PARKINSON’S DISEASE MEDICAL-SURGICAL NURSING

PARKINSON’S DISEASE

• Less dopamine – about 60-80% are lost

• Dopamine is a neurotransmitter produced in the brain.
• *A chronic, progressive degenerative disorder, that primarily affects the neurons of the basal
ganglia
• Substantia nigra is damaged, injured resulting to disappearance that can lead to inadequate
production of dopamine
Dopamine
• Inhibitory Neurotransmitter
• Substantia Nigra
• Action: responsible for helping move electrical signals through the brain; going to inhibit too
much muscle contractions. It is needed by the body to have coordinated or smooth movements
of our muscle like walking
• We can maintain balance so that we can move
Acetylcholine (Ach)
• Excitatory neurotransmitter
• Enable muscle action, learning,a dn emmory
*There are two neurotransmitters that should be balanced to have coordinated movement -
acetylcholine (excitatory) and dopamine (inhibitory) neurotransmitter

Neurotransmitters are how the brain interacts with each other

• Gabba - inhibit
• Gamma Amino Butyric Acid - main inhibitory neuro
• Acetylcholine - excitatory
• Dopamine - inhibitory (20-30% inhibit)
• Norepinephrine
• Serotonin - happy neurotransmitter (gives good mood) *eat plenty of bananas if you're in a bad
mood

*Structures in the brain that produces inhibitory neurotransmitter such as dopamine but have a
percentage of excitatory is in the substantia nigra (black) of the basal ganglia. In Parkinson’s disease,
substantia nigra are slowly disappearing.

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Less dopamine signs and symptoms

• Muscle stiffness
• Muscle cramps
• Muscle aches
• Loss of balance; cannot walk straight
• Shuffling gait
• Difficulty in swallowing, masticating = DYSPHAGIA
Psychological effects
• Depressed
• Anxious
• Unmotivated
*When you destroy dopamine, acetyl will be higher in amount because people with PD often have
decreased in dopamine that will allow acetylcholine to take over
• Once this happens, muscles become too excited leading to jerking movements and tremors
• Muscle rigidity
***NO CURE FOR PARKINSON'S

Axon is connected to axon terminal

which is connected to tissue
Enveloped by Myelin sheath is for
good conduction so that whatever
message coming from the brain will
immediately be said to the muscle
and whatever the skin feels will
immediately go to the brain so that
the brain will tell that part what to
do

Pathophysiology

Vesicle containing acetylcholine in the pre-synaptic neuron

will be released in the synaptic cleft and that acetylcholine
will open the sodium gate/doors, once it is released, the
sodium gate will be open, and sodium will enter the muscle
at the same time. For every 3 sodium that will enter the
muscles two potassium go out. The entrance of the sodium
is going to cause the muscle to contract. Acetylcholine
contracts the muscle, dopamine inhibits it if the muscle
contracts excessively.

Prevalence:
• 60 years old and above
• Men are about 1.5 times more likely to develop PD than women

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Etiology
• Unknown
• Genetic
• Advanced age
• Episodes of cerebral anoxia (hindering oxygen in the brain)
• Repeated head trauma (edema happens which lessens the oxygen entering the brain)
• Environmental risk factors
• Exposure to pesticides, industrial chemicals
6 Cardinal Symptoms ***TRAP*** (Tremors, Rigidity, Akinesia, Postural instability)
1. Tremor at rest "Pill Rolling" (on one side/unilateral, is the FIRST MANIFESTATION IN 70% OF
PATIENTS)
• Disappears during voluntary movements
• Produced by damage to basal ganglia
2. Rigidity and Stiffness in the muscles
3. Bradykinesia - cannot smoothly seat down because their muscles are rigid due to too much Ach
4. Postural Instability Stooped, Leaning Forward - as if they're going to fall
5. Loss of postural reflexes
6. Freezing movement (while walking or seating, they stop for several seconds then after that they
will walk or seat again
7. Shuffling gait, lack of swinging of the arms while walking, sometimes, the head is shaking
• *Need a walker for akinesia
8. Facial expressions
• Mask-like (wide open fixed staring eyes)
• Prone to corneal abrasion
• Less facial movements including can't blinking
• Facial skin: Oily face
• Dysphagia
• How to know if there's difficulty in swallowing? Drooling of saliva
• Orthostatic hypotension.
• Constipation/urinary retention - due to less peristalsis, movements are slow, mobility is slow.
Peristalsis is the movement that pushes the faeces out
• Speech low in volume, monotonous in tone, and slow
• Words are poorly articulated (dysarthria)
** Symptoms are always bilateral but usually involve one side early in the illness
Levodopa will only lessen the muscle rigidity but will not cure the Parkinson's disease

Drugs: (Generic--- Brand)

1. Levodopa - improve motor ability
• Once it reaches the brain, it can cross the blood-brain barrier (BBB)
• Never given intramuscularly, because if given parentally, will not cross the BBB
• Levodopa: Given orally - can cross the BBB ---> will be converted to Dopamine
i. This increases the staying power of levodopa in the brain. They mix it with other drugs in order
to put that levodopa in power while it is in the brain; so that it will be more potent and the
levodopa will be there for a longer time and dose of levodopa will be less and all drugs will have
adverse effects
ii. Take the drug with or just after food intake to prevent anorexia
iii. Avoid driving an automobile or operating hazardous machinery due to blurred vision and
drowsiness

