another dose of edrophonium is given over the next 2 minutes, and muscle strength is tested again. If no increase in muscle strength occurs with this higher dose, the muscle weakness is not caused by myasthenia gravis. Clients receiving injections of this medication commonly demonstrate a drop in blood pressure, feel faint and dizzy, and are flushed.

(text p. 1390)

Anticholinergic drugs such as trihexyphenidyl and benztropine (Cogentin) are also used to manage PD. These drugs decrease the activity of ACh, thus providing balance between cholinergic and dopaminergic actions. Antihistamines (e.g., diphenhydramine) with anticholinergic properties may be used to manage tremors.

Apomorphine must not be taken with the antiemetics in the _____ drug class, because this drug combination can _____. (text p. 1390)

Apomorphine must not be taken with the antiemetics in the serotonin (5-HT3) receptor antagonist class (e.g., ondansetron [Zofran]) because this drug combination can lead to very low blood pressure and loss of consciousness.

Common symptoms of PD:

BG/extrapyramidal damage High tone, rigidity and reduced ROM Tremors face limbs at rest Mask-like face Small writing Excess saliva/decreased swallowing Monopitch, low pitch, harsh/breathy voice Imprecise consonants Irregular breathing Parkinson's - too much inhibition BG

Because PD has no cure, interprofessional care focuses on ______. (text p. 1389)

Because PD has no cure, interprofessional care focuses on symptom management (Table 58-15).

Are there diagnostic studies to help diagnose PD? (text p. 1389)

Because no specific diagnostic test exists for PD, diagnosis is based on the patient's history and clinical features.

Overview of treatment / care with PD

Because there is no Parkinson's disease cure, the treatment options are used only to alleviate some of the symptoms. One of the most profound symptoms of PD is tremors. This is caused by a reduction of the movement-controlling chemical, dopamine. To counteract this, patients can take dopamine agonists. These drugs mimic the effects of dopamine in the brain. Common dopamine agonists are Pramipexole, Ropinirole, Rotigotine, and Apomorphine. Possible side effects include: Daytime sleepiness Confusion Visual hallucinations Swelling of the ankles Compulsive behaviors such as eating, shopping, gambling and sexual urges. Other treatment drugs options include Levodopa, Amantadine, Anticholinergic drugs, COMT-inhibitors, and MAO-B inhibitors. Some surgical treatment options include deep brain stimulation (DBS). In DBS, surgeons implant a battery-operated device called a neurostimulator. This device delivers an electrical charge to areas in the brain that control movement. They block the abnormal nerve signals that cause tremors. Exercise is another way to address the symptoms of PD. Activities like bicycling, yoga and tai chi can improve your motor coordination, balance, and flexibility. Experts recommend regular exercise with intense efforts worked in a few times a week.

Benztropine is used to treat ....

Benztropine is used to treat symptoms of Parkinson's disease or involuntary movements due to the side effects of certain psychiatric drugs.

Evidence-based practice related to Parkinson's disease (Part 1) -- Applying the Evidence: Dancing and Parkinson's Disease -- You are a nurse working with T.K., a 77-yr-old male, who was diagnosed with Parkinson's disease 5 yr ago. You note he has a moderate tremor, shuffling gait, and decreased arm flexion. He asks you what types of physical activity he can do with his decreased mobility. He currently enjoys daily neighborhood walks but finds it hard to keep his balance. Making Clinical Decisions .... (text p. 1389)

Best Available Evidence. Patients with mild to moderately severe Parkinson's disease (PD) have improvements in balance, motor impairment, endurance, quality of life, and participation in social activities after engaging in dance classes at least twice/week. Clinician Expertise. You know it is important to promote and encourage patients with PD to engage in physical exercise to help maintain functional mobility. You are also aware that personal exercise programs should be designed around physical activities that the individual enjoys. Patient Preferences and Values. T.K. states that in years past he enjoyed dancing with his wife and would like to do so again.

The health care provider (HCP) writes a prescription for carbamazepine for a client who was admitted to the hospital. The nurse contacts the HCP to verify the prescription if which condition is noted in the assessment data?

Bone marrow depression -- Carbamazepine is classified as an iminostilbene derivative and is used as an anticonvulsant, antineuralgic, antimanic, and antipsychotic. It is used to treat seizure disorders, trigeminal neuralgia, and diabetic neuropathy. The medication can cause blood dyscrasias as an adverse effect and is contraindicated if the client has a history of bone marrow depression, hypersensitivity to tricyclic antidepressants, or concurrent use of monoamine oxidase inhibitors.

The nurse is collecting data from a client and notes that the client is taking carbamazepine. The nurse determines that this medication has been prescribed to treat which condition?

Carbamazepine is classified as an iminostilbene derivative and is used as an anticonvulsant, antineuralgic, antimanic, and antipsychotic. It is not used to treat Parkinson's Disease, Diabetes, or Glaucoma.

The nurse is administering medications to a client with trigeminal neuralgia. The nurse expects that which medication will be prescribed for pain relief?

Carbamazepine and gabapentin -- The anticonvulsant medications carbamazepine and gabapentin help relieve the pain in many clients with trigeminal neuralgia. They act by inhibiting the reactivity of neurons in the trigeminal nerve. (This is associated with MS and Parkinson's. )

A client taking carbamazepine asks the nurse what to do if a dose is inadvertently missed. The nurse responds that which action should be taken?

Carbamazepine is an anticonvulsant that should be taken around the clock, precisely as directed. If a dose is omitted, the client should take the dose as soon as it is remembered, as long as it is not close to the time that the next dose is due. The medication should not be double-dosed. If more than 1 dose is omitted, the client should call the HCP.

