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Parkinson’s DiseaseCase Study:Muhammad AliAdult Med-Surg II
04/05/10
Allen, S., Daniels, M., Masih, L., Nirala, K., Swartz, E.
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Case Study: Muhammad Ali
Patient: Muhammad Ali(born Cassius M. Clay)
Male, 68 y/o, retired American boxer
Admission: 03/27/2010Hx: Parkinson’s Disease (PD)
(1992).◦ Falls, tremors, mild dementia,
and dysphagia secondary to PD.
(http://en.wikipedia.org/wiki/Muhammad_Ali)
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What is Parkinson’s Disease (“PD”)
A slowly progressing neurologic movement disorder that leads to disability.
Degenerative or idiopathic form is the most common.
Secondary form usually linked to a known or suspected cause.
Muhammed Ali Parkinson’s Center Movement Disorders Clinic., Parkinson’s disease. http://maprc.com.
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IncidenceFourth most common neurologic
disorder.1% of persons age 65 and older2% of persons age 85 and olderAffects men more frequently than
women. Usually first appears in fifth decade of
life.Can occur as early as 30 years of age.
(Smeltzer, S.C., Barle, B.G., Hinkle, J.L, & Cheever, K.H. ,2008)
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Diagnosis
Criteria for diagnosis of PDGroup A: Features characteristics
of PD:Resting tremor Bradykinesia Rigidity Asymmetric onset
Gelb (1999), Advisory Council of the National Institute of Neurological Disorders and Stroke, US National Institutes of Health.
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DiagnosisCriteria for diagnosis of PDGroup B: Features suggestive of
alternative diagnoses◦Features unusual early in the clinical course ◦Prominent postural instability in the first 3
years after symptom onset ◦Freezing phenomena in the first 3 years ◦Hallucinations unrelated to medications in
the first 3 years ◦Dementia preceding motor symptoms or in
the first year
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Diagnosis
GROUP B (cont.):Supranuclear gaze palsy (other than
restriction of upward gaze) or slowing of vertical saccades
Severe, symptomatic dysautonomia unrelated to medications
Documentation of a condition known to produce Parkinsonism and plausibly connected to the patient’s symptoms.
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DiagnosisCriteria for POSSIBLE diagnosis of Parkinson’s
disease At least 2 of the 4 features in Group A are present;
at least 1 of these is tremor or bradykinesia And either: none of the features in Group B is present or symptoms have been present for less than 3
years, and none of the features in Group B is present to date
And either: substantial and sustained response to levodopa or
a dopamine agonist has been documented or patient has not had an adequate trial of
levodopa or dopamine agonist
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DiagnosisCriteria for probable diagnosis of
Parkinson’s diseaseAt least 3 of the 4 features in Group A
are present And none of the features in Group B is
present (note: symptom duration of at least 3 years is needed to meet this requirement)
And substantial and sustained response to levodopa or a dopamine agonist has been documented
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DiagnosisCriteria for definite diagnosis of PD:All criteria for possible PD are met, and Histopathological confirmation
(autopsy):◦Substantial nerve cell depletion with gliosis
in substantia nigra ◦At least one Lewy body in substantia nigra or
in locus coeruleus.◦No pathological evidence for other diseases
that produce Parkinsonism (eg progressive supranuclear palsy, multiple system atrophy, cortical–basal ganglionic degeneration).
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Diagnosis
Basal Ganglia
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Diagnosis
The basal ganglia includes the caudate nucleus, putamen, globus pallidus, subthalamic nucleus, and substantia nigra.
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Diagnosis
Gliosis: A process leading to scars in the central nervous system(CNS) that involves CNS production of a dense fibrous network of neuroglia (supporting cells) in areas of damage. Gliosis is a prominent feature of many diseases
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Lewy Bodies
Lewy bodies: Abnormal aggregates of protein that develop inside the nerve cells in PD.
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PathophysiologyAssociated with loss of dopamine nerve
cells in the substantia nigra in the basal ganglia of the brain.
Loss of dopamine causes imbalance of neurotransmitters, which affects voluntary movement.
