Ch. 59: Parkinson's Disease
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| This is a disease of the basal ganglia characterized by slowing down in the initiation execution of mvmt (bradykinesia), inc. muscle tone (rigidity), tremor at rest, and gait disturbance. | Parkinson's disease (PD)
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| With PD there is a lack of what in the brain? | dopamine
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| What is the onset of PD like? | Gradual and insidious with ongoing progression.
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| What is the classic triad of PD? | tremor (hand, diaphragm, tongue, lips, jaw), rigidity (inc. resistance to passive motion when limbs go through ROM), bradykinesia (loss of automatic mvmts such as blinking of eyelids, swallowing, self-expression)
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| Beginning stages of PD may involve what CM? | mild tremor, slight limp, or decreased arm swing
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| Later stages of PD may involve what CM? | shuffling, propulsive gait (leaning forward) w/arms flexed, and loss of postural reflexes; some have slight speech changes
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| Postural instability is common. Patients may complain of being unable to stop themselves from going forward (propulsion) or backward (retropulsion). How is this assessed? | the "pull test"; the examiner stands behind the patient and gives a tug backwards on the shoulder, which causes patients to lose their balance and fall backwards
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| What are some nonmotor CM of PD? | depression, anxiety, fatigue, pain, constipation, sleep problems, short-term memory loss
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| What are some complications from PD? | dysphagia may result in malnutrition & aspiration; general debilitation may lead to pneumonia, UTIs, and skin breakdown; orthostatic hypotension could result in falls & injuries
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| How is PD diagnosed? | No specific tests but dx based on hx & clinical features. Firm dx can be made when at least two of three characteristics of the classic triad (tremor, rigidity, and bradykinesia) are present.
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| What is the ultimate confirmation of PD? | A positive response to antiparkinsonian drugs.
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| How is PD treated? | No cure for PD. Collaborative management is aimed at relieveing symptoms.
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| What is often the first drug used in PD? | Levodopa with carbidopa (Sinemet)
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| What is the net result of the combination of levodopa and carbidopa? | That more levodopa reaches the brain, and therefore less drug is needed.
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| Prolonged use of levodopa often results in what? | dyskinesias and "off/on" periods when the medication will unpredictably start or stop working.
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| Effectiveness of Sinemet could wear off after a few years so some initiate therapy with this instead? | DA receptor agonists such as bromocriptine (Parlodel), pergolide (Permax), ropinirole (Requip), and pramipexole (Mirapex)
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| What doe DA receptor agonists do? | directly stimulate DA receptors
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| These drugs are a degradative enzyme for DA and increase the levels of DA and prolong the half life of levodopa. | MAO-B inhibitors such as selegiline and rasagiline (Azilect)
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| These drugs break down levodopa in the peripheral circulation, prolonging the effects of Sinemet. | entacapone and tolcapone
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| Anticholinergic drugs are used to manage PD. Examples are? | trihexyphenidyl (Artane) and benztropine (Cogentin)
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| Antihistamines with anticholinergic or B-adrenergic blockers are used to manage what? | tremors
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| This antiviral is an effective antiparkinsonian drug that promotes the effect of DA. | amantadine (Symmetrel)
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| These drugs are used to treat mild to moderate Parkinson's dementia. | rivastigmine (Exelon) or donepezil (Aricept)
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| This drug may be used to treat depression. | amitriptyline (Elavil)
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| Within 3-5 years of tx, pts experience epsiodes of what? | hypomobility is the inability to rise from a chair, to speak, or to walk.
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| How is hypomobility treated? | with apomorphine (Apokyn) and needs to be taken with an antiemetic drug
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| What antiemetics should you not take with apomorphine (Apokyn) b/c it can lead to very low BP and loss of consciousness? | serotonin (5-HT3) receptor antagonists such as ondansetron (Zofran)
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| What kind of surgical therapy can be done for PD? | ablation, DBS, and transplantation of fetal neural tissue
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| When is surgical therapy for PD done? | For patients who are usually unresponsive to drug therapy or have developed severe motor complications.
