Parkinson’s disease (PD) is a degenerative condition caused by the loss of dopamine, which disrupts the suppression of excitatory impulses and causes the extrapyramidal system to malfunction. It is a chronic, disabling condition that worsens over time. Falls, poor self-care, dysfunctional body systems, and depression can result from debilitation.
Although the exact cause of Parkinson’s disease is idiopathic (unknown), the following factors appear to be involved:
- Increasing age
- Genetics and family history
- Male sex
- Environmental triggers (exposure to herbicides and pesticides)
In Parkinson’s disease, there is a slow onset of symptoms that may be unnoticeable. Although tremors are common, the disease can also produce stiff or sluggish movement.
The following symptoms may appear in PD:
- Bradykinesia (abnormally slow movement and sluggish physical and mental responses)
- Akinesia (inability to move muscles voluntarily)
- Progressively smaller handwriting
- Tremors in hands and fingers at rest (pill-rolling)
- Increasing tremors when fatigued
- Decreasing tremors with purposeful activity or sleep
- Rigidity with jerky movements
- Mask-like facial appearance
- Drooling, monotonous speech
- Dysphagia and dysarthria
- Loss of coordination and balance
- Shuffling steps, stooped position, and propulsive gait
- Difficulty with memory or concentration
Nursing Process
Since there is no cure for PD, the current treatment goal is to reduce the symptoms and slow the progression of the disease. Nurses offer patients and families emotional support from diagnosis through the palliative treatment stages to end-of-life care. Nurses educate on what to expect with disease progression, managing symptoms, medication side effects, and lifestyle modifications.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for emphysema, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for emphysema.
Impaired Verbal Communication
Impaired verbal communication associated with Parkinson’s disease can be caused by the inability to control the muscles on the face, throat, mouth, and vocal cords resulting in difficulty to speak and communicate. It is also caused by damage to the part of the brain that regulates speech and comprehension.
Nursing Diagnosis: Impaired Verbal Communication
Related to:
- Inability to control face, throat, mouth, and vocal cord muscles
- Degeneration of nerve cells
- Depletion of dopamine
- Inhibition of excitatory impulses
- Extrapyramidal system dysfunction
As evidenced by:
- Drooling
- Alteration in voice (hoarseness)
- Difficulty in speech (dysarthria)
- Difficulty in comprehension
- Change in verbal fluency (stammering, stuttering, or slurring of words)
- Presence of speech pauses
- Difficulty with memory or concentration
- Slow speech
- Soft-spoken or monotone voice
Expected outcomes:
- Patient will demonstrate an improvement in dysarthria resulting in improved enunciation and slurred speech
- Patient will be able to establish different methods of communication
- Patient will be able to use verbal and nonverbal communication congruently
Assessment:
1. Determine the patient’s ability and methods to communicate.
Establishing communication with the patient will prevent confusion and ensure understanding of the information given.
2. Assess the comprehension of communication.
Patients with PD may also struggle with aphasia and the ability to comprehend communication. Assess the patient’s ability to respond or follow commands.
3. Determine the patient’s focus and concentration.
Ensuring the patient’s attention will promote an easy flow of communication and a better understanding of instructions.
Interventions:
1. Establish a trusting relationship with the patient.
Build a rapport with the patient to encourage communication of feelings and assessment cues that will help in managing PD. PD symptoms can be embarrassing for some patients and cause isolation so it’s important to build trust.
2. Allow time for the patient to communicate and express themself.
Both the patient and the listeners may become frustrated with the sluggish and stuttering speech of patients with PD. Allow plenty of time for the patient to respond before continuing to speak.
3. Provide as many communication skills and methods as possible.
Teach energy-saving practices such as how to communicate nonverbally or with short phrases as this can prevent frustration and confusion between the patient and the care provider.
4. Introduce communication aids.
Patients with PD often have soft speech and hoarseness. Amplifiers can increase loudness and prevent voice straining. Text-to-speech devices can also help the patient communicate since tremors can make handwriting illegible.
5. Refer to speech-language pathologists.
SLPs can assist the patient with PD in improving cognitive functioning, comprehension, and memory, and teaching oral exercises to improve speech and voice.
Impaired Walking/Risk for Falls
Impaired walking/risk for falls associated with Parkinson’s disease can be caused by impaired neuromuscular (muscle weakness, tremors, bradykinesia) and musculoskeletal (joint rigidity) changes. It is also caused by damage to the part of the brain that regulates movement.
Nursing Diagnosis: Impaired Walking/Risk for Falls
Related to:
- Inability to control muscles
- Damage to the substantia nigra in the brain
- Degeneration of nerve cells
- Depletion of dopamine
- Inhibition of excitatory impulses
- Extrapyramidal system dysfunction
As evidenced by:
- Bradykinesia
- Akinesia
- Tremors
- Rigidity with jerky movements
- Restlessness
- Pacing
- Shuffling steps
- Stooped position
- Propulsive gait
- Diminished independence
- Loss of quality of life
- Social isolation
- Activity reluctance
Expected outcomes:
- Patient will be able to walk around the facility independently with minimum assistance
- Patient will be able to use an assistive device while walking
- Patient will be able to participate actively in physical therapy and rehabilitation
- Patient will not experience falls
Assessment:
1. Assess the neurological status.
Parkinson’s disease is a chronic condition that progressively affects both the neurological system and musculoskeletal system affecting balance and muscle control. Neurological effects can be tested through grip strength and coordination tests.
2. Assess the patient’s Parkinson’s movement symptoms.
Symptoms may include stiff muscles, rigidity, and delayed movement. Patients with mid-stage to advanced PD experience freezing or the feeling of the feet being glued to the floor, as well as short, shuffling steps.
3. Determine the patient’s ability to move independently.
Parkinson’s symptoms can be reduced with continuous movement, which can also boost confidence and independence while preventing falls.
4. Observe the patient’s body posture.
Stooped posture can cause neck or back pain when the natural curves of the spine are out of alignment. Postural instability raises the risk of falling.
Interventions:
1. Encourage independence with safety precautions.
Parkinson’s disease treatment aims to lessen symptoms and keep functionality intact for as long as possible. Allow the patient to participate in self care as much as possible. PD causes slow movements so the patient will require patience to complete tasks.
2. Assist with ambulation.
Patients with PD may move slowly with tremors and stiff muscles. Continuous ambulation will prevent muscle atrophy and improve quality of life. Assisting in ambulation will allow the patient to move independently while providing safety.
3. Provide assistive devices.
Most people with gait and stability issues use assistive ambulatory devices as their primary form of adjunctive care. Provide walkers, canes, and wheelchairs as needed.
4. Instruct the patient on how to walk safely.
Ask the patient to start moving by rocking back and forth. Remind them to pick their feet up to prevent shuffling. Encourage the patient to wear flat-heeled footwear.
5. Teach proper posture.
Teach the patient to hold their hands behind their backs to maintain an upright spine and neck to establish appropriate posture.
6. Administer antiparkinsonian medications as ordered.
Antiparkinsonian medications increase the level of dopamine in the CNS to control symptoms (tremors and muscle weakness/rigidity) and slow the progression of PD.
7. Refer to physical therapy and rehabilitation.
To improve patients’ health, well-being, and quality of life, physical therapy and rehabilitation will help restore, maintain, and improve movements, activities, and functioning.
8. Encourage tai chi and exercise.
Exercise reduces the risk of falls. Tai chi is a highly recommended form of exercise for those with PD to improve balance.
Impaired Swallowing
Impaired swallowing associated with Parkinson’s disease is caused by the inability to control throat and mouth muscles resulting in difficulty chewing and swallowing food. This can lead to aspiration pneumonia, which is the leading cause of death in PD.
Nursing Diagnosis: Impaired Swallowing
Related to:
- Inability to control throat and mouth muscles
- Degeneration of nerve cells
- Depletion of dopamine
- Extrapyramidal system dysfunction
As evidenced by:
- Blank facial expression (mask-like face)
- Drooling
- Dysphagia
- Dysarthria
- Weight loss
- Increased incidence of pneumonia
- Coughing while eating or drinking
- Clearing of the throat while eating or drinking
- A feeling of food stuck in the throat during feeding
Expected outcomes:
- Patient will demonstrate appropriate swallowing without coughing/gagging, drooling, or pocketing food
- Patient will be able to maintain an acceptable weight for their height and gender
- Patient will not develop aspiration pneumonia
Assessment:
1. Assess the patient’s ability to swallow and chew.
The muscles in the throat that regulate food passage can stiffen or become slow-moving, which may leave residue in the throat. The patient may complain of food stuck in the throat. The nurse can perform a bedside swallow assessment by giving the patient a teaspoon of water and ensuring the patient can swallow without gagging or coughing.
2. Monitor the patient’s weight.
Weight and nutritional status must be consistently monitored. Impaired swallowing is associated with weight loss in PD.
3. Assess for signs of aspiration pneumonia.
Fever, dyspnea, chest pain, coughing, and lethargy are signs of possible aspiration pneumonia.
Interventions:
1. Assist with meals.
The nurse can prevent aspiration by assisting with feeding at mealtimes. This includes offering small bites, reminding to chew completely and coaching to swallow, and monitoring for signs of impaired swallowing.
2. Place the patient in an upright position during feeding.
Choking and aspiration risks can be reduced by eating while sitting upright. This allows the food to enter the stomach with the help of gravity. Allow the patient to remain upright for 30 minutes after eating to prevent reflux.
3. Promote aspiration precautions.
Thickener may be added to liquids to slow the liquid flow and decrease the risk of liquid entering the airway which can cause aspiration. Diet modifications may be required such as soft or pureed diets.
4. Administer antiparkinsonian medications between meals.
Medication administration frequency will depend on the physician’s orders, but attempt to administer between meals. Levodopa is not absorbed as well when taken with high-protein meals which can reduce its efficacy.
5. Consult with a speech therapist.
Speech therapists can assist with evaluating dysphagia and teaching patients and families how to improve swallowing.
References
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth’s textbook of medical-surgical nursing (13th ed.). Wolters Kluwer India Pvt.
- Rengifo, M. L., Jonasson, S. B., Ullén,, S., Carlgren, N. M., & Nilsson, M. H. (2021, April 1). Perceived walking difficulties in Parkinson’s disease – predictors and changes over time. BioMed Central. https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-021-02113-0
- Silvestri, L. A., Silvestri, A. E., & Grimm, J. (2022). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier Inc.