The nurse has completed discharge teaching for a client prescribed carbamazepine. Which statement by the client indicates that education about the main effect of the medication was effective?

Carbamazepine is classified as an iminostilbene derivative and is used as an anticonvulsant, antineuralgic, antimanic, and antipsychotic.

When teaching a patient about carbidopa-levodopa (Sinemet), what information should the nurse include about this medication? [Lilley]

Carbidopa decreases levodopa's conversion in the periphery, increasing the levodopa available to cross the blood-brain barrier. Adding carbidopa to levodopa inhibits the breakdown of levodopa in the periphery, increasing the amount available to cross the blood-brain barrier and decreasing the extrapyramidal adverse effects caused by dopamine in the periphery, resulting in fewer unwanted adverse effects.

The nurse is providing care for a patient with a diagnosis of Parkinson's disease who has preexisting liver failure. What class of medications, if prescribed, would the nurse question? [Lilley]

Catechol ortho-methyltransferase (COMT) inhibitors COMT inhibitors are contraindicated in patients with liver failure or liver disease. Potential liver failure is also a known adverse effect.

Hypokinetic Dysarthria

Characterized by a rush of rapid speech. This is the type of dysarthria in Parkinson's Disease

Clinical Manifestations - What are the classic manifestations of PD? (text p. 1387)

Classic manifestations of PD are easily remembered by the mnemonic TRAP (tremor, rigidity, akinesia, and postural instability)

A client began taking amantadine approximately 2 weeks ago. The client reports to the clinic for a follow-up evaluation. The nurse determines that the client is experiencing a side or adverse effect related to the use of this medication if which is noted?

Client complaints of urinary retention -- Amantadine is an antiparkinson agent that potentiates the action of dopamine in the central nervous system. The expected effect of therapy is a decrease in akinesia and rigidity. Leukopenia, urinary retention, and hypotension are all side and adverse effects of the medication.

A client who has been taking phenytoin for seizure control has a serum phenytoin level of 8 mcg/mL (35.71 mmol/L). On the basis of this finding, which note should the nurse enter in the client's health record?

Client has an inadequate medication level. -- The therapeutic serum level range for phenytoin is 10 to 20 mcg/mL (40 to 79 mmol/L). A laboratory value of 8 mcg/mL is below the therapeutic range, indicating an inadequate medication level, so this should be noted in the health record and the health care provider should be notified.

What is required to clinically diagnose PD? (text p. 1389)

Clinical diagnosis requires the presence of TRAP and asymmetric onset. [Diagnosing Parkinson's disease isn't simple. There's no specific test to diagnose Parkinson's disease. Instead, doctors look for four cardinal features of the movement disorder. To diagnose the disease, doctors use the mnemonic TRAP: Tremor or shaking at rest, involving the thumb, entire hand, arm, chin, lips, and feet Rigidity felt by the doctor when rotating a patient's wrist or elbow Akinesia or bradykinesia (lack of movement or slowness of movement) when walking or swinging an arm Postural instability, making it necessary to hold onto something to maintain balance when walking or rising from a chair ]

Carbamazepine has been prescribed for a client. The nurse should tell the client that which blood test will be done periodically while the client is taking this medication?

Complete blood cell (CBC) count. -- Carbamazepine is classified as an iminostilbene derivative and is used as an anticonvulsant, antineuralgic, antimanic, and antipsychotic. The medication can cause blood dyscrasias as an adverse effect, and the client should have a CBC count done before therapy and periodically during therapy. Additional laboratory tests that should be done include a serum iron determination, urinalysis, blood urea nitrogen determination, and carbamazepine level.

A client is scheduled to begin therapy with carbamazepine. The nurse should assess the results of which test(s) before administering the first dose of this medication to the client?

Complete blood cell count -- Carbamazepine may be used to treat a seizure disorder. It can cause leukopenia, anemia, thrombocytopenia, and, very rarely, fatal aplastic anemia. To reduce the risk of serious hematological effects, a complete blood cell count should be done before treatment and periodically thereafter. This medication should be avoided in clients with preexisting hematological abnormalities. The client also is told to report the occurrence of fever, sore throat, pallor, weakness, infection, easy bruising, and petechiae.

A client is receiving phenytoin. To monitor for side and adverse effects of this medication, the nurse assesses the results of which laboratory test?

Complete blood count (CBC) -- Phenytoin (Dilantin) is an anticonvulsant used to treat seizure disorders. The nurse monitors the CBC because hematological effects of this therapy include aplastic anemia, agranulocytosis, leukopenia, and thrombocytopenia. Other test results that warrant monitoring include serum calcium levels, urinalysis, and hepatic and thyroid function tests. Electrolyte results and renal function tests are not a concern with this medication

How is a PD diagnosis confirmed? (text p. 1389)

Confirmation of PD is a positive response to antiparkinsonian drugs (levodopa or dopamine agonist). MRI and CT have a limited role in diagnosis of PD because they do not show a specific pathologic finding. However, they can rule out a stroke or brain tumor.

The nurse has a prescription to administer phenytoin 100 mg mixed in 5% dextrose in water by the intravenous (IV) route to a client. After reading this prescription, which action should the nurse take?

Contact the health care provider (HCP) to question the prescription. -- Precipitation will occur if phenytoin is mixed with any solution other than 0.9% (normal) saline. This is especially true with solutions containing dextrose. Therefore, the nurse would contact the HCP who prescribed the medication to change the prescription. Phenytoin is very irritating to the vein wall or other tissues and an in-line filter reduces the chance of precipitants entering the bloodstream. However, the prescription needs to be questioned and changed.