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• Levodopa won't replace all of the lost dopamine, but it can help to reduce symptoms of
Parkinson's disease
• Effective 3-6 months
• Patient will take this continuously for 5-10 years
• An hour before eating is the best time to be given
• Starts to work within 30 minutes/half an hour and last until 5 hours
• *Some will work shorter or longer hours that's why doctors ask what the patients feels about
the drugs

2. Carbidopa + Levodopa --- Sinemet, Carpidel

• *Why carbidopa? If only levodopa, some of these levodopa is already being converted to
dopamine while still in the periphery. The amount of levodopa that will cross the blood brain
barrier is less so the doctors will increase the dose of levodopa but since it has adverse effects,
they will get another chemicals and combine it with levodopa such as sinemet and carpidel
Nursing Considerations (Carbidopa-Levodopa)
• Avoid high protein diet as this can slow or prevent absorption of Carbidopa-Levodopa.
Moderate amount
• Avoid foods high in Pyridoxine/Vit B6 as it can increase the conversion of levodopa to dopamine
while still in the periphery
o Beef, Liver, avocados, bananas, sweet potatoes, ham, pork, egg yolks, oatmeal, and chicken
• Increase dietary fiber and fluids to prevent constipation
• Change position slowly to prevent dizziness/fainting due to orthostatic hypotension
• Do not abruptly stop Levodopa due to parkinsonian crisis that can develop
3. Bromocriptine --- Parlodel
• Reduce muscle rigidity and prolong the action of levodopa
• Also allows the dosage of levodopa to be reduced
4. Entacapone --- Comtan
• It prolongs the half-life of levodopa by 50-75% thereby prolongs the time that levodopa is
available to the brain. It can allow the doctor to lower the dose of levodopa
• Adverse Effects: orthostatic hypotension, nausea, diarrhea/constipation, yellow-orange
discoloration of the urine

DEEP BRAIN STIMULATION (DBS)

• includes placing of electrodes on specific parts of the brain and using a generator to send
electrical impulses through brain
• These electrodes produce electric impulses that regulate abnormal impulses
• Regulated by physician
• Purpose: To lessen tremors, muscle rigidity, & muscle spasm
• It will last about 15 years
• 1.6 - 2.7 Million Cost
• Surgery last for 3-4 hours

POST-OP CARE FOR DBS

• Can't take a full bath until surgical stitches are removed. Be careful when coming the hair
• Do not use lotions
• If you wear a hat or scarf, be sure it is clean
• Rest when you feel tired (less dopamine , easily tired)

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• Be active. Walking isa good choice

• 4-6 weeks: avoid activities that strain your chest or upper arm muscles like vacuuming the floor
• Able to go back to work 1-2 weeks after the surgery
• To increase dopamine: the patient should be encouraged to participate in daily exercise like
stretching, strengthening and aerobic activities-- this is to preserve muscle function and balance
How to increase dopamine?
• Increase probiotic-rich foods like yakult, yogurt, halo-halo, kimchi, miso soup (fermented
soybeans)
• Sourdough bread
• Exercise 30 mins everyday

NURSING DIAGNOSIS
I. RISK FOR INJURY RELATED TO ALTERED MOBILITY SECONDARY TO PARKINSONISM due to
stooped posturing
• Promote safety.
• Wear sturdy shoes when walking
• Use of cane/walker
• Grabber/Reacher
• Adequate lighting in the home
• Remove throw rugs, cords, clutter (like big shoes, small rug, cords, chairs) and other hazards
• Use of assistive devices
• An elevated toilet seat so that they can hold onto it
• Grab bars must be in the comfort room so that the patient will not fall and hold onto it
• Put rope at the end of the bed if they want to stand up so that they can hold onto it and to not
call you anymore
• Have a bell on the bedside so that the patient can call you as well

(II) RISK FOR ASPIRATION RELATED TO IMPAIRED SWALLOWING SECONDARY TO PARKINSON'S DISEASE

• Encourage adequate nutrition and decrease the risk for aspiration:

• Sitting position while eating and for an hour afterward
• Avoid the use of straws
• Soft foods and remind the patient to eat slowly (half a teaspoon not more than a teaspoon)

(III) RISK FOR CONSTIPATION RELATED TO IMMOBILITY/ SIDE EFFECTS SECONDARY TO PARKINSON'S
DISEASE/ANTIPARKINSONIAN AGENTS
• Exercise
• Increase fibers
• Increase fluid intake or hydrate
• Natural laxatives: Psyllium (bulk-forming laxative)

*Research findings indicate that caffeine intake is associated of Parkinson's diseases

(IV) IMPAIRED VERBAL OMMUNICATION RELATED TO DYSARTHRIA SECONDARY TO PARKINSON'S

DISEASE
• Give them ample time to express what they want to say
• Ask them questions that can be answerable by yes or no

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• Do not interrupt them, supply word occasionally

• Lessen the noise of the environment
• Encourage patients to practice talking, even if they must talk to themselves
• Use touch and gestures to enhance communication
• Rephrase the patient's message aloud to validate it

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