Parkinson disease: Responses to Discussion Posts

I am sending three discussion post and I need you to respond to them INDIVIDUALLY. I need you to provide constructive and insightful comments that go beyond that of agree or disagree. 1) This post is from Kellie:. Parkinson's disease is characterized by progressive destruction of dopamine producing neuronal cells in the brain which ultimately results in a continual decrease in dopamine production/availability. Dopamine and acetylcholine work together to relay messages to higher motor centers in the brain which control and refine motor responses that create the typical smooth, predictable movements of the body. As dopamine slowly disappears; the balance between acetylcholine and dopamine becomes unstable and results in more available acetylcholine than dopamine. Because acetylcholine is an excitatory neurotransmitter and dopamine is an inhibitory neurotransmitter, less dopamine means the body has trouble inhibiting or stopping the excitatory responses of acetylcholine, thus the distinctive uncontrolled tremors, stiffness, and bradykinesia associated with Parkinson's disease. I was surprised to learn that by the time a person begins to show signs of the disease, more than 60% of the dopamine-producing neurons are gone, and 80% of the (striatal) dopamine is gone. Parkinsons currently has no cure, so the course of treatment involves managing the symptoms holistically through a multidisciplinary approach using medications, nutrition, exercise, environmental controls, and sometimes surgery in order to help the patient maintain a functional quality of life for as long as possible. The 3 cardinal signs are rigidity of arms, legs and trunk, tremors at rest, and bradykinesia. Classic signs also include: -Pill rolling movements of the fingers. -Postural instability and trouble with balance. Secondary symptoms include: -Small, cramped handwriting, called micrographia. -Reduced arm swing on the affected side. -Slight foot drag on affected side creating a shuffled walk. -“Freezing” a term used to describe the phenomenon of being “stuck in place” when attempting to walk. -Loss of facial expression due to rigidity of facial muscles (hypomimia). -Low voice volume or muffled speech (hypophonia). -Tendency to fall backwards (retropulsion). -Decrease ability in automatic reflexes such as blinking and swallowing. Because of increased motor control problems, the patient has difficulty and requires extra time with daily activities such as eating, drinking, dressing, toileting, and ambulating. Initial treatment generally involves antiparkinsonian medications which replace the dopamine in the brain. Unfortunately, after several years of use, the side effects of these medications; dyskinesias, hallucinations, depression, disturbed sleep patterns and in severe circumstances, neuroleptic malignant syndrome, outweigh the benefit of continued use. From a nursing perspective, there are many ways the nurse can help to enhance and maintain quality of life for a patient diagnosed with Parkinsons. Next to proper nutrition which is the foundation of good health, one of the most important teaching points centers on exercise. Daily exercise helps to improve flexibility, strength, balance and may help to reduce the rigidity and contractures commonly noted with Parkinsons. The nurse could also include the following in her instruction plan: -Instruct the patient in special techniques for walking; for instance, using a wide based gait, practicing arm swing, and heel/toe placement which will help improve gait, balance, and safety. -Suggest warm baths and massage as a way to calm to client, improve circulation and relax sore muscles. -Engage occupational therapist to assess the patient's mobility limitations in order to make suggestions for environmental adjustments that would encourage both mobility and safety in the home. Grab bars, removal of loose rugs, clear pathways, special beds with rails, non-skid strips, and special toileting devices assist with ambulation and overall safety. -Speech therapist should also be invited for an assessment in order to make recommendations for improving speech patterns, eating, and drinking since chewing and aspiration become a larger problem as the disease progresses. -Provide clothing with limited buttons, hooks and fasteners. -Educate on the disease process itself, so the family understands why their loved one moves slower and with less coordination, and the importance of allowing for time and patience when working with the patient. -Education should also incorporate strategies that continue to bring meaning to the patient's life. -The family and the patient should be taught about medications, side effects and management of side effects. Teach about drug interactions and adverse reactions which should be reported immediately. -The family should be introduced to community resources which can offer ongoing group support and respite care. Parkinson's disease is complex and has a chronic, insidious onset; however, the very nature of this disease provides time for the patient and the caregiver to adapt to changes and learn new techniques in managing the symptoms. Regardless of where a nurse practices, there is a responsibility to be well versed in the care and management of these patients. A nurse who is confident in his or her knowledge has the ability to relay information and teach effective coping skills that will create self-reliance and resourcefulness for the patient and the family. This in turn will help to enhance the overall perception of their quality of life. 2)This post is from Marita:. Parkinson's Disease (PD) can cause serious life threatening complications as the disease progresses. The registered nurse (RN) can assist the patient with PD to reduce the likelihood of complications, such as pneumonia. The RN can educate the patient on ways to prevent pneumonia by offering a vaccine to protect the patient from getting bacterial pneumonia. Influenza can make viral pneumonia more likely, therefore, the patient with PD should also be offered the flu vaccine. The RN can educate the patient other ways to prevent bacterial or viral pneumonia such as wash hands often, eat a healthy diet, exercise, get plenty of rest, do not smoke and avoid people with colds or flu. The patient should be taught the symptoms of pneumonia and to contact their physician if they experience any symptoms of pneumonia. They should not wait for symptoms to worsen because pneumonia can be life threatening for a patient with PD. Aspiration is when a foreign body such as, food or liquid, is drawn into the respiratory tract during inhalation. This is another serious