The nurse is reviewing the results of a test on a sample drawn from a child who is receiving carbamazepine for the control of seizures. The results indicate a serum carbamazepine level of 10 mcg/mL (42.33 mmol/L). The nurse analyzes the results and anticipates that the health care provider (HCP) will note which prescription?

Continuation of the presently prescribed dosage -- When carbamazepine is administered, blood levels need to be tested periodically to check for the child's absorption of the medication. The amount of the medication prescribed is based on the blood level achieved. Carbamazepine's therapeutic serum range is 6 to 12 mcg/mL (34 to 51 mmol/L). Therefore, the nurse anticipates that the HCP will continue the presently prescribed dosage.

Parkinsonism is through vascular processes. Current understanding of the pathophysiology of migraine points to a vasculopathic process...A client with vascular headaches is taking ergotamine. The home health nurse should periodically assess him or her for which finding?

Cool, numb fingers and toes -- Ergotamine can produce vasoconstriction. The nurse periodically assesses for hypertension; cool, numb fingers and toes; muscle pain; and nausea and vomiting. This medication does not cause hypotension, constipation, or dependent edema.

S/S of Stroke: FAST

F- face drooping (ask pt. to smile) A- arm weakness (ask pt. to raise both arms) S- speech difficulty (ask pt. to complete a sentence) T- time! to call 911

Many patients are given Sinemet early in the disease course for the management of motor symptoms. However, some HCPs believe that, after a few years of therapy, the effectiveness of Sinemet wears off. Therefore they prefer to start therapy with a _____, such as ______. (text p. 1389)

DA receptor agonist, a drug that directly stimulates DA receptors, such as Ropinirole (Requip) and pramipexole (Mirapex) which may be used alone or in combination with Sinemet. Bromocriptine (Parlodel) should not be used as first-line treatment because of possible serious side effects (e.g., high blood pressure, seizure, heart attack, stroke).

Deep brain stimulation (DBS) can be used to treat tremors and uncontrolled movements of Parkinson's disease. Electrodes are _____ and _____. (text p. 1391)

Deep brain stimulation (DBS) can be used to treat tremors and uncontrolled movements of Parkinson's disease. Electrodes are surgically placed in the brain and connected to a neurostimulator (pacemaker device) in the chest.

A client has been prescribed dextroamphetamine. The client complains to the nurse that the client cannot sleep well at night and does not want to take the medication any longer. Before making any specific comment, the nurse plans to investigate whether the client takes the medication at which proper time schedule?

Dextroamphetamine is a central nervous system (CNS) stimulant that acts by releasing norepinephrine from nerve endings. The client should take the medication at least 6 hours before going to bed at night to prevent sleep disturbance.

A hospitalized client has a prescription for dextroamphetamine daily. The unit nurse collaborates with the dietitian to limit the amount of which item on the client's dietary trays?

Dextroamphetamine is a central nervous system (CNS) stimulant. Caffeine is a stimulant also, so caffeine intake should be limited in the client taking this medication. The client should be taught to limit his or her own caffeine intake as well. It is not necessary to limit fat, starch, or protein while taking this medication.

Nursing Management of PD: Nursing Process -- Diagnosis Nursing diagnoses for the patient with PD may include, but are not limited to ____. (text p. 1391)

Diagnosis • Impaired physical mobility related to rigidity, bradykinesia, akinesia, and postural instability • Imbalanced nutrition: less than body requirements related to inability to ingest food • Impaired swallowing related to neuromuscular impairment (e.g., decreased or absent gag reflex) • Impaired verbal communication related to dysarthria, tremor, and bradykinesia

How is nutritional therapy used to manage PD? (text p. 1391)

Diet is of major importance to patients with PD because malnutrition and constipation can be serious consequences of inadequate nutrition.

A client with trigeminal neuralgia tells the nurse that acetaminophen is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication?

Direct bilirubin level of 2 mg/dL (34 mcmol/L) -- In adults, overdose of acetaminophen causes liver damage. The correct option is an indicator of liver function and is the only option that indicates an abnormal laboratory value. The normal direct bilirubin level is 0.1 to 0.3 mg/dL (1.7 to 5.1 mcmol/L). The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). The normal prothrombin time is 11 to 12.5 seconds (11 to 12.5 seconds). The normal platelet count is 150,000 to 400,000 mm3 (150 to 400 × 109/L).

A client has a medication prescription for phenytoin to be administered by the intravenous route. After drawing up the medication, the nurse notes the presence of precipitate in the syringe. Which action should the nurse take?

Discard the syringe and begin again. -- If the injectable solution is not clear or if precipitate is present, the medication should not be used and should be discarded. The nurse may have to call the pharmacy department to obtain another vial of the medication.

A client is receiving phenobarbital sodium. Which finding on the nursing assessment would indicate that the client is experiencing a common side or adverse effect of this medication?

Drowsiness -- Drowsiness is a common side or adverse effect of phenobarbital, which is a barbiturate and antiseizure medication. Hypocalcemia is a rare effect. Blurred vision is not an associated side effect of this medication. Seizure activity could occur from abrupt withdrawal of this medication therapy or as a toxic reaction.

What is the goal of drug therapy for PD? How does it basically work? (text p. 1389)

Drug therapy for PD is aimed at correcting the imbalance of neurotransmitters within the CNS. Antiparkinsonian drugs either enhance the release or enhance the supply of DA (dopaminergic neurons) or antagonize or block the effects of the overactive cholinergic neurons in the striatum (anticholinergic) (Fig. 58-7).

