Parkinson’s disease (PD) is a progressive neurodegenerative disorder characterized by the loss of dopamine-producing neurons in the brain. This dopamine depletion disrupts the delicate balance of neurotransmitters, leading to an impaired suppression of excitatory nerve impulses and subsequent malfunction of the extrapyramidal system, which controls movement. This chronic and debilitating condition gradually worsens over time, significantly impacting a patient’s quality of life. Debilitation from PD can lead to serious complications such as falls, self-care deficits, dysfunction of various body systems, and depression.
Understanding Parkinson’s Disease
While the precise cause of Parkinson’s disease remains idiopathic, several factors are recognized as contributing to its development:
- Advancing Age: The risk of Parkinson’s increases significantly with age.
- Genetic Predisposition: Family history and genetics play a role in susceptibility.
- Male Gender: Men are statistically more likely to develop Parkinson’s disease than women.
- Environmental Exposures: Exposure to certain environmental toxins like herbicides and pesticides has been linked to an increased risk.
Parkinson’s disease typically manifests with a gradual onset of symptoms, often so subtle initially that they go unnoticed. While tremors are a hallmark symptom, PD can also present with stiffness and slowness of movement.
Common signs and symptoms of Parkinson’s disease include:
- Bradykinesia: Abnormal slowness of movement and sluggishness in both physical and mental responses.
- Akinesia: Difficulty initiating movement, or a state of immobility, where muscles are unable to move voluntarily.
- Micrographia: Progressively smaller handwriting as writing continues.
- Resting Tremors: Tremors in the hands and fingers that are most prominent when at rest (“pill-rolling” tremor).
- Fatigue-Exacerbated Tremors: Tremors that worsen when the person is fatigued.
- Activity- or Sleep-Reduced Tremors: Tremors that lessen during purposeful activity or sleep.
- Rigidity: Muscle stiffness accompanied by jerky movements (cogwheel rigidity).
- Masked Facies: A decrease in facial expression, resulting in a mask-like appearance.
- Speech Changes: Drooling, monotonous speech, and reduced voice volume.
- Dysphagia and Dysarthria: Difficulty swallowing and speaking clearly.
- Impaired Balance and Coordination: Loss of balance and coordination.
- Gait Disturbances: Shuffling steps, a stooped posture, and a propulsive gait (tendency to lean forward while walking).
- Cognitive Difficulties: Challenges with memory and concentration.
The Nursing Process in Parkinson’s Disease Management
Currently, there is no cure for Parkinson’s disease. The primary goals of treatment are to alleviate symptoms and slow the disease’s progression. Nurses play a crucial role in providing holistic care to patients and their families, offering emotional support from the initial diagnosis through palliative care and end-of-life stages. A key aspect of nursing care is patient education, encompassing disease progression, symptom management, medication side effects, and necessary lifestyle adjustments.
Parkinson’s Disease Nursing Care Plans
Nurses utilize nursing diagnoses to identify specific patient needs related to Parkinson’s disease. Nursing care plans then serve as roadmaps to prioritize assessments and interventions, guiding both short-term and long-term care goals. The following sections detail examples of nursing care plans commonly used in the management of Parkinson’s disease.
Impaired Verbal Communication
Impaired verbal communication in Parkinson’s disease arises from the disease’s impact on muscle control in the face, throat, mouth, and vocal cords. This muscle dysfunction makes speaking and clear communication challenging. Furthermore, PD can affect brain regions responsible for speech regulation and comprehension.
Nursing Diagnosis: Impaired Verbal Communication
Related Factors:
- Loss of muscle control in the face, throat, mouth, and vocal cords.
- Degeneration of nerve cells.
- Depletion of dopamine neurotransmitter.
- Inhibition of excitatory nerve impulses.
- Extrapyramidal system dysfunction.
Evidenced By:
- Drooling.
- Changes in voice quality (hoarseness).
- Difficulty articulating speech (dysarthria).
- Challenges in comprehending verbal communication.
- Alterations in speech fluency (stammering, stuttering, slurring).
- Frequent pauses during speech.
- Difficulties with memory or concentration impacting communication.
- Slow rate of speech.
- Soft or monotonous voice.
Expected Outcomes:
- The patient will demonstrate measurable improvement in dysarthria, evidenced by clearer enunciation and reduced slurring of speech within a specified timeframe.
- The patient will successfully establish and utilize alternative methods of communication to express needs and preferences.
- The patient will demonstrate congruent use of verbal and nonverbal communication strategies.
Nursing Assessment:
1. Assess the patient’s current communication abilities and preferred methods.
Rationale: Understanding the patient’s baseline communication skills is crucial for tailoring interventions. This assessment helps to identify strengths and weaknesses and allows the nurse to establish effective communication strategies, preventing potential confusion and ensuring accurate information exchange.
2. Evaluate the patient’s comprehension of communication.
Rationale: Parkinson’s disease can affect cognitive functions, including language comprehension. Assessing the patient’s ability to understand spoken and written language is essential. Observe the patient’s responses to questions and their ability to follow simple commands to gauge their level of comprehension.
3. Determine the patient’s attention span and concentration levels.
Rationale: Attention and concentration are vital for effective communication. If a patient has difficulty focusing, communication can become fragmented and misunderstood. Assessing these cognitive functions helps the nurse create an environment conducive to communication and adjust communication strategies accordingly, ensuring better understanding of instructions and information.
Nursing Interventions:
1. Develop a trusting and supportive relationship with the patient.
Rationale: Building rapport is fundamental to encouraging open communication. Parkinson’s symptoms, particularly speech difficulties, can be emotionally challenging and lead to social isolation. A trusting relationship encourages the patient to express feelings, anxieties, and needs, providing valuable assessment cues for managing their condition and fostering emotional well-being.
2. Allow ample time for the patient to communicate and express themselves.
Rationale: The slowed speech and potential stuttering associated with PD can be frustrating for both the patient and listener. Rushing the patient can increase anxiety and communication barriers. Providing sufficient time and patience allows the patient to communicate at their own pace, fostering a more relaxed and effective exchange of information.
3. Offer a variety of communication tools and techniques.
Rationale: Employing multiple communication methods can overcome verbal communication barriers. Teach energy-saving strategies like using nonverbal cues (gestures, facial expressions), short phrases, or written communication. This variety reduces frustration and enhances clarity in communication between the patient and caregivers.
4. Introduce and utilize communication aids as appropriate.
Rationale: Assistive devices can significantly improve communication for individuals with PD. Voice amplifiers can increase speech volume, addressing soft speech. Text-to-speech devices can help patients communicate effectively, particularly when tremors make handwriting difficult to read. Explore and implement assistive technologies to support the patient’s communication needs.
5. Refer the patient to a speech-language pathologist (SLP).
Rationale: SLPs are specialists in communication disorders. They can provide comprehensive assessments and develop individualized therapy plans to improve cognitive function, comprehension, and memory related to communication. SLPs also teach oral motor exercises to strengthen muscles involved in speech and voice production, maximizing the patient’s communication abilities.
Impaired Walking / Risk for Falls
Impaired walking and an increased risk of falls in Parkinson’s disease are primarily due to neuromuscular and musculoskeletal changes. These include muscle weakness, tremors, bradykinesia, and joint rigidity. Damage to brain regions that regulate movement also contributes significantly to these mobility challenges.
Nursing Diagnosis: Impaired Walking / Risk for Falls
Related Factors:
- Impaired muscle control.
- Damage to the substantia nigra in the brain.
- Degeneration of nerve cells.
- Depletion of dopamine neurotransmitter.
- Inhibition of excitatory nerve impulses.
- Extrapyramidal system dysfunction.
Evidenced By:
- Bradykinesia (slow movement).
- Akinesia (difficulty initiating movement).
- Tremors.
- Rigidity with jerky movements.
- Restlessness and agitation.
- Pacing behavior.
- Shuffling gait.
- Stooped posture.
- Propulsive gait (tendency to lean forward).
- Reduced independence in mobility.
- Diminished quality of life related to mobility limitations.
- Social isolation due to fear of falling.
- Reluctance to engage in physical activity.
Expected Outcomes:
- The patient will ambulate within the facility with minimal assistance or supervision, demonstrating improved mobility and safety.
- The patient will effectively utilize prescribed assistive devices (e.g., walker, cane) to enhance walking stability and safety.
- The patient will actively participate in physical therapy and rehabilitation programs to improve strength, balance, and mobility.
- The patient will remain free from falls and fall-related injuries during the care period.
Nursing Assessment:
1. Conduct a thorough neurological assessment, focusing on motor function.
Rationale: Parkinson’s disease is a progressive condition that impacts both the neurological and musculoskeletal systems, affecting balance, coordination, and muscle control. Neurological assessments, including grip strength and coordination tests, provide objective data on the extent of motor impairment and guide the development of targeted interventions.
2. Assess and document the patient’s specific Parkinson’s movement symptoms.
Rationale: Understanding the specific motor symptoms is crucial for tailoring interventions. Document the presence and severity of rigidity, tremors, bradykinesia, and gait abnormalities. Pay particular attention to “freezing” episodes (feeling stuck in place) and shuffling steps, which are common in mid-to-advanced PD and significantly increase fall risk.
3. Determine the patient’s current level of independent mobility.
Rationale: Assessing the patient’s ability to move independently is essential for promoting autonomy and safety. Continuous movement, even with PD, can help mitigate symptoms, build confidence, and maintain functional independence. Evaluate the patient’s ability to perform transfers, walk, and perform daily activities safely and independently.
4. Observe and document the patient’s posture.
Rationale: Stooped posture is a common characteristic of PD and can lead to musculoskeletal pain and further balance issues. Postural instability significantly elevates the risk of falls. Assessing posture helps identify specific balance deficits and guides interventions aimed at improving postural alignment and stability.
Nursing Interventions:
1. Promote independence while ensuring safety precautions are in place.
Rationale: The goal of Parkinson’s treatment is to manage symptoms and preserve function for as long as possible. Encourage patient participation in self-care activities to maintain autonomy and dignity. Be mindful that PD-related slowness requires patience; allow ample time for task completion and provide support as needed.
2. Provide assistance with ambulation as needed.
Rationale: Patients with PD often move slowly, with tremors and stiffness increasing fall risk. Assisted ambulation provides physical support and reduces the risk of falls while promoting mobility. Regular ambulation helps prevent muscle atrophy, improves cardiovascular health, and enhances overall quality of life.
3. Ensure availability and proper use of assistive devices.
Rationale: Assistive devices are crucial for improving mobility and safety in PD. Provide walkers, canes, and wheelchairs based on individual needs and functional assessments. Educate the patient and caregivers on the correct and safe use of these devices to maximize their benefit and minimize risks.
4. Instruct the patient on safe walking techniques.
Rationale: Specific walking techniques can compensate for PD-related gait disturbances. Teach patients to initiate movement by rocking back and forth to overcome “freezing.” Remind them to consciously lift their feet to avoid shuffling. Recommend wearing flat-heeled, supportive footwear to enhance stability and reduce trip hazards.
5. Teach and reinforce proper posture.
Rationale: Maintaining an upright posture improves balance and reduces fall risk. Instruct patients to consciously hold their hands behind their back to promote spinal extension and upright neck alignment. Regular posture correction exercises can help improve postural control and reduce pain associated with stooped posture.
6. Administer antiparkinsonian medications as prescribed.
Rationale: Antiparkinsonian medications are the cornerstone of pharmacological treatment for PD. These medications, such as levodopa, increase dopamine levels in the central nervous system, mitigating motor symptoms like tremors, rigidity, and bradykinesia. Adhering to the prescribed medication regimen is vital for symptom control and slowing disease progression.
7. Refer the patient to physical therapy and rehabilitation services.
Rationale: Physical therapy is essential for optimizing mobility and function in PD. Physical therapists develop individualized exercise programs to improve strength, balance, coordination, and gait. Rehabilitation programs aim to restore, maintain, and enhance movement, activity levels, and overall functional abilities, improving independence and quality of life.
8. Encourage participation in Tai Chi and other suitable exercises.
Rationale: Regular exercise is highly beneficial for individuals with PD, reducing fall risk and improving overall well-being. Tai Chi, in particular, is a recommended exercise modality due to its focus on balance, coordination, and slow, deliberate movements. Encourage participation in exercise programs tailored to PD to enhance physical function and reduce the risk of falls.
Impaired Swallowing
Impaired swallowing, or dysphagia, in Parkinson’s disease results from the disease’s impact on the muscles controlling the throat and mouth. This muscle dysfunction leads to difficulties in chewing and safely swallowing food and liquids. Aspiration pneumonia, a serious complication arising from dysphagia where food or liquid enters the lungs, is a leading cause of death in PD.
Nursing Diagnosis: Impaired Swallowing
Related Factors:
- Loss of muscle control in the throat and mouth.
- Degeneration of nerve cells.
- Depletion of dopamine neurotransmitter.
- Extrapyramidal system dysfunction.
Evidenced By:
- Blank facial expression (mask-like facies).
- Drooling.
- Dysphagia (reported or observed difficulty swallowing).
- Dysarthria (difficulty speaking clearly).
- Unexplained weight loss.
- Recurrent or increased incidence of pneumonia.
- Coughing or choking while eating or drinking.
- Frequent throat clearing during meals.
- Patient report of food “sticking” in the throat.
Expected Outcomes:
- The patient will demonstrate safe and effective swallowing, without evidence of coughing, gagging, drooling, or pocketing food in the mouth during and after meals.
- The patient will maintain a stable weight within an acceptable range for their height and gender, indicating adequate nutritional intake and safe swallowing.
- The patient will remain free from aspiration pneumonia and other respiratory complications related to impaired swallowing.
Nursing Assessment:
1. Assess the patient’s ability to swallow and chew.
Rationale: Muscles in the throat responsible for food passage can become stiff or slow-moving in PD, leading to food residue in the throat and a sensation of food being “stuck.” A bedside swallow assessment, involving a small amount of water, allows the nurse to observe for signs of swallowing difficulty, such as coughing or gagging, providing initial insights into swallowing function.
2. Monitor the patient’s weight regularly.
Rationale: Weight fluctuations are a sensitive indicator of nutritional status and swallowing difficulties. Impaired swallowing often leads to reduced oral intake and subsequent weight loss in PD. Consistent weight monitoring helps identify nutritional risks and the need for dietary modifications or swallowing interventions. Assess for signs of imbalanced nutrition.
3. Assess for signs and symptoms of aspiration pneumonia.
Rationale: Aspiration pneumonia is a severe complication of dysphagia. Early detection is critical for prompt treatment. Monitor for respiratory symptoms such as fever, dyspnea, chest pain, coughing, and lethargy, which may indicate aspiration and the need for immediate medical intervention.
Nursing Interventions:
1. Provide mealtime assistance and supervision.
Rationale: Direct assistance during meals is crucial to prevent aspiration. Offer small, manageable bites of food. Remind the patient to chew thoroughly and swallow consciously. Closely monitor for signs of swallowing difficulty, such as coughing, choking, or wet voice, and intervene promptly if needed.
2. Position the patient upright during and after meals.
Rationale: Maintaining an upright position (90 degrees) during eating and for at least 30 minutes afterward significantly reduces the risk of choking and aspiration. Gravity assists food passage into the stomach. Keeping the patient upright post-meal prevents reflux and further minimizes aspiration risk.
3. Implement aspiration precautions.
Rationale: Aspiration precautions are essential for safe feeding. Thickening liquids can slow their flow rate, reducing the risk of aspiration into the airway. Dietary modifications, such as soft or pureed foods, may be necessary to ensure safer swallowing. Collaborate with a dietitian to optimize diet texture and consistency based on swallowing abilities.
4. Administer antiparkinsonian medications strategically.
Rationale: Medication timing can impact swallowing. Administering antiparkinsonian medications, particularly levodopa, between meals may improve medication absorption and efficacy. Levodopa absorption can be reduced when taken with high-protein meals, potentially diminishing its symptom-controlling effects. Consult with the physician and pharmacist to optimize medication timing related to meals.
5. Consult with a speech therapist specializing in swallowing disorders.
Rationale: Speech therapists are experts in dysphagia management. They can conduct comprehensive swallowing evaluations (including instrumental assessments like videofluoroscopy if needed) to identify the nature and severity of swallowing impairments. SLPs develop individualized therapy plans, teach swallowing exercises and techniques, and provide education to patients and families on safe swallowing strategies and dietary modifications.
Risk for Aspiration
Parkinson’s disease-related nerve and muscle degeneration directly impacts the swallowing process, leading to cough dysfunction (dystussia) and swallowing difficulties (dysphagia). These impairments significantly elevate the patient’s risk for aspiration, where food, liquid, or saliva enters the airway and lungs.
Nursing Diagnosis: Risk for Aspiration
Related Factors:
- Underlying disease process of Parkinson’s Disease.
- Presence of dysphagia (difficulty swallowing).
- Ineffective cough reflex.
- Generalized poor muscle tone affecting swallowing musculature.
Evidenced By:
- Risk diagnoses do not have “evidenced by” statements because the problem has not yet occurred. Nursing interventions are focused on prevention.
Expected Outcomes:
- The patient will maintain a patent airway, free from obstruction, as evidenced by clear and equal breath sounds bilaterally.
- The patient will demonstrate the ability to eat and swallow safely and effectively, without coughing, choking, or gagging during or after meals.
Nursing Assessment:
1. Continuously assess the patient’s swallowing ability, particularly before and during meals.
Rationale: Ongoing assessment of swallowing function is crucial for early identification of difficulties and timely intervention. Closely monitor for subtle signs of aspiration risk, such as frequent coughing, gagging, throat clearing, drooling, or a wet voice quality, especially when eating or drinking.
2. Monitor the patient’s respiratory status regularly.
Rationale: Respiratory changes can be early indicators of aspiration. Assess respiratory rate, depth, and effort. Monitor for signs of respiratory distress, such as dyspnea, hoarseness, wheezing, or the production of foul-smelling sputum, which may suggest aspiration or developing pneumonia.
3. Auscultate lung sounds before and after feeding.
Rationale: Lung auscultation is a key assessment for detecting aspiration. Listening to lung sounds before and after meals helps identify changes that may indicate aspiration has occurred. The new onset of adventitious breath sounds, particularly crackles or wheezing, can be suggestive of aspiration pneumonia.
Nursing Interventions:
1. Recommend a comprehensive swallowing evaluation by a specialist.
Rationale: If swallowing difficulties are suspected or identified during nursing assessment, a formal swallowing evaluation by a speech-language pathologist is essential. Discuss the need for instrumental swallowing assessments, such as a modified barium swallow study (videofluoroscopy) or Flexible Endoscopic Evaluation of Swallowing (FEES), to objectively evaluate swallowing mechanics and aspiration risk and guide individualized management.
2. Implement specific measures to minimize aspiration risk during meals.
Rationale: Adhering to aspiration precautions during feeding is paramount. Educate and ensure consistent implementation of these strategies:
- Maintain an upright position (90 degrees) for the patient during meals and for at least 30 minutes after eating to utilize gravity and reduce reflux.
- Instruct the patient to use a chin tuck swallowing technique, tilting the chin down towards the chest when swallowing, to protect the airway.
- Ensure the patient fