39 Parkinsonism
Assessment
Mental health/psychiatric:
Dementia (e.g., forgetfulness, irritability, paranoia, hallucinations) is commonly associated with PD. However, not all patients develop impaired intellectual and mental functioning. Mental status testing may be complicated by the patient’s movement disorder. Some patients may experience akathisia, a condition of motor restlessness in which there is a compelling need to walk about constantly. Depression is common. Psychosis is often drug-induced.
Diagnostic tests
Urinalysis for dopamine metabolites:
May reveal decreased dopamine level, which supports the diagnosis.
Cineradiographic study of swallowing:
May show abnormal pattern and delayed relaxation of cricopharyngeal muscles.
Electroencephalogram:
Nursing diagnosis:
Risk for falls
related to unsteady gait occurring with bradykinesia, tremors, and rigidity
Desired Outcome: Following instruction, patient demonstrates safe and effective ambulatory techniques and preventive measures against falls and remains free of trauma.
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess ambulation and movement for deficit(s). | This assessment will help the nurse tailor interventions specific to the patient’s deficit(s). |
| During ambulation, encourage patient to deliberately swing arms and raise feet. | These actions assist gait, thereby helping to prevent falls. |
| Advise patient to step over imaginary object or line, practice taking long steps, and avoid shuffling. | This will help raise feet higher and increase stride, which will help prevent falls. |
| Have patient practice movements that are especially difficult (e.g., turning). Teach patient to walk in a wide arc (“U-turn”) rather than pivot when turning. | These actions prevent crossing of one leg over the other and causing a fall. |
| Teach head and neck exercises. | These exercises promote good posture, which in turn helps the gait. |
| Remind patient repeatedly to maintain upright posture and look up, not down, especially when walking. | This is particularly important for patients with bifocal glasses inasmuch as a stooped posture promotes looking down through the reading portion of the bifocal lens where distant items are blurred. |
| Advise patient to stop or consciously slow down periodically. Teach patient to concentrate on listening to feet as they touch the floor and to count cadence to prevent too fast a gait. | This will slow the walking speed, which is less likely to result in falls. |
| Encourage patient to lift toes and to walk with heels touching floor first. | This action keeps soles of feet flat on the floor, which is less likely to cause tripping. |
| Remind patient to maintain a wide-based gait. | This gait improves balance. |
| Provide a clear pathway while patient is walking. Teach patient to avoid crowds, scatter rugs, uneven surfaces, fast turns, narrow doorways, and obstructions. | These actions minimize risk of tripping and falling. |
| Encourage patient to perform range of motion and stretching exercises daily. | Exercising promotes flexibility, strength, gait, and balance, thereby decreasing risk of falls. Routine exercises, along with prescribed medications, may prevent or delay disability. |
| Advise patient to wear leather-soled or smooth-soled shoes but to test shoes to ensure they are not too slippery. | Rubber-soled or crepe-soled shoes tend to catch on floors, especially carpeted floors, and may cause falls. |
| Encourage patient not to hurry or rush. | Hurrying may precipitate falls. |
| Encourage males to keep a urinal at bedside. A commode at bedside may be helpful for females. | Slowness of gait and inability to get to the bathroom fast enough may cause incontinence or falls in an effort to get there. |
| Ask physical therapy department to suggest exercises that improve balance. | Tai chi, for example, uses slow, graceful movements to relax and strengthen muscles and joints and may be encouraged as an option for some patients. |
| For other interventions, see Risk for Falls, p. 242, in “General Care of Patients with Neurologic Disorders.” |
Nursing diagnosis:
Impaired physical mobility
related to difficulty initiating movement
Desired Outcome: Following instruction, patient demonstrates measures that enhance ability to initiate desired movement.
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess mobility and movements. | This assessment will enable the nurse to tailor interventions to the patient’s specific needs. |
| For patients having difficulty initiating movement, teach patient measures that may help. | Patients with PD often have difficulty initiating movement because their disease affects the brain centers that regulate movement and balance. Rocking from side to side may help initiate leg movement. Marching in place a few steps before resuming forward motion also may be helpful. Other measures include relaxing back on heels and raising toes; tapping hip of the leg to be moved; bending at knees and straightening up; raising arms in a sudden, short motion; or humming a marching tune. |
| If feet remain “glued” to the floor despite these measures, suggest that patient think of something else for a few moments and then try again. | It might help also to try changing directions (e.g., move sideways if going forward is impossible). |
| Teach patient to get out of a chair by getting to edge of seat, placing hands on arm supports, bending forward slightly, moving feet back, and then rhythmically rocking in the chair a few times before trying to get up. | The deficit of dopamine, which has an inhibitory effect, allows the relative excess of acetylcholine. The excitatory effect of acetylcholine causes overactivity of the basal ganglia, which interferes with normal muscle tone and the control of smooth, purposeful movement, causing the characteristic symptoms of PD: muscle rigidity, tremors, and slowness of movement. These combined problems make it difficult to get out of a chair. |
| Advise patient to sit in chairs with backs and arms and to purchase elevated toilet seats or sidebars in the bathroom. | These items will assist with rising from a sitting position and help prevent falls. |
| Teach measures that may help with getting out of bed: rocking to a sitting position, placing blocks under legs of head of bed to elevate it, and tying a rope or sheet to foot of bed to help patient pull to a sitting position. | See discussion with getting out of a chair, above. |
| Teach patient and significant others to recognize situations that can cause freezing episodes. | “Freezing” is variable and can fluctuate with stress or emotional state. For example, attempting two movements simultaneously, such as trying to change direction quickly while walking can cause freezing. Distracting environmental, visual, or auditory stimuli also can precipitate a freezing episode. Doorways; narrow passages; or a change in floor color, texture, or slope can pose problems for many patients. |
| Provide a referral to an organization such as Canine Partners as indicated. | Specially trained dogs (e.g., Canine Partners) can help patients walk and get up after a fall and are trained to help break a “freeze” by tapping on patient’s foot. |
| Suggest that sexual relations be planned for when the prescribed drug is working to good effect and the person is rested. Being flexible about time; experimenting with positions; use of manual, oral, and vibrator stimulation; and use of sildenafil have proved beneficial. | PD makes it more difficult to move, which can affect intimacy. |
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