Concepts: Parkinson and Mobility

Carbidopa/levodopa is prescribed for a client with Parkinson disease. What will the nurse teach the client about this medication? "Take this medication between meals." "Blood levels of the drug should be monitored weekly." "It can cause happy feelings followed by feelings of depression." "You may experience dizziness when moving from sitting to standing.

"You may experience dizziness when moving from sitting to standing. Carbidopa/levodopa is a metabolic precursor of dopamine; it reduces sympathetic outflow by limiting vasoconstriction, which may result in orthostatic hypotension. Carbidopa/levodopa should be administered with food to minimize gastric irritation. Although periodic tests to evaluate hepatic, renal, and cardiovascular status are required for prolonged therapy, whether these tests should be done on a weekly basis has not been established. Carbidopa/levodopa may produce either happiness or depression, but no established pattern of such responses exists.

Parkisonism

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How does this happen

-Ach is an excitatory neuro -Dopamine: inhibitory neuro -Dopamine keeps ach in balance but in Parkinson there is an imbalance in DOP so ach is left unchecked and keeps neurons stimulated -As neurons cont to be polarizing this causes GABA to be released ; as it increases we have symptomatic movement disorder occurs

Clinical Manifestations

-Early Signs: Subtle and insidious with ongoing progression. -Mild tremors - more prominent at rest.; aggravated with stress/emotional -Involve only one extremity Late Signs: TRAP Pneumonic Tremor, Rigidity increase resistance to motion, Akinesia or Bradykinesia, Postural Instability. -muscles contraction or KOG will -Flat expression -Shuffled gate -Postural instability; forward leading head \ -Positive diagnosis of PD is a positive tp anti-parkinson's drugs

Etiology and Patho

-Exact cause of PD unknown Possibly a result of a complex interplay between environmental factors and the person's genetic makeup - Risk factors include but not limited to the following: -Family history -Exposure to toxins may trigger disease. -Drug-induced parkinsonism: reglan or haldol , amphetaminic -Genetic mutation -Age

Safety

-Get out of a chair by using arms and placing the back legs on small blocks -Remove rugs and excess furniture -Simplify clothing from buttons and hooks -Use elevated toilet seats. Use an ottoman to elevate legs

Collaborative care: deep brain stimulations

-Involves placing an electrode in the thalamus, globus pallidus, or subthalamic nucleus -Connected to a generator placed in the upper chest -Device is programmed to deliver specific current to targeted brain location.

Parkinson's meds

-Medication Treatment regimen ØAnticholinergics -Block cholinergic receptors ØAntihistamines -Has anticholinergic effect ØDopamine Pre-cursors -Converted to dopamine in basal ganglia ØDopamine Receptor Agonists -Stimulate dopamine receptors ØDopamine agonists -Blocks NMDA-type glutamate receptors, increases dopamine release, and blocks dopamine reuptake ØMAO-B inhibitors -Inhibit MAO-B enzyme that interferes with dopamine ØCOMT inhibitors -Inhibit COMT enzyme that inactivates dopamine

Nursing mng and Nursing Implementation

-Promote physical exercise and a well-balanced diet - -Limit the consequences from decreased mobility -Specific exercises to strengthen muscles involved with speaking and swallowing -Do not take protein rich foods & Vitamin B6 when taking Parkinson medications. -Maintenance of good health -Encouragement of independence, especially in ADL's. -Avoidance of complications such as contractures, falls, aspiration, constipation, weight loss, depression and communication barriers.

Parkinsons

-diagnosed by positive affects to medication

Parkinson's disease

-disease of the central nervous system -chronic, and progressive neurodegenerative disorder -Characterized by: bradykinesia, rigidity, tremors, and gait disturbance

Discharge planning for an ambulatory client with Parkinson disease (PD) includes recommending equipment for home use that will help with activities of daily living. To foster independence, the nurse should promote the use of which equipment? A raised toilet seat Side rails for the bed A trapeze above the bed Crutches for ambulatio

A raised toilet seat A raised toilet seat will reduce strain on the back muscles and make it easier for the client to rise from the seat without injury. The client is not bedridden and will not need side rails for the bed or a trapeze above the bed. Clients with Parkinson disease have poor balance and a propulsive gait, which makes it unsafe to use crutches.