Drug-induced parkinsonism can also follow therapy with ______. (text p. 1387)

Drug-induced parkinsonism can also follow therapy with metoclopramide (Reglan), reserpine, methyldopa, lithium, haloperidol (Haldol), and chlorpromazine. Parkinsonism can be seen after the use of illicit drugs, including amphetamine and methamphetamine.

A client has been prescribed benztropine. The nurse should assess for which gastrointestinal (GI) problems as a side or adverse effect of this medication?

Dry mouth -- This medication is classified as an anticholinergic medication and is used to treat Parkinson's disease. Common GI side effects of benztropine therapy include constipation, dry mouth, and nausea. An adverse effect is ileus. These effects are the result of the anticholinergic properties of the medication.

Why is it recommended that the patient with PD eat six small meals per day? (text p. 1391)

Eating six small meals a day may be less exhausting than eating three large meals a day. Plan ample time for eating to avoid frustration.

(text p. 1390)

Entacapone (Comtan) and tolcapone (Tasmar) block the enzyme catechol O-methyltransferase (COMT), which breaks down levodopa in the peripheral circulation, and thus prolong the effect of Sinemet. These drugs are used only as adjuncts to levodopa; both drugs can exacerbate adverse effects of levodopa. Tolcapone is rarely prescribed because it has been associated with fatal hepatotoxicity.

Nursing Management of PD: Nursing Process -- Evaluation (text p. 1392)

Evaluation The expected outcomes are that the patient with PD will: • Perform physical exercise to deter muscle atrophy and joint contractures • Use assistive devices appropriately for ambulation and mobility • Maintain nutritional intake adequate for metabolic needs • Experience safe passage of fluids and/or solids from the mouth to the stomach • Use methods of communication that meet needs for interaction with others

Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect?

Impaired voluntary movements -- Dyskinesia and impaired voluntary movements may occur with high carbidopa-levodopa dosages. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia are frequent side effects of the medication.

Nursing Management of PD: Nursing Process -- Implementation (text p. 1391)

Implementation Because PD is a chronic degenerative disorder with no acute exacerbations, teaching and nursing care are directed toward maintenance of good health, encouragement of independence, and avoidance of complications such as contractures and falls. Problems secondary to bradykinesia can be alleviated by relatively simple measures.

Clinical Manifestations - What are the symptoms of beginning stages of PD? (text p. 1387)

In the beginning stages, only a mild tremor, a slight limp, or a decreased arm swing may be evident.

What is the incidence of Parkinson's Disease and who commonly gets it? (text p. 1387)

Incidence of PD increases with age, but an estimated 4% of people with PD are diagnosed before 50 years of age. PD is more common in men by a ratio of 3 : 2.

A client is having the dosage of clonazepam adjusted. The nurse should plan to perform which action?

Institute seizure precautions. -- Clonazepam is a benzodiazepine that is used as an anticonvulsant. During initial therapy and during periods of dosage adjustment, the nurse should initiate seizure precautions for the client. Weight, glucose levels, and ecchymosis are unrelated to this medication.

The nurse is caring for a client who is taking oral benztropine mesylate daily. What is the priority nursing assessment for the client?

Intake and output -- Urinary retention is a side effect of benztropine mesylate. The nurse needs to observe for dysuria, distended abdomen, infrequent voiding of small amounts, and overflow incontinence. The remaining options are unrelated to the side effects of this medication.

How does Parkinson's affect the heart? https://www.apdaparkinson.org/article/heart-and-parkinsons/

It has long been understood that Parkinson's disease (PD) does not just cause movement symptoms, but also causes a litany of non-motor symptoms with effects throughout the body. In PD, there are two major reasons why the automatic control of the cardiac system is impaired. First, areas of the brain that control this system often contain Lewy bodies and have undergone neurodegeneration. In addition, the autonomic nervous system itself is directly affected by Lewy body-like accumulations and neurodegeneration. This means, when the baroreceptors in the heart and carotid artery sense a drop in blood pressure and try to generate a signal to the heart and blood vessels to increase the blood pressure, the message may not get through. This results in neurogenic orthostatic hypotension (nOH), or drops in blood pressure upon standing due to autonomic nervous system dysfunction. There are no medications that can cure nOH by restoring the autonomic nervous system in PD. nOH however, can be treated. Another cardiac effect in PD however, is changes in heart rate. Heart rate variability, which is a measure of the variation in the time interval between heart beats, was found to be more pronounced in patients who eventually developed PD than those who did not, suggesting that cardiac autonomic dysfunction can be an early non-motor symptom of Parkinson's disease. Other studies have shown that people with PD tend to have certain features on their electrocardiogram. These features include a prolonged PR interval and possibly a prolonged QTc interval, referring to longer than normal segments of the tracing of the heart. It remains unclear what the clinical consequences of these changes are, although they are not thought to commonly lead to cardiac rhythm abnormalities. MONITOR: heart rate and rhythm; orthostatic hypotension

Clinical Manifestations - What are the symptoms of later stages of PD? (text p. 1387)

Later in the disease, the patient may have a shuffling, propulsive gait with arms flexed, and show loss of postural reflexes.

DRUG ALERT: Levadopa (text p. 1389)

Levodopa has many side effects and drug interactions. Prolonged use often results in dyskinesias [involuntary movement that you cannot control] and "off/on" periods when the medication will unpredictably start or stop working.

What drug is the primary drug used to treat symptoms of PD? (text p. 1389)

Levodopa with carbidopa (Sinemet) is the primary treatment for symptomatic patients. Levodopa is a chemical precursor of DA and can cross the blood-brain barrier. It is converted to DA in the basal ganglia. Sinemet is the preferred drug because it also contains carbidopa, an agent that inhibits the enzyme dopa-decarboxylase in the peripheral tissues. Dopa-decarboxylase breaks down levodopa before it reaches the brain. The net result of the combination of levodopa and carbidopa is that more levodopa reaches the brain, and therefore less drug is needed.

_____ , unusual clumps of protein, are found in the brains of patients with PD. (text p. 1387)

Lewy bodies, unusual clumps of protein, are found in the brains of patients with PD. It is not known what causes these bodies to form, but their presence indicates abnormal functioning of the brain. Lewy body dementia is discussed in Chapter 59.

A client experiencing spasticity as a result of spinal cord injury has a new prescription for dantrolene. Before administering the first dose, the nurse checks to see if which baseline study has been done?

Liver function studies -- Dantrolene is a skeletal muscle relaxant and can cause liver damage; therefore, the nurse should monitor the results of liver function studies. They should be done before therapy starts and periodically throughout therapy. Dantrolene is discontinued if no relief of spasticity is achieved in 6 weeks.

A client is scheduled to begin medication therapy with valproic acid. The nurse looks for the results of which laboratory test(s) before administering the first dose?

Liver function tests -- Gastrointestinal effects from valproic acid are common and typically mild, but hepatotoxicity, although rare, is serious. To minimize the risk of fatal liver injury, liver function is evaluated before initiation of treatment and periodically thereafter.

A patient is prescribed selegiline (Eldepryl), an MAO-B inhibitor, as adjunctive therapy in treatment of Parkinson's disease. What potential adverse effects should the nurse include in education for this patient? (Select all that apply.) [Lilley]

MAO-B inhibitors have many potential adverse effects, including dizziness, insomnia, hallucinations, ataxia, agitation, depression, paresthesia, somnolence, headache, dyskinesia, nausea, diarrhea, hypotension [blood pressure changes] or hypertension, chest pain, weight loss, dermatologic reactions, rhinitis, and pharyngitis.

What are some secondary [or atypical] parkinsonism causes ? (text p. 1387)

Many forms of secondary (atypical) parkinsonism exist other than PD. Symptoms of parkinsonism have occurred after exposure to a variety of chemicals, including carbon monoxide and manganese (among copper miners) and the product of meperidine analog synthesis, MPTP.

What forms of PD medications help to improve client compliance with drug therapy? (text p. 1390)

Many of PD medications are available in extended-release forms that improve patients' ability to adhere to treatment regimens. Rotigotine (Neupro), another DA receptor agonist, is available a transdermal patch applied once daily as an adjunctive therapy for patients taking Sinemet.

The nurse is giving medication instructions to a client who is receiving phenytoin for epilepsy. Which instruction should the nurse include to promote adherence to the medication?

Monitor plasma medication levels to provide information about compliance. -- Epilepsy is a chronic disease that requires regular and continuous therapy. It is not self-limiting, and nonadherence to the medication regimen results in treatment failure. Family and friends should be involved in the treatment regimen to help promote compliance. Monitoring plasma medication levels helps to provide information about adherence and can promote coaching and enhance compliance.

The nurse should question a prescription for which medication in the client concurrently receiving tramadol?

Monoamine oxidase inhibitors (MAOIs) -- Tramadol can precipitate a hypertensive crisis if combined with an MAOI. The combination is contraindicated. Its use is not contraindicated with beta blockers, histamine H2 antagonists, or calcium channel blockers.

The nurse is preparing an intravenous (IV) infusion of phenytoin as prescribed by the health care provider for the client with seizures. Which solution should the nurse plan to use to dilute this medication?

Normal saline solution -- IV infusion of phenytoin should be administered by injection into a large vein. The medication may be diluted in normal saline solution; however, dextrose solution should be avoided because of medication precipitation. The medication is administered as intermittent doses. Continuous IV infusions should not be used. Infusion rates of more than 50 mg/minute may cause hypotension or cardiac dysrhythmias, especially in older and debilitated clients.

Nursing Management of PD: Nursing Process -- Assessment: Objective Data - Cardiovascular; Gastrointestinal (text p. 1391)

Objective Data Cardiovascular: Postural hypotension Gastrointestinal: Drooling

Nursing Management of PD: Nursing Process -- Assessment: Objective Data - Musculoskeletal (text p. 1391)

Objective Data Musculoskeletal -- Cogwheel rigidity, -- dysarthria [difficult or unclear articulation of speech that is otherwise linguistically normal], -- bradykinesia, -- contractures, -- stooped posture, -- shuffling gait

Nursing Management of PD: Nursing Process -- Assessment: Objective Data - Neurologic (text p. 1391)

Objective Data Neurologic Tremor at rest, first in hands (pill rolling), later in legs, arms, face, and tongue. Aggravation of tremor with anxiety, absence in sleep. Poor coordination, cognitive impairment and dementia, impaired postural reflexes

Nursing Management of PD: Nursing Process -- Assessment: Objective Data - Possible Diagnostic Findings (text p. 1391)

Objective Data Possible Diagnostic Findings --No specific tests. --Diagnosis based on history and physical findings and ruling out of other diseases

Nursing Management of PD: Nursing Process -- Assessment: Objective Data - General (text p. 1391)

Objective Data General --Blank (masked) facial expression, --slow and monotonous speech, --infrequent blinking Integumentary Seborrhea, --dandruff; --ankle edema

Other causes of parkinsonism include _____. (text p. 1387)

Other causes of parkinsonism include hydrocephalus, other neurodegenerative disorders, hypoparathyroidism, infections, stroke, tumor, and trauma.27

Genetic Link - Mutations in genes resulting in familial PD are often associated with _____. (text p. 1387)

Other genes involved in familial PD are parkin (PARK2, PARK7), PINK1, and SNCA. Mutations in these genes are often associated with a younger age of onset and have additional manifestations than those typically seen with age-related PD.

Genetic Link - What is related to rare, early-onset form of PD? (text p. 1387)

PINK1 mutations are related to a rare, early-onset form of PD. It is not fully understood how genetic changes cause PD or influence the risk of developing the disorder.

shuffling gait

Parkinson disease is characterized by; appears as if the person is dragging their feet as they walk. Steps may also be shorter in stride (length of the step)

What is Parkinson's disease? (text p. 1387)

Parkinson's disease (PD) is a chronic, progressive neurodegenerative disorder characterized by slowness in the initiation and execution of movement (bradykinesia), increased muscle tone (rigidity), tremor at rest, and gait disturbance. It is the most common form of parkinsonism (a syndrome characterized by similar symptoms).

Treatment for Parkinson's focuses on _____. Mayfield Brain & Spine, Cincinnati, OH

Parkinson's disease (PD) is a progressive disorder that affects nerve cells in the brain responsible for body movement. When dopamine-producing neurons die, symptoms such as tremor, slowness, stiffness, and balance problems occur. Treatments focus on reducing symptoms to enable a more active lifestyle and include medication, diet, exercise, and deep brain stimulation surgery.

Long term disturbances in the trigeminal system are the underlying cause of most forms of Parkinson's. In most cases the trigeminal nerve disturbance will be due to jaw malalignment, though it could be from other disturbances within the trigeminal system.

Parkinson's. Trigeminal Neuralgia is a constant numb burning pain with intermittent shooting pains into mostly left side of face and eyes. I have a feeling like I am wearing a party hat with the elastic under my chin and going up the sides of my face.

The nurse in a long-term care facility is reviewing the health care provider's (HCP's) prescriptions on an assigned client. The nurse notes that the HCP prescribed ropinirole hydrochloride. The nurse determines that this medication has been prescribed to treat which condition in the client?

Parkinsonian syndrome -- Ropinirole hydrochloride is a medication that is used to treat idiopathic parkinsonian syndrome. It normally is administered 3 times a day to treat the client.

What are complications in PD that the nurse should be alert to with regards to nutritional therapy? (text p. 1391)

Patients who have dysphagia and bradykinesia need appetizing foods that are easily chewed and swallowed. The diet should contain adequate fiber and fruit to avoid constipation. Cut food into bite-sized pieces before it is served, and serve it on a warmed plate to preserve its appeal.

The nurse is speaking with a client taking phenytoin for seizure control. The client states that she has started using birth control pills to prevent pregnancy. Which would be an important point for the nurse to emphasize to the client?

Phenytoin may decrease the effectiveness of birth control pills, and additional measures should be taken to avoid pregnancy. -- Phenytoin enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth control pills. The nurse should tell the client to alert the health care provider about the use of birth control pills so that counseling may be provided about alternative birth control methods.

Nursing Management of PD: Nursing Process -- Planning (text p. 1391)

Planning The overall goals are that the patient with PD will (1) maximize neurologic function, (2) maintain independence in activities of daily living for as long as possible, and (3) optimize psychosocial well-being.

The nurse is preparing to ambulate a client with Parkinson's disease who has recently been started on levodopa/carbidopa. Before performing this activity with the client, the nurse should include which most important assessment in the client's plan of care?

Postural (orthostatic) vital signs -- Clients with Parkinson's disease are at risk for postural (orthostatic) hypotension from the disease. This problem is exacerbated with the introduction of levodopa/carbidopa, which also can cause postural hypotension and increase the client's risk for falls. Although knowledge of the client's use of assistive devices and history of falls is helpful, neither of these options is the most important element of the assessment, based on the wording of this question. Clients with Parkinson's disease generally have resting tremor, not intention tremor.

Describe "postural instability" manifested in a client with PD. (text p. 1389)

Postural instability is common. Patients may complain of 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 his or her balance and fall backward.

Describe rigidity associated with PD. (text p. 1388)

Rigidity is the increased resistance to passive motion when the limbs are moved through their range of motion. Parkinsonian rigidity is typified by a jerky quality (cogwheel rigidity), as if there were intermittent catches in the passive movement of a joint. Sustained muscle contraction causes the rigidity and consequently elicits complaints of muscle soreness; feeling tired and achy; or pain in the head, upper body, spine, or legs. Slowness of movement is another consequence of rigidity because it inhibits the alternating contraction and relaxation in opposing muscle groups (e.g., biceps and triceps).

(text p. 1390)

Rivastigmine (Exelon) or donepezil (Aricept) is used to treat dementia. Amitriptyline may be used to treat depression

Which antiparkinson drug causes an increase in the levels of dopaminergic stimulation in the central nervous system (CNS) and therefore allows a decreased dose of other medications? [Lilley]

Selegiline (Eldepryl) Selegiline is a selective monoamine oxidase (MAO) B inhibitor that has been shown to cause an increase in the levels of dopaminergic stimulation in the CNS and thus allow the dose of levodopa to be decreased.

