PARKINSON

NURSING CARE MANAGEMENT

Hafna Ilmy Muhalla

Hafna's file, 2018 1

 AIM OF THE LECTURE

• To increase students knowledge and understanding of

Parkinson’s
• To better understand the needs of people living with and
caring for people with Parkinson’s
• To increase students knowledge and understanding of
Parkinson’s nursing care
Hafna's file, 2018 3
 Parkinson Disease (PD): an Overview

• Chronic • Non-contagious
• Progressive • Rarely directly inherited
• Fluctuates • Everyone is different
• Neurological – loss of • Symptoms: begin slowly,
dopamine in the brain develop gradually and in no
particular order
• Currently no cure
(Parkinsons.org.uk ), (Withey Ruth, South Australia Health) Hafna's file, 2018 5
 Essay on the Shaking Palsy

“….involuntary tremulous motion, with lessened muscular

power, in parts not in action … with a propensity to bend
the trunk forward, and to pass from a walking to a running
pace… the senses and intellect being uninjured.”
Dr James Parkinson, London 1817
Parkinsons.org.uk

Hafna's file, 2018 6

 Essay on the Shaking Palsy

“….involuntary tremulous motion, with lessened

muscular power, in parts not in action … with a
propensity to bend the trunk forward, and to pass
from a walking to a running pace… the senses and
intellect being uninjured.”
Dr James Parkinson, London 1817
Parkinsons.org.uk
 What goes wrong in Parkinson’s Disease?

 In Parkinson’s disease (PD) a small area of the brain called the

substantia nigra loses many of its nerve cells

 These nerve cells produce the neurotransmitter ‘dopamine’

 Dopamine is responsible for transmitting signals between the

substantia nigra and other parts of the brain and spinal cord, that
control coordination of movement.
Hafna's file, 2018 8
 Brain regions
affected by
Parkinson’s disease

Hafna's file, 2018 9

 Parkinsonism

• Classic - idiopathic Parkinson’s • Other Causes –

(around 85% of cases)
• Atypical - Parkinson’s plus
syndromes
• Multiple-System Atrophy (MSA)
• Progressive Supranuclear Palsy (PSP)
• Drug-induced Parkinson’s –
neuroleptic drugs/anti-emetics
• Post Encephalitic Parkinson’s
• Trauma
• Toxins
• Vascular parkinsonism
 DRUG INDUCED PARKINSON’S

STOP All medications that • Cinnarizine

cause Parkinson’s • Sodium Valproate
• Metoclopramide NB. Domperidone is an
• Maxolon acceptable alternative for
• Prochlorperazine managing nausea

• Flunarizine
 DIAGNOSIS OF PARKINSON’S: SIGNS AND
SYMPTOMS

• Slowness of movement • Reduced size of

(bradykinesia) movements (amplitude)
• Lack of co-ordination of
• Poverty of movement
movements (sequencing)
(hypokinesia)
• Stiffness (rigidity)
• Difficulty starting a movement
(initiation) • Tremor (rest)
 Other features
 Speech problems  Dementia
 Constipation  Swallowing problems
 Difficulties with balance  Depression
 Pain  Handwriting problems
 Lack of facial expression  Excessive tiredness
 Incontinence  Motor freezing
 Altered posture  Sleep disorders
Speech Motor symptoms of Parkinson’s
Postural
instability
Hypomimia Micrographia
Reduced arm
Turning in bed
swing

Posture
Motor Turning

Tremor
symptoms Freezing

Arising from
of Parkinson's
Gait festination
a chair

Bradykinesia Shuffling gait

Rigidity Falls
 Non-motor symptoms of Parkinson's
Neuropsychiatric Autonomic Sleep disturbance Sensory symptoms

Dementia REM sleep disorder

Depression RLS
Apathy Vivid dreams
Anxiety Daytime somnolence
Loss of libido Dystonia
Constipation
Urinary incontinence Pain
Erectile dysfunction Paresthesia
Excessive sweating
Postural hypotension
Excessive salivation
 Non – motor Symptoms
Non - motor symptoms are common in PD and often more
troublesome and disabling than motor symptoms.
They include:
Mood disorders such as depression, anxiety and irritability
Cognitive changes such as slowing of thought, attention and planning.
Language and memory difficulties, personality changes, dementia.
Hallucinations and delusions
 Non – motor Symptoms
• Sleep disorders such as insomnia, excessive daytime sleepiness,
REM sleep (rapid eye movement behaviour disorder), vivid dreams,
restless leg syndrome, cramp, difficulty turning in bed.
• Orthostatic hypotension
> Constipation
• Urinary urgency, frequency and incontinence
• Vision changes double vision, dry eyes, blepharospasm
 Non – motor Symptoms
• Speech difficulties - soft voice
• Swallowing problems, drooling or excessive saliva
• Sexual difficulties can include erectile dysfunction.
• Skin changes
• Impulse control disorders – such as binge eating, excessive
shopping or gambling, usually a side effect of medications.
Non-motor
symptoms
Questionnaire
The Impact of Parkinson’s -

Slowness of Movement
• Affecting a person’s
• “Learned Voluntary Actions”
 THE IMPACT OF PARKINSON’S

• Motor symptoms
Slowness and poverty of movement/rigidity/tremor

• Non-motor symptoms
Many everyday activities are affected
 The impact of Parkinson’s
Everyday activities that can be affected

Cooking
Walking Eating Climbing stairs
Washing Talking
Going to the toilet
Household chores Dressing
Cleaning teeth
Driving Shopping
Dancing Gardening Playing sport
Enjoying hobbies Working Writing
Rising from a chair Having Sex Socialising
Getting out of bed Turning over in bed Answering the phone
 The Impact of Parkinson’s
Everyone is Different
• Constipation
• Eating & swallowing difficulties • Incontinence
• Drooling & Excessive sweating • Handwriting
• Drop in blood pressure • Other fine movements
• Anxiety & Depression • Pain
• Turning over in bed
• Dementia
• Tiredness/sleep disorders
• Sexual dysfunction
• Tremor
• Psychosis/hallucinations • Falls
• Smell/taste dysfunction • “Freezing”
 The impact of Parkinson’s
Communication difficulties
How do we usually communicate effectively?

Words 7%
Tone/gesture 38%
Body language 55%

Mehrabian, A Silent messages: implicit communication of emotions and attitudes (1981)

 Communication Tips
• Please GIVE PLENTY OF TIME
• Please try not to appear rushed or angry
• Find Quiet area / avoid large groups
• Look the person in the eye, Eye contact is very important
• Suggest words…but try not to interrupt
• Don’t talk about / in front of them
• Use adult language
 The Impact of Parkinson’s -
Parkinson’s affects….

• …… relationships, mobility, deterioration, slowness, withdrawal

from activities, communication problems, motor fluctuations,
involuntary movements, confusion, depression, anxiety,
hallucinations, memory changes, constipation, incontinence,
weight loss, hypotension, swallowing problems, pain, loss of
dignity, loss of choice, isolation……
 Managing Parkinson’s
• Medication
• Surgery (Deep brain stimulation, Lesioning &
Stem cell transplants)

• Multidisciplinary Team
Physiotherapy, Speech & Language Therapy,
Occupational Therapy, Pharmacist, Dietician, Social
worker
 Access all available resources
General practitioner (GP)
Pharmatist Neurologist/ geriatrician

Parkinson’s specialist nurse

Social services
Person with
Carers’ organisations
Parkinson’s Physiotherapist
and carer

Occupational therapist Parkinson’s org

Information and support
Social worker
Speech and language therapist Dietician
 Parkinson’s Nurse Consultant

The PNC provides nurse led clinic assessment and support:

> Allowing for screening of non-motor symptoms, identification of carer
burden, risk of falls, malnutrition, dementia, etc.
> The patient is referred on to relevant members of the multidisciplinary
team for early intervention.
> The patient is referred on to community supports as required.
> Exercise is extremely important - patients are referred on to exercise
groups, physiotherapy in the home and falls avoidance programs.
 Changes as a result of Parkinson's
Nurse role
> Phone and clinic support has led to early intervention and
troubleshooting of issues.
> Improved adherence to medication regimes and the taking of
medications on time.
> Reduced emergency department presentations and hospital
admissions due to: Dizziness and falls, Constipation, Anxiety and
panic attacks, Infections UTI’s & CI’s - confusion, delirium,
hallucinations and paranoia
 Changes as a result of Parkinson's
Nurse role

• Early identification and treatment of depression has led

to improved Parkinson’s control and quality of life.

• Improved access to exercise maintaining balance,

posture and strength for longer.
 Changes as a result of Parkinson's
Nurse role
• Extra support for people with young onset PD has enabled them to
communicate with their employers and remain in employment for longer,
access disability support, improve relationships with their partners and
family, avoid complications of Impulse control disorders.

• Consultive service for inpatients - has improved delivery of medications

on time, avoidance of complications from the prescribing of contra
indicated medications - reduction of inpatient days.
 Changes as a result of
Parkinson's Nurse role
>The introduction of Apomorphine therapy at the
LMH has been possible since the role was
introduced.
>Home visits have led to a better understanding of
risks to safety and better access to equipment.
 Changes as a result of Parkinson's
Nurse role
• Attending neurology outpatient clinic has enabled
greater support to newly diagnosed PWPD and early
interventions.
• Educational talks on PD have led to better
understanding among health professionals and improved
care of PWPD.
 Parkinson’s Nurse Consultant

• Referrals are accepted from other health care

professionals, GP’s, Neurologists, Geriatricians,
residential care facilities, hospital wards and
emergency departments.
 Physiotherapist

Education and support

for patient and carer
Early intervention
Pain management

Maximise functional
Teach compensatory ability and minimise
strategies and cueing secondary
techniques complications6
Assessment & treatment
programmes for:
• Gait Ultrasound for Apo
Falls prevention morphine nodules
• Balance
• Posture
 Occupational Therapist

• Involved if there is difficulty with activities of daily living

• Maintenance of independence, safety and interaction within own
environment
• Comprehensive and holistic assessment and treatment of functional
activities of daily living and non-motor issues:

Practical assistance Emotional assistance

• Self care (eating, drinking, washing
and dressing) • Cognition
• Domestic activities (cleaning, • Mood
shopping etc) • Sleep
• Functional mobility, transfers and • Carer strain
transport • Advice and education
• Leisure and work
• Environment (ramps, rails)
 Speech and Language Therapist

Can advise on:

• Speech
– Exercises and techniques to help PwP control their
breathing and pace their speech
– Lee Silverman Voice Treatment4
– Maintaining and improving the volume, clarity and
expression of the voice
• Body and environment
– Improving facial expression and body language
– Posture and positioning
– The best environment for speech and communication