Clinical symptoms do not appear until 60% of dopamine neurons are lost and dopamine level is decreased by 80%.
Cellular degeneration impairs control of semiautomatic functions and coordinated movements.
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Causes
Cause is unknown, may be linked to:
GeneticsAtherosclerosisExcessive oxygen free radicals Viral infectionsHead traumaChronic use of antipsychotic
medicationsEnvironmental exposures.
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CausesHead trauma
◦Considered a risk factor for PD since past episodes are reported more frequently by individuals with PD than by others in the population.
◦Recent studies suggest no true relationship between severe head injury and PD.
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Causes Genetics
◦Someone with PD is more likely to have relatives who also have PD.
◦Inheritance of PD is usually complex and not due to a single gene defect.
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Pharmacological TherapyAntiparkinsonian medicationsAnticholinergicsAntiviral therapyDopamine AgonistsMonoamine oxidase inhibitorsCatechol-O-methyltransferase
(COMT) inhibitorsAntidepressantsAntihistaminesSmeltzer, et al (2008)
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Pharmacologic TherapyAntiparkinsonian medications:Increase striatal dopaminergic activityReduce excessive influence of
excitatory cholinergic neuronsRestore balance between
dopaminergic and cholinergic activitiesOrAct on neurotransmitter pathways
other than the dopaminergic pathway.
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Antiparkinsonian MedicationsLarodopa (Levodopa) Most effective treatmentConverted to dopamine in basal
ganglia, producing symptom relief.Benefits wane over several yearsAdverse effects with long-term use
- confusion, hallucinations, depression, sleep alterations
Protein, Vitamin B6 may decrease effectiveness
Deglin, J. and Vallerand, A. (2009)
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Antiparkinsonian MedicationsSinemet (carbidopa)Usually administered with levodopa Prevents breakdown of levodopa;
reduces adverse effects of levodopaLong-term use can cause:
◦Dyskinesia◦On-off syndrome (acute episodes of near-
immobility followed by sudden return of mobility)
◦Neuroleptic malignant syndrome (medical emergency)
Deglin (2009)
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Anticholinergics
CogentinControl tremor – may be used in
combination with levodopa. Counteracts action of acetylcholine. Side effects poorly tolerated in the elderly
(blurred vision, flushing, rash, constipation, urinary retention, acute confusion)
Monitor for urinary retention in patients with enlarged prostate
Contraindicated in patients with narrow-angle glaucoma
Deglin (2009)
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Dopamine Agonists
Parlodel and PermaxMay postpone the need for carbidopa
or levodopa therapy.May be used after carbidopa or
levodopa lose effectiveness. Monitor for adverse reactions:
◦N/V, diarrhea◦Lightheadedness, hypotension◦ Impotence◦Psychiatric effects
Smeltzer, et al (2008)
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Other Pharmacological TherapyMonoamine Oxidase InhibitorsEldepry - inhibits dopamine breakdownSelegiline - Used with dopamine agonist to
delay carbidopa or levodopa therapy Catechol-O-methyltransferase (COMT) InhibitorsComtan and TasmarIncrease duration of action of carbidopa or
levodopaReduce motor fluctuations in patients with
Parkinson’s
Smeltzer, et al (2008)
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Other Pharmacological TherapyAntiviral TherapySymmetrel
◦ Used in early stages of disease◦ Reduces rigidity, tremor, bradykinesia, postural
changes◦ Low incidence of side effects
AntihistaminesBenadryl, Banflex, Neo-Synephrine
◦ Mild central anticholinergic and sedative effects◦ May reduce tremors.
Smeltzer, et al (2008)
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AssessmentClinical diagnosis based on:
◦Patient’s history◦Presence of two of the four cardinal
manifestations: Tremors; pill-rolling tremor of the hands Muscle rigidity Bradykinesia (abnormal slow movement) Stooping, forward posture
Smeltzer, et al (2008)
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AssessmentObserve the degree of disability
and functional changes that occur throughout the day, such as response to medication.
Assess nutritional status.Assess for mood swings,
depression, and cognitive impairments.
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AssessmentAsk patient if they ever experience:Leg or arm stiffnessIrregular jerking of your arms or legsFeeling “frozen” to a spot and unable
to moveExcessive saliva production or droolingGrimacing, facial contortions, or
chewing movementsDifficulty performing specific activities
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AssessmentObserve patient for: Dysphonia - soft, slurred, low-pitched, and quiet
speech Dysphagia - swallowing deficits Drooling, poor head control, coughing Bradykinesia (slowness of movement) Tremors (pill-rolling movements) Weakness Stooping, forward posture Muscle rigidity Loss of facial expression (“flat” effect) Autonomic symptoms (orthostatic hypotension,
flushing, and diaphoresis).
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Assessment
Assess for medication-related S/S:Adverse reactionsSide effectsFood-drug interactionsDrug-drug interactionsEffectiveness of medications
Deglin (2009)
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Nursing DiagnosesRisk for aspiration r/t swallowing deficits.Risk for falls r/t impaired balance and tremors.Constipation r/t medication and reduced activity.Impaired mobility r/t muscle rigidity and
weakness.Imbalanced nutrition - less than body
requirements, r/t chewing and swallowing deficits.
Self-care deficits r/t tremor and motor disturbance.
Impaired verbal communication r/t dysphonia Ineffective coping r/t depression, secondary to
disease progression.
Ackley, B. J. & Ladwig, G. B., (2006).
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PlanningImprove functional mobility
◦Implement an exercise program that will increase muscle strength, improve coordination and dexterity, reduce muscular rigidity, and prevent contractures that occur when muscles are not used.
◦Examples: walking with care, riding a stationary bike, swimming
◦PT/OT referral
Ackley (2006)
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PlanningAchieve adequate bowel
elimination◦Encourage increase fluid intake◦Follow a regular time pattern◦Stool softener (avoid laxatives b/c
they may cause bowel obstruction)◦Eat balanced diet with plenty of
fruits, vegetables, and whole grains b/c of their high fiber content
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PlanningAttain and maintain acceptable
nutritional status◦Supplemental feedings to increase
caloric intake◦Consult dietician◦In later stage of disease, a
nasogastric tube or percutaneous endoscopic gastroscopy may be needed to maintain adequate nutrition
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PlanningAchieve effective communication
◦Speech therapy referral◦Use of electronic amplifier if difficulty
hearing patientOther referrals/consults
◦Case manager◦Home health◦Social worker
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InterventionsEnhance SwallowingEnsure patient is in upright position during
mealtime.Provide semisolid diet with thick liquids; avoid
thin liquids.Teach patient to think through the swallowing
sequence with eat bite.Teach patient to chew first on one side of the
mouth and then the other. Teach patient to hold head upright and make
conscious effort to swallow to control saliva buildup.
Smeltzer et al (2008)
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Interventions
Improve Bowel EliminationEncourage moderate fiber intake.Provide adequate fluids.Encourage and assist with regular,
daily exercise.Provide raised toilet seat.Allow pt sufficient time for toileting.Avoid psyllium (can cause bowel
obstruction).
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Interventions
Improve MobilityEncourage and assist with daily
exercise◦Improves muscle strength,
coordination and dexterity; can delay progression of the disease.
◦Reduces muscular rigidity; prevents contractures.
◦Walking, riding stationary bicycle, swimming, and gardening can help maintain joint mobility.
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Interventions
Improve MobilityStretching (stretch–hold–relax)
and range-of-motion exercises promote joint flexibility.
Postural exercises - counter the tendency of the head and neck to be drawn forward and down.
Special walking techniques - compensate for balance issues caused by arm rigidity.
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InterventionsImprove NutritionMonitor daily weight during inpatient stay.Request swallowing and nutrition consults.Identify patient’s food likes and dislikes-
provide food the patient enjoys. Provide supplemental feedings.Encourage daily exercise to stimulate
appetite.Provide adaptive equipment for meals
(non-tip cup, raised utensils, warming tray).
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InterventionsPromote Self-Care ActivitiesEncourage, teach, and support the patient
during ADLs.Overbed frame with a trapeze can provide
assistance in pulling up without help. Allow sufficient time to self-dress, eat, and
perform personal hygiene.Encourage pt to wear clothing without
buttons, zippers, or snaps; slip-on, non-skid shoes.
Encourage use of assistive devices.Wissman (2007)
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Interventions
Improve CommunicationTeach the patient to:
◦Face the listener◦Exaggerate enunciation of words◦Speak in short sentences◦Take a few deep breaths before
speaking. Provide a sign board/marker
boardRequest speech therapy consult
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Interventions
Support Coping AbilitiesVisit with patient daily to reduce
social isolation/Refer to support groups,
community resources and Internet resources:
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Discharge PlanningEnsures that the patient leaves
the hospital in a timely manner with the necessary resources.
Begins at admission.Nurse provides information about
to the patient and caregivers r/t the disease and self-care.
Potter, P.A. & Perry, A., (2008).
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Discharge PlanningNurse provides information about:Medication instructions; potential food-
drug interactionsActivity restrictionsRehabilitation techniques/adaptationAccess to available community
resourcesGuidance on when and how to obtain
follow-up carePatient/family responsibilities in
patient’s care
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Discharge PlanningMultidisciplinary process that may involve:Speech-Language Therapy (SLT)- Swallowing
and speech needs.PT consult – Walking/balance issues; assistive
equipment needsOT – ADL teaching/adaptive equipment needsCase Manager – Coordination of discharge
planningSocial Worker – Financial, caregiver, and
home environment needs.Dietitian - Nutritional/dietary educationHome Health – In-home care
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EvaluationStrives toward improved mobilityRange-of-motion exercise to all joints three
times dailyMassage and stretch muscles to reduce
stiffnessWalks with wide base of support;
exaggerates arm swinging when walkingAvoid staying in one position for prolonged
periodsRest without a pillow and lie prone
frequently to deter flexed posture Ackley (2007)
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Evaluation
Progresses toward self-careAllows time for self-care activitiesExplore the use of assistive
devices
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Evaluation SafetyExamine the home environment for
risks of injuryModify the environment to improve
lighting and remove hazardsConsider installing devices such as
raised toilet seats and grab barsChange position slowly if orthostatic
hypotension develops
Smeltzer et al (2008)
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EvaluationMaintains adequate nutrition and
bowel functionTakes time when eatingSmall frequent meals if fatigue is a
problem during mealsSwallow without aspiration and practice
taking small bitesConsumes adequate fluid Increase intake of fiberReports regular pattern of bowel
function
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Evaluation
Achieves a method of communication
Exercise the voice regularly by singing or reading aloud
Attempt to project the voice and alter volume and pitch
Consult a speech therapist if vocal problems are severe
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Evaluation
Copes with effects of Parkinson’s disease
Sets realistic goalsDemonstrates persistence in
meaningful activitiesVerbalizes feelings of appropriate
person
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ReferencesAckley, B. J. & Ladwig, G. B., (2006). Nursing diagnosis
handbook: an evidence-based guide to planning care. St. Louis: Mosby Elsevier.
American Parkinson's Disease Association. (n.d). Basic information about Parkinson’s disease. Retrieved March 31, 2010, from www.apdaparkinson.org.
Deglin, J. and Vallerand, A. (2009). Davis’s Drug Guide for Nurses. (20th ed.). Philadelphia: F.A. Davis Company.
Muhammad Ali Parkinson’s Center Movement Disorders Clinic. (n.d.). Parkinson’s disease. Retrieved March 31, 2010, from http://maprc.com.
Potter, P.A. & Perry, A., (2008). Fundamentals of nursing (7th ed.). St. Louis: Mosby Elsevier.
Smeltzer, S.C., Barle, B.G., Hinkle, J.L, & Cheever, K.H., (2008). Brunner & Suddarth’s textbook of medical-surgical nursing (11th ed.). Philadelphia: Lippincott Williams & Willams.
Wissmann, J., (2007). Adult medical-surgical nursing RN edition (7.1 ed.). Olathe, KS: Assessment Technologies Institute.