(text p. 1390)

Selegiline (Eldepryl) and rasagiline (Azilect) are monoamine oxidase type B (MAO-B) inhibitors that may be used in combination with Sinemet. By inhibiting MAO-B, the degradative enzyme for DA, these agents increase the levels of DA and prolong the half-life of levodopa. Rasagiline can also be used alone as therapy in early PD. However, MAO-B inhibitors are less effective at treating motor symptoms than DA receptor agonists.

S/S of high blood pressure

Severe headache Fatigue or confusion Vision problems Chest pain Difficulty breathing Irregular heartbeat Blood in the urine Pounding in chest, neck, or ears Dizziness Nausea / Vomiting

A client with Parkinson's disease has begun therapy with levodopa/carbidopa. The nurse determines that the client understands the action of the medication if he or she verbalizes that results may not be apparent for how long?

Signs and symptoms of Parkinson's disease usually begin to resolve within 2 to 3 weeks of starting therapy, although in some clients marked improvement may not be seen for up to 6 months. The client needs to understand this concept to aid in compliance with medication therapy.

A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL (140 mcmol/L). Which finding would be expected as a result of this laboratory result?

Slurred speech -- The therapeutic phenytoin level is 10 to 20 mcg/mL (40 to 79 mcmol/L). At a level higher than 20 mcg/mL, involuntary movements of the eyeballs (nystagmus) occur. At a level higher than 30 mcg/mL (120 mcmol/L), ataxia and slurred speech occur. (seizures are associated with Parkinson's disease.

Nursing Management of PD: Nursing Process -- Assessment: Subjective Data - Functional Health Patterns (2) (text p. 1391)

Subjective Data Functional Health Patterns: -- Activity-exercise: Difficulty in initiating movements, frequent falls, loss of dexterity, micrographia (handwriting deterioration) --Sleep-rest: Insomnia, nightmares, daytime sleepiness

Nursing Management of PD: Nursing Process -- Assessment: Subjective Data - Functional Health Patterns (1) (text p. 1391)

Subjective Data Functional Health Patterns: -- Health perception-health management: Fatigue -- Nutritional-metabolic: Excessive salivation, dysphagia, weight loss -- Elimination: Constipation, incontinence, excessive sweating

Nursing Management of PD: Nursing Process -- Assessment: Subjective Data - Functional Health Patterns (3) (text p. 1391)

Subjective Data Functional Health Patterns: Cognitive-perceptual: Diffuse pain in head, shoulders, neck, back, legs, and hips. Muscle soreness and cramping Self-perception-self-concept: Depression, mood swings, hallucinations

Nursing Management of PD: Nursing Process -- Assessment: Subjective Data -- Important Health Information (text p. 1391)

Subjective Data Important Health Information: -- Past health history: Central nervous system trauma, cerebrovascular disorders, exposure to metals and carbon monoxide, encephalitis or other infections -- Medications: Major tranquilizers, especially haloperidol (Haldol), and phenothiazines, reserpine, methyldopa, amphetamines

What is the goal of surgical therapies to treat PD? (text p. 1390)

Surgical procedures aimed at relieving symptoms of PD are usually used in patients who are unresponsive to drug therapy or who have developed severe motor complications.

Absorption of levodopa prescribed for the patient with PD can be influenced by intake of ____ and ____. How can this problem be managed? (text p. 1391)

The absorption of levodopa can be impaired by protein ingestion and vitamin B6. Therefore some patients are advised to limit their protein intake to the evening meal to decrease this problem. They also need to consult with their HCP regarding possible inclusion of vitamin B6 in their multivitamins and fortified cereals.

(text p. 1390)

The antiviral agent amantadine is a weak antagonist of NMDA-type glutamate receptors, increases dopamine release, and blocks dopamine reuptake. Thus it provides only mild relief and is seldom used in early stages of PD. In addition, withdrawal of amantadine even after extended therapy can worsen dyskinesia.

A client has been prescribed codeine sulfate. The nurse has given the client instructions for its use. The nurse concludes that the client understands the instructions if the client verbalizes to self-assess for which side effect?

The client is taught about side and adverse effects that could occur with the use of codeine sulfate. The most common side effects include drowsiness, confusion, hypotension, nausea and vomiting, and constipation. Adverse effects include bradycardia, respiratory depression, and urinary retention.

A client with myasthenia gravis who is taking neostigmine is experiencing frequent exacerbations of myasthenic crisis and cholinergic crisis. The nurse teaches the client that it is most important that this medication be taken in which manner?

The client should take neostigmine exactly on time. Taking the medication early or late could result in myasthenic or cholinergic crisis. Taking the medication on time is especially important for the client with dysphagia because the client may not be able to swallow the medication if it is given late. These clients are taught to set an alarm clock to remind them of dosage times. The medication should be administered with food or milk to minimize side and adverse effects. The client should never skip or double up on missed doses or titrate the dose, depending on symptoms. The client needs to take the medication exactly as prescribed.

Parkinson's Disease Etiology and Pathophysiology (text p. 1387)

The exact cause of PD is unknown. Although PD is not considered a hereditary condition, genetic risk factors should be evaluated for their interplay with environmental factors. About 15% of patients with PD have a positive family history for the disease (familial cases) that may be caused by mutations in specific genes. In other people, risk for PD may be increased by well water, pesticides, herbicides, industrial chemicals, and wood pulp mills. Rural residence is also considered a risk factor.

_____ is a drug prescribed to patients with advanced PD to improve movement in hypomobility episodes. What is a precaution attached to taking this drug? (text p. 1390)

The injectable DA receptor agonist apomorphine (Apokyn) is also used to improve movement in hypomobility episodes. Apomorphine must be taken with an antiemetic drug (e.g., trimethobenzamide [Tigan]) because it causes severe nausea and vomiting when taken alone.