complication for a patient with PD. Aspiration can lead to aspiration pneumonia which is a complication of mealtime swallowing problems due to inhalation of food and/or drink. The respiratory system has an important role in swallowing problems and there are therapies to help these patients re-coordinate breathing and swallowing patterns, reducing the risk for aspiration pneumonia (Medical News Today, 2008). The RN can assist the patient by referring them to a swallowing expert and a speech therapist. Speech therapy can help improve swallowing functions. Early intervention for management of swallowing abnormalities are important to prevent major complications. Speech therapy strengthens muscles involved in swallowing and breathing. The RN can work with the client on swallowing exercises prescribed by the dysphagia team. Instruct the patient and family to ensure there is adequate time for the patient to eat and educate them about the rationales for food consistency. Safety is another potential complication for patients with PD due to motor function disturbances that cause tremors and rigidity in the arms, legs, face and spine. Bradykinesia, postural instability and gait impairment place the patient at an increased risk for falls. Daily exercise will improve muscle strength and coordination. Stretching and range of motion exercises reduce muscle rigidity. Balance may be affected and the patient should be taught special walking techniques. The RN can refer the patient to a physical therapist to assist in developing an exercise program for the client (Smeltzer, Bare, Hinkle & Cheever, 2010) . The RN should assess the home environment for factors that create barriers to physical mobility. Teach the client relaxation techniques to use during exercise, such as deep breathing. Assistive devices such as a cane or walker should be used if necessary, to increase mobility. The RN should remind the patient and family that self-care activities are important so the patient can remain as independent as possible. Improving mobility will assist the patient in reducing safety risks (Ladwig& Ackley, 2011). Pharmacological therapy is used for patients with PD and is individualized for each client based on symptoms and social, occupational and emotional needs. Anticholinergic drugs reduce muscle rigidity and some of the tremors associated with PD. Long-term use of these drugs can cause restlessness and confusion, dry mouth, urinary retention, constipation, blurred vision and increased heart rate. The RN should advise the patient to avoid alcohol, cigarettes, caffeine and aspirin to reduce gastric acidity. The RN should educate the client ways to reduce these side effects. Encourage the client to relieve dry mouth with ice chips or sugarless chewing gum. Advise the client to void before taking the medication to minimize urinary retention. Encourage the patient to have a diet high in fiber and to increase fluid intake to prevent constipation. Dopaminergic medications are also used to relieve tremors and rigidity in patients with PD. Long-term use of the dopaminergic medication, carbidopa-levodopa, can cause motor fluctuations, dystonic movement, psychotic behavior and “wearing off” periods. The client and family should be educated that the timing of dosage administration is important. The RN could suggest the use of extended release medication to the physician if the patient experiences any of these side effects. This may also be managed by increasing frequency of dose administration and decreasing the dose administered. The patient may also experience “on-off” fluctuations. The patient that has this side effect may benefit from more frequent administration of medication. The RN should warn the client to never abruptly stop taking the medication without first notifying the health care provider (Kee, Hayes & McCuistion, 2012). 3)This post is from Jamie: Parkinson disease is a neurodegenerative disease affecting motor and non-motor functions. The RN can assist the patient by education, instruction, medication review and referrals to support groups. Physical therapy and occupational therapy should play a major role in the patient's life in addition to exercise and diet regimes and instructions. The key motor function features of Parkinson's are tremors at rest, rigidity, akinsia or bradykinesia and postural instability. Key non- motor functions are sleep disturbances, sensory impairment, swallowing problems, psychosis and GI problems. Early detection and diagnosis are essential in improving the life of the person and providing effective treatment. The RN can complete a thorough subjective and objective assessment of the patient. Some of the mobility issues can be addressed by instructing the patient to pull up all throw rugs, wear non skid shoes or socks, walk with heel to toe placement, and encourage the patient to concentrate on walking erect while swinging arms at their side. Most of the gait training would come from PT but some things the RN should go over with the patient. To help prevent aspiration and pneumonia, the nurse would consult speech therapy to instruct on proper chewing and swallowing techniques. I imagine depending on the disease process, the consistency of their food may need to be adjusted. Chopped, soft, puree or thickened liquids may be effective. Occupational therapy could be used to evaluate and instruct on ADL tasks and modifications that can assist the patient with motor function. Medications are available to lessen the symptoms of Parkinson's and the most common one is Levodopa. This medication is known to be the most effective in the early phases of treatment and is credited with increasing the life expectancy of people with Parkinson's. Levodopa can cause adverse effects that become more pronounced over time and include hallucinations, confusion, sleep disturbances and the most troublesome for the patient, jerking and involuntary movements of the body, limbs, face and head. These effects of the medication, called dyskinesias usually occur a few years into the therapy. Adjunct therapies such as dopamine agonists such as Parlodel and Mirapex work to offset some of those side effects but come with their own risks as well. These drug therapies work to reduce the dyskinesias but may worsen the non- motor functions of the pt. Nausea, depression, fluctuations in blood pressure and compulsiveness are all side effects of these medications. The patient along with his/her physician can work over many years to find the right balance of treatment concerning medications. This therapy, the ones listed above and Complementary and Alternative treatments can result in a greater quality of life for the patient.