Neurotrasmitters

Acetylcholine (ACh), a neurotransmitter essential for processing memory and learning, -chief neurotransmitter of the parasympathetic nervous system -Cholinesterase inhibitors increase the amount of acetylcholine and its effects. -Anticholinergics block acetylcholine and stop it from working! It is not advisable to use anticholinergics in a patient who is on cholinesterase inhibitors. Dopamine -an increase in the level of dopamine may cause symptoms of the hyperactive type of delirium, including hallucinations and delusions. -Some studies have shown that suboptimal levels of dopamine cause atrophy of the midbrain and prefrontal cortex. -We believe dopamine is linked to the entire cascade of metabolic and behavioral events that may lead to delirium. Gamma-aminobutyric acid (GABA) and glutamate. -GABA and glutamate have both been implicated in the development of delirium. -Glutamate is metabolized into GABA, which is an inhibitory neurotransmitter. -Hypnotic or sedative drug withdrawal may cause the level of GABA to drop, which in turn may cause delirium. Glutamte -plays an important roles in learning and memory. -important neurotransmitter present in over 90% of all brain synapses and is a naturally occurring molecule that nerve cells use to send signals to other cells in the central nervous system. -serves as the predominant excitatory neurotransmitter in the brain. Glutamate plays a critical role in cognitive, motor, and sensory functions. It exerts its effects by binding to glutamate receptors on neurons. C-reactive protein (CRP). -C-reactive protein (CRP) can stimulate the formation of reactive oxygen species, which cause disruption of BBB and manifest as delirium. -Studies have shown that higher levels of CRP and interleukin (IL)-6 are associated with greater incidence of delirium in postoperative hip surgery patients

Meds cont: Benztropin or Cogentin

Anticholinergics Ø Benztropin or "Cogentin" AE: urinary retention, hallucinations, mood changes Dopamine Precursor: Carbidopa-Levodopa "Sinemet""(food precautions - protein rich foods and Vit B6 can decrease the effects of the medication). -Take several weeks to work -body fluids can change; normal effect -over time there is a wearing off affect Dopamine Agonist & Receptor Agonist Ø Amantadine (antiviral) Ropirionale "Requip" AE: severe drowsiness MAO Inhibitors Type B (food cautions - tyramine foods, aged cheese, smoked cured meats, fermented foods, and beer, red wine can cause a hypertensive crisis) Ø Rasagiline "Azilect" AE: hypertensive crisis COMT Inhibitors Ø Entacopone "Comtan" used with Sinemet -blocks comt enzyme that breaks down levodopa

When helping a client with Parkinson disease to ambulate, what instructions should the nurse give the client? Avoid leaning forward. Hesitate between steps. Rest when tremors are experienced. Keep arms close to the center of gravity.

Avoid leaning forward. The client with Parkinson disease often has a stooped posture [1] [2] [3] because of the tendency of the head and neck to be drawn down; this shift away from the center of gravity causes instability. -Hesitation is part of the disease; clients may use a marching rhythm to help maintain a more fluid gait. The tremors of Parkinson disease occur at rest (resting tremors). The client must consciously attempt to maintain a natural arm swing for balance.

Causes

Chronic, progressive degenerative disorder that affects the dopamine producing neurons in the brain that affects muscle movement

Levodopa/carvadopa

Classification - Dopaminergic agonist Pharmacokinetics- PO Onset - 2-3 weeks for therapeutic effect Peak - 0.5-2hr Duration - 5- hrs or more Routes - PO, controlled release and extended-release Pharmacodynamics - Levodopa converted to dopamine in brain, replaces depletion. -Carbidopa inhibits initial breakdown of levodopa and allows for much lower doses of levodopa to be used Adverse effects -Palpitations -Hypotension -Urinary retention dyskinesia -mood changes Safety -Orthostatic hypotension precautions Usual dose - 25/250 mg to max 8 tablets a day Developmental concerns Pregnancy Category C

Antiparkinsonias drugs (anticholinergic effects)

Nursing Interventions -Monitor vital signs. -Monitor urine output for early detection of urinary retention. -Increase fluid intake, fiber, and exercise to avoid constipation. -serve for involuntary movements. -Advise patient to avoid alcohol, cigarettes, caffeine, and aspirin to decrease gastric acidity. -Encourage patient to relieve dry mouth with ice chips, hard candy, or sugarless chewing gum. Suggest use of sunglasses for photophobia. Anticholinergic effects -Fluid retention -Dry mouth -Pupil dilation -Vasodilation and flushing -Tacky -Hallucinations -Hyperthermia -Photophobia: wear sunglasses

A client is diagnosed with Parkinson disease and asks the nurse what causes the disease. On which underlying pathology does the nurse base a response? Disintegration of the myelin sheath Breakdown of upper and lower neurons Reduced acetylcholine receptors at synapses Degeneration of the neurons of the basal ganglia

Degeneration of the neurons of the basal ganglia Parkinson disease involves destruction of the neurons of the substantia nigra, reducing dopamine. The cause of this destruction is unknown. Disintegration of the myelin sheath is associated with multiple sclerosis. Breakdown of upper and lower motor neurons is associated with Lou Gehrig disease or amyotrophic lateral sclerosis. Reduced acetylcholine receptors at synapses are associated with myasthenia gravis.

A nurse is caring for two clients. One has Parkinson disease, and the other has myasthenia gravis. For which common complication associated with both disorders should the nurse assess these clients? Cogwheel gait Impaired cognition Difficulty swallowing Nonintention tremors

Difficulty swallowing Difficulty swallowing (dysphagia) is a manifestation of both neurologic disorders. With Parkinson disease there is a progressive loss of spontaneity of movement, including swallowing, related to degeneration of the dopamine-producing neurons in the substantia nigra of the midbrain. With myasthenia gravis there is a decreased number of acetylcholine (Ach) receptor sites at the neuromuscular junction, which interferes with muscle contraction, impairing muscles involved in chewing, swallowing, speaking, and breathing. A cogwheel gait is associated with Parkinson disease, not myasthenia gravis. Impaired cognition is associated with Parkinson disease, not myasthenia gravis. Nonintention tremors are associated with Parkinson disease, not myasthenia gravis. The nonintention tremors associated with Parkinson disease result from the loss of the inhibitory influence of dopamine in the basal ganglia, which interferes with the feedback circuit within the cerebral cortex.

Nigrostriatal Disorder in Parkinsonism

Dopamine is carried through the nigrostriatal fibers to the brain with movement

Neuro abnormalities in PD

Drug therapy in parkinson is aimed at correcting the imbalances between ach and dopamine which is accomplished by -increasing the supply of dopamine -blocking or lowering ach levels

A nurse is performing the history and physical examination of a client with Parkinson disease. Which assessments identified by the nurse support this diagnosis? Select all that apply. Nonintention tremors Frequent bouts of diarrhea Masklike facial expression Hyperextension of the neck Rigidity to passive movement

Nonintention tremors Masklike facial expression Rigidity to passive movement Nonintention tremors associated with Parkinson disease result from degeneration of the dopaminergic pathways and excess cholinergic activity in the feedback circuit. A masklike facial expression results from nigral and basal ganglial depletion of dopamine, an inhibitory neurotransmitter. Cogwheel rigidity is increased resistance to passive motion and is a classic sign of Parkinson. Constipation, not diarrhea, is a common problem because of a weakness of muscles used in defecation. The tendency is for the head and neck to be drawn forward, not hyperextended, because of loss of basal ganglial control.

A client with a history of parkinsonism recently developed rigidity, tremors, and signs of pneumonia. The client is hospitalized for treatment. What should the nursing plan of care include? Gait training in the physical therapy department daily Isometric exercises every two hours while awake Active range-of-motion exercises at least every four hours Passive range-of-motion exercises at least every eight hours

Passive range-of-motion exercises at least every eight hours Passive range-of-motion exercises at least every eight hours maintain the range of joint movement with a minimum of energy expenditure by the client. Ambulation may fatigue the client and does not provide sufficient movement of the upper extremities. Isometric exercises do not provide the joint movement necessary to prevent contractures. Active range-of-motion exercises at least every four hours increase the client's metabolic rate and need for oxygen; the client's ability to meet increased oxygen demand is decreased in the presence of pneumonia.

PD medication treatment cont

Rapid swings in response to levodopa occur ("on-off phenomenon") •PD worsens when too little dopamine is present •Dyskinesia occurs when too much dopamine is present "Wearing-off phenomenon" •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") -10 years

A nurse is caring for a client with Parkinson disease. Which clinical indicators does the nurse expect to find upon assessment? Select all that apply. Resting tremors Flattened affect Muscle flaccidity Tonic-clonic seizures Slow voluntary movements

Resting tremors Flattened affect Slow voluntary movements -Resting (nonintention) tremors, commonly accompanied by pill-rolling movements of the thumb against the fingers, are associated with destruction of the neurons of the basal ganglia and substantia nigra. -Destruction of the neurons of the basal ganglia and substantia nigra results in decreased muscle tone. The masklike appearance, unblinking eyes, and monotonous speech patterns can be interpreted as a flat affect. Slow voluntary movements (bradykinesia) are associated with this disorder. Muscle flaccidity is not associated with Parkinson disease. Rigidity is caused by sustained muscle contractions. Movement is jerky in quality (cogwheel rigidity). Tonic-clonic seizures are not associated with Parkinson disease.

The nurse is caring for a client with Parkinson disease. Which is a priority nursing concern? Decreased physical mobility related to stooped posture Risk for injury related to gait disturbances Impaired skin related to drooling Pain related to headache

Risk for injury related to gait disturbances

Medication therapy

Use of only one drug is preferred •Fewer side effects •Dosages are easier to adjust •Combination therapy is often required as disease progresses •Excessive dopaminergic drugs can lead to paradoxical intoxication

Carbidopa-levodopa is prescribed for a client with Parkinson disease. The nurse monitors the client for which side effects of the medication? Select all that apply. Vomiting Anorexia Slow heart rate Changes in mood Peripheral edema

Vomiting Anorexia Changes in mood Nausea and vomiting may occur; it reflects a central emetic reaction to levodopa. Anorexia may occur; decreased appetite results because of nausea and vomiting. Changes in affect, mood, and behavior are related to toxic effects of the drug. Tachycardia and palpitations, not bradycardia, occur. Peripheral edema is not a side effect of carbidopa-levodopa.

consequences of immobility

•Cardio- reduced CO, orthostatic hypotension, DVT, syncope •Respiratory - Reduced lung expansion, atelectasis, pooling of secretions, reduced cough and effort increases risk for PNA., hypercapnia •MS - reduction in muscle mass, contractures, decrease in bone density - calcium loss and osteoporosis.

PD cont

•Diagnosis increases with age -older population 50 to 60yo •More common in men than women 3:2 •Prevalence of PD is about 160 per 100,000.

Nursing mng and diagnosis

•Impaired physical mobility •Imbalanced nutrition: less than body: smaller meals more frequently •Impaired swallowing •Impaired verbal communication •Depression •Risk for Injury, Falls.

Cont

•Integumentary: skin breakdown/pressure ulcer patient is at risk for infection/sepsis. Possible poor nutrition and incontinence furthers tissue breakdown and inability to heal. •GI - Constipation due to inability to sit upright and have a BM, decrease peristalsis - •Psychological - boredom, depression, hopelessness, social isolation, body image disturbance, and grief.

mobility

•Mobility refers to purposeful physical movement, including gross simple movements, fine complex movements, and coordination. •Scope- Full mobility, partial mobility, to complete immobility.

Mobility and collaboration

•Risk for Injury/Falls due to decrease in motor function. •Need for early mobilization and independence as much as possible. Use of appropriate assistive devices as needed. •Proper body alignment when in bed, turning q2 hours, proper skin care, IS, TCBD, bed exercises, ROM, anti-inflammatory drugs NSAIDS, Analgesics, Muscle Relaxers, and Vit D and Calcium supplements.