After review of the client's laboratory values, the nurse notes that a phenytoin level for a client receiving phenytoin is 7 mcg/mL (27.78 mmol/L). The nurse makes which interpretation regarding this laboratory result?

The level is lower than the expected therapeutic range. -- the target range for a therapeutic serum level of phenytoin is between 10 and 20 mcg/mL (40 to 79 mmol/L). Levels below 10 mcg/mL are too low to control seizures. At levels above 20 mcg/mL (79 mmol/L), signs of toxicity begin to appear. This client has a low serum level, and the dosage is likely to be increased.

What is the most common surgical treatment for PD? Describe. (text p. 1390)

The most common surgical treatment is DBS, which involves placing an electrode in the thalamus, globus pallidus, or subthalamic nucleus and connecting it to a generator placed in the upper chest (similar to a pacemaker) (Fig. 58-10). The device is programmed to deliver a specific current to the targeted brain location. DBS is preferred to ablation procedures because it is reversible and programmable and can be safely performed bilaterally.

What accounts for the stooped posture, masked face [deadpan expression], drooling of saliva, and shuffling gait [festination] that are characteristic of a person with PD? (text p. 1389)

The patient with PD does not execute automatic / involuntary / subconscious movements and lacks spontaneous activity. This accounts for the stooped posture, masked face (deadpan expression), drooling of saliva, and shuffling gait (festination) that are characteristic of a person with this disease. The posture is that of a slowed "old man" image, with the head and trunk bent forward and the legs constantly flexed.

The nurse has a prescription to administer diazepam 5 mg by the intravenous (IV) route to a client. The nurse should administer the medication over a period of at least how long?

The recommended rate of infusion of diazepam is to give each 5 mg of the medication over at least 1 minute. This will prevent adverse effects, including apnea, bradycardia, hypotension, and possibly cardiac arrest.

(text p. 1390)

The use of only one drug is preferred because fewer side effects occur and the drug dosage is easier to adjust than when several drugs are used. However, as the disease progresses, combination therapy is often required. Excessive amounts of dopaminergic drugs can lead to aggravation rather than relief of symptoms (paradoxic intoxication).

What are some common complications related to PD? (text p. 1389)

These include motor symptoms (e.g., dyskinesias [spontaneous, involuntary movements], weakness, neurologic problems (e.g., dementia), and neuropsychiatric problems (e.g., depression, hallucinations, psychosis). As PD progresses, it often results in dementia, which is associated with an increase in mortality. As swallowing becomes more difficult (dysphagia), malnutrition or aspiration may result. General debilitation may lead to pneumonia, urinary tract infections, and skin breakdown. Orthostatic hypotension occurs commonly and, along with loss of postural reflexes, may result in falls or other injury. The patient's increased fall risk increases the need for the primary caregiver to be aware of environmental conditions that may also contribute to falls.

A client who was started on clonazepam tells the nurse of increasing clumsiness and unsteadiness since starting the medication. The client is visibly upset by these manifestations and asks the nurse what to do. The nurse's response is based on which understanding?

These symptoms are most severe during initial therapy and decrease or disappear with long-term use. -- Clonazepam is classified as a benzodiazepine and is used as an anticonvulsant and antianxiety agent. Drowsiness, unsteadiness, and clumsiness are expected effects of the medication during early therapy. They are dose related and usually diminish or disappear altogether with continued use of the medication. They are unrelated to an interaction with another medication. The client is encouraged to take this medication with food to minimize gastrointestinal upset. These symptoms do not indicate that an adverse effect is occurring.

The nurse is caring for a patient with Parkinson's disease who has been taking entacapone (Comtan) for the past week to treat an on-off phenomenon. The patient expresses concern over brown-orange urine. What information will the nurse provide to the patient? [Lilley]

This is a normal adverse effect of entacapone (Comtan) and is not harmful. Patients should be instructed that entacapone (Comtan) can turn urine a brownish-orange color, and this is not a harmful adverse effect.

What is the goal of pharmacologic therapy in treating Parkinson's disease? [Lilley]

To balance cholinergic and dopaminergic activity in the brain Parkinson's disease results from a decrease in dopaminergic (inhibitory) activity, leaving an imbalance with too much cholinergic (excitatory) activity. By increasing dopamine, the neurotransmitter activity becomes more balanced and symptoms become controlled.

How does trihexyphenidyl hydrochloride work?

antagonizes activities of acetylcholine via muscarinic receptors. This balances the cholinergic and dopaminergic activity in the basal ganglia leading to an improvement of classic Parkinson symptoms such as rigidity and tremor. In addition, trihexyphenidyl hydrochloride exerts a direct antispasmodic effect on smooth muscle.

The nurse is reading the laboratory results for a client being treated with carbamazepine for prophylaxis of complex partial seizures. When evaluating the client's laboratory data, the nurse determines that which value is consistent with a side or adverse effect of this medication? a. Sodium level, 136 mEq/L (136 mmol/L) b. Platelet count, 350,000 mm3 (350 × 109/L) c. White blood cell count, 3200 mm3 (3.2 × 109/L) d. Blood urea nitrogen (BUN), 19 mg/dL (6.84 mmol/L)

c. White blood cell count, 3200 mm3 (3.2 × 109/L) -- Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, and leukopenia. Other adverse effects include cardiovascular disturbances, thrombophlebitis, dysrhythmias, and dermatological effects.