Nursing Process: The Patient With Parkinson’s Disease

NURSING PROCESS: THE PATIENT WITH PARKINSON’S DISEASE

Assessment

Assessment focuses on how the disease has affected the patient’s activities of daily living and functional abilities. Patients are ob-served for degree of disability and the functional changes that occur throughout the day, such as responses to medication. Nearly every patient with a movement disorder has some functional alteration and may have some type of behavioral dysfunction. The following questions may be useful to assess alterations:

·      Do you have leg or arm stiffness?

·      Have you experienced any irregular jerking of your arms or legs?

·      Have you ever been “frozen” or rooted to the spot and un-able to move?

·      Does your mouth water excessively? Have you (or others) noticed yourself grimacing or making faces or chewing movements?

·      What specific activities do you have difficulty doing?

During this assessment, the nurse observes the patient for quality of speech, loss of facial expression, swallowing deficits (drooling, poor head control, coughing), tremors, slowness of movement, weakness, forward posture, rigidity, evidence of men-tal slowness, and confusion. Parkinsonian symptoms, as well as side effects of medications, put these patients at high risk of falls; therefore, a fall risk assessment should be included (Gray & Hildebrand, 2000).

Diagnosis

NURSING DIAGNOSES

Based on the assessment data, the patient’s major nursing diag-noses may include the following:

·      Impaired physical mobility related to muscle rigidity and motor weakness

·      Self-care deficits (feeding, dressing, hygiene, and toileting) related to tremor and motor disturbance

·      Constipation related to medication and reduced activity

·      Imbalanced nutrition, less than body requirements, related to tremor, slowness in eating, difficulty in chewing and swallowing

·       Impaired verbal communication related to decreased speech volume, slowness of speech, inability to move facial muscles

·      Ineffective coping related to depression and dysfunction due to disease progression

Other nursing diagnoses may include sleep pattern distur-bances, deficient knowledge, risk for injury, risk for activity in-tolerance, disturbed thought processes, and compromised family coping.

Planning and Goals

The goals for the patient may include improving functional mo-bility, maintaining independence in activities of daily living, achieving adequate bowel elimination, attaining and maintaining acceptable nutritional status, achieving effective communication, and developing positive coping mechanisms.

Nursing Interventions

IMPROVING MOBILITY

A progressive program of daily exercise will increase muscle strength, improve coordination and dexterity, reduce muscular rigidity, and prevent contractures that occur when muscles are not used. Walking, riding a stationary bicycle, swimming, and gardening are all exercises that help maintain joint mobility. Stretching (stretch–hold–relax) and range-of-motion exercises promote joint flexibility. Postural exercises are important to counter the tendency of the head and neck to be drawn forward and down. A physical therapist may be helpful in developing an individualized exercise program and can provide instruction to the patient and caregiver on exercising safely. Faithful adherence to an exercise and walking program helps to delay the progress of the disease. Warm baths and massage in addition to passive and active exercises help relax muscles and relieve painful muscle spasms that accompany rigidity.

Balance may be adversely affected because of the rigidity of the arms (arm swinging is necessary in normal walking). Special walking techniques must be learned to offset the shuffling gait and the tendency to lean forward. The patient is taught to con-centrate on walking erect, to watch the horizon, and to use a wide-based gait (ie, walking with the feet separated). A conscious effort must be made to swing the arms, raise the feet while walking,and to use a heel-toe placement of the feet with long strides. The patient is advised to practice walking to marching music or to the sound of a ticking metronome because this provides sensory re-inforcement. Doing breathing exercises while walking helps to move the rib cage and to aerate parts of the lungs. Frequent rest periods aid in preventing frustration and fatigue.

ENHANCING SELF-CARE ACTIVITIES

Encouraging, teaching, and supporting the patient during activ-ities of daily living promote self-care.

Environmental modifications are necessary to compensate for functional disabilities. Patients may have severe mobility prob-lems that make normal activities impossible. Adaptive or assistive devices may be useful. A hospital bed at home with bedside rails, an overbed frame with a trapeze, or a rope tied to the foot of the bed can provide assistance in pulling up without help. An occu-pational therapist can evaluate the patient’s needs in the home and make recommendations regarding adaptive devices and teach the patient and caregiver how to improvise.

IMPROVING BOWEL ELIMINATION

The patient may have severe problems with constipation. Among the factors causing constipation are weakness of the muscles used in defecation, lack of exercise, inadequate fluid intake, and de-creased autonomic nervous system activity. The medications used for the treatment of the disease also inhibit normal intestinal se-cretions. A regular bowel routine may be established by encour-aging the patient to follow a regular time pattern, consciously increase fluid intake, and eat foods with a moderate fiber content. Laxatives should be avoided. Psyllium, for example, decreases con-stipation but carries the risk for bowel obstruction (Herndon et al., 2000). A raised toilet seat is useful because the patient has diffi-culty in moving from a standing to a sitting position.

IMPROVING NUTRITION

Patients may have difficulty maintaining their weight. Eating be-comes a very slow process, requiring concentration due to a dry mouth from medications and difficulty chewing and swallowing. They are at risk for aspiration because of impaired swallowing and the accumulation of saliva. They may be unaware that they are aspirating, and subsequently bronchopneumonia may develop.

Monitoring weight on a weekly basis indicates whether caloric intake is adequate. Supplemental feedings increase caloric intake. As the disease progresses, a nasogastric tube or percutaneous en-doscopic gastroscopy may be necessary to maintain adequate nu-trition. A dietitian can be consulted regarding nutritional needs.