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| This surgery involves stereotactic destruction of areas in the thalamus (thalamotomy), globus pallidus (pallidotomy), & subthalamic nucleus (subthalamic nucleotomy). | ablation surgery
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| This surgical therapy can be adjusted to control symptoms better and is reversible (the device can be removed) and has been shown to improve motor function and reduce dyskinesia and medication usage. | deep brain stimulation (DBS)
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| Describe the DBS procedure. | It involves placing an electrode in the thalamus, globus pallidus, or subthalamic nucleus; is connected to a generator placed in the upper chest; and the device is programmed to deliver specific current to targeted brain location.
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| This surgical therapy involves transplantation of fetal neural tissue into the basal ganglia and provides what? | DA-producing cells in the brains of patients
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| What kind of nutritional therapy is needed for PD? | Food that's easily chewed & swallowed & cut into bite-sized pieces, adequate roughage. Several small meals to prevent fatigue. Limit protein intake to the evening meal to prevent impairment of Levodopa.
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| You should promote physical exercise and a well balanced diet by? | Limiting the consequences from decreased mobility and do specific exercises to strengthen muscles involved with speaking and swallowing.
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| How would you teach a PD patient to get out of a chair? | By using arms and placing the back legs on small blocks.
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| To prevent falls what should you remove? | rugs and excess furniture
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| Clothing can be simplified by? | Use of slip-on shoes and velcro hook-and-loop fasteners or zippers.
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| Patients with PD should use elevated toilet seats and ottomans can help with what? | avoid dependent ankle edema
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| This is post-infective ascending paralysis that usually affects cranial nerves and the peripheral nervous system. | Guillain-Barre Syndrome
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| What is the most serious complication of Guillan-Barre Syndrome? | respiratory failure and immobility
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| How is Guillain-Barre Syndrome diagnosed? | Based on clinical signs and hx. Elevated protein level 7-10 days in CSF; MRI can rule out MS
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| What is the goal of care for Guillain-Barre Syndrome? | supportive care especially respiratory
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| What is helpful with Gauillain-Barre Syndrome in the first 2 weeks? | plasmapharesis
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| How long can Guillain-Barre Syndrome last? | Weeks to years. Can have descending repair with 85--95% almost completely recover but may have some residual weakness.
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| This disease is characterized by loss of motor neurons. Death usually 2-6 yrs after dx. Onset 40-60 yrs, men 2x more. Characterized by limb weakness, dysarthia (difficult articulation of speech), dysphagia (difficulty swallowing). | Amyotrophic Lateral Sclerosis (ALS); Lou Gehrig's Disease
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| How is ALS treated? | There is no cure but Riluzole may slow progression.
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| What are some nursing interventions for ALS? | Facilitate communication; reduce risk of aspiration; early identification of respiratory problems; decrease pain from muscle weakness; decrease risk of injury from falls; provide diversional activities.
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| This is an autoimmune neuromuscular disease in which antibodies attach acetylcholine and is characterized by weakness of certain skeletal muscles and gets worse as day progresses. | Myasthenia Gravis (MG)
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| What muscles are involved with MG? | Muscles that move the eyes and eyelids, chewing, swallowing, speaking, and breathing.
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| What can cause a Myasthenia crisis? | Infection, surgery, emotional distress, drug overdose, or inadequate dosing.
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| How is MG diagnosed? | By history, EMG, CT of thymus, Tensilon test
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| How is MG treated? | Drugs such as anticholinesterase, corticosteroids, immunosuppressants; surgical removal of thymus; plasmapharesis & IV immunoglobulin can give short term relief of symptoms.
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| What drugs are contraindicated with MG or used with caution? | anesthetics, antidysrhythmics, antibiotics, antipsychotics, barbiturates, sedatives, opioids, diuretics,
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| What are goals of care for MG? | Maintain optimal muscle function, monitor for side effects of meds, avoid complications, quality of life.
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| This disease is genetic, autosomal dominant, offspring of person infected has 50% chance of contracting. Characterized by abnormal & excessive involuntary movements (chorea) of face, limbs, & body. | Huntington's Disease (HD)
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| What can result from HD? | depression, anxiety, agitation, inability to talk and eat.
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| How is HD treated? | Palliative care and meds such as tetrabenazine, sertraline, paroxetine, and haloperidol
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