ENHANCING SWALLOWING

Swallowing disorders can be due to poor head control, tongue tremor, hesitancy in initiating swallowing, difficulty in shaping food into a bolus, and disturbances in pharyngeal motility. To offset these problems, the patient should sit in an upright posi-tion during mealtime. A semisolid diet with thick liquids is easier to swallow than solids; thin liquids should be avoided. It is help-ful for patients to think through the swallowing sequence. The patient is taught to place the food on the tongue, close the lips and teeth, lift the tongue up and then back, and swallow. The pa-tient is encouraged to chew first on one side of the mouth and then on the other. To control the buildup of saliva, the patient is reminded to hold the head upright and make a conscious effort to swallow. Massaging the facial and neck muscles before meals may be beneficial.

ENCOURAGING THE USE OF ASSISTIVE DEVICES

An electric warming tray keeps food hot and permits the patient to rest during the prolonged time that it takes to eat. Special uten-sils also assist at mealtime. A plate that is stabilized, a nonspill cup, and eating utensils with built-up handles are useful self-help devices. The occupational therapist can assist in identifying appropriate adaptive devices.

IMPROVING COMMUNICATION

Speech disorders are present in most patients with Parkinson’s disease. Their low-pitched, monotonous, soft speech requires that they make a conscious effort to speak slowly, with deliberate at-tention to what they are saying. Patients are reminded to face the listener, exaggerate the pronunciation of words, speak in short sentences, and take a few deep breaths before speaking.

A speech therapist may be helpful in designing speech im-provement exercises and assisting the family and health care per-sonnel to develop and use a method of communication to meet the patient’s needs. A small electronic amplifier is helpful if the patient has difficulty being heard.

SUPPORTING COPING ABILITIES

Support can be given by encouraging the patient and pointing out that activities are being maintained through active participa-tion. A combination of physiotherapy, psychotherapy, medica-tion therapy, and support group participation may help reduce the depression that often occurs.

Patients often feel embarrassed, apathetic, inadequate, bored, and lonely. These feelings may be due, in part, to physical slow-ness and the great effort that even small tasks require. Patients are assisted and encouraged to set achievable goals (eg, improvement of mobility).

Because parkinsonism tends to lead to withdrawal and de-pression, patients must be active participants in their therapeutic program, including social and recreational events. There should be a planned program of activity throughout the day to prevent too much daytime sleeping as well as disinterest and apathy.

Every effort should be made to encourage patients to carry out the tasks involved in meeting their own daily needs and to remain independent. Doing things for the patient merely to save time is contrary to the basic goal of improving coping abilities and pro-moting a positive self-concept.

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care

Patient and family education is important in the management of Parkinson’s disease. Teaching needs depend on the severity of symptoms and the stage of the disease. Care must be taken not to overwhelm the patient and family with too much information early in the disease process. The patient’s and family’s need for information is ongoing as adaptations become necessary. The education plan should include a clear explanation of the disease, assisting the patient to remain functionally independent as long as possible. Every effort is made to explain the nature of the dis-ease and its management to offset disabling anxieties and fears. The patient and family must be taught about the effects and side effects of medications and about the importance of reporting side effects to the physician (Chart 65-4).

Continuing Care

In the early stages patients can be managed well at home. Family members often serve as caregivers, with home care or community services available to assist in meeting health care needs as the dis-ease progresses. The family caregiver may be under considerable stress from living with and caring for a person with a significant disability. Providing information about treatment and care pre-vents many unnecessary problems. The caregiver is included in the plan and may be advised to learn stress reduction techniques, to include others in the caregiving process, to obtain periodic re-lief from responsibilities, and to have a yearly health assessment. Allowing family members to express feelings of frustration, anger, and guilt is often helpful to them.

The patient should be evaluated in the home for adaptation and safety needs and compliance with the plan of care. In the ad-vanced stages, patients usually enter long-term care facilities when family support is absent. Periodically, admission to an acute care facility may be necessary for changes in medical management or treatment of complications. Nurses provide support, education, and monitoring of patients over the course of illness.

The nurse involved in home and continuing care needs to remind patients and family members of the need to address health promotion needs such as screening for hypertension and stroke risk assessments in this predominantly elderly popula-tion. Patients who have not been involved in these practices in the past are educated about their importance and are referred to appropriate health care providers. Informational booklets and a newsletter for patient education are published by the National Parkinson’s Foundation, Inc. and the American Parkinson’s Disease Association.

Evaluation

EXPECTED PATIENT OUTCOMES

Expected patient outcomes may include:

1)    Strives toward improved mobility

a)     Participates in exercise program daily

b)    Walks with wide base of support; exaggerates arm swing-ing when walking

c)     Takes medications as prescribed

2)    Progresses toward self-care

a)     Allows time for self-care activities

b)    Uses self-help devices

3)    Maintains bowel function

a)     Consumes adequate fluid

b)    Increases dietary intake of fiber

c)     Reports regular pattern of bowel function

4)    Attains improved nutritional status

a)     Swallows without aspiration

b)    Takes time while eating

5)    Achieves a method of communication

a)     Communicates needs

b)    Practices speech exercises

6)    Copes with effects of Parkinson’s disease

a)     Sets realistic goals

b)    Demonstrates persistence in meaningful activities

c)     Verbalizes feelings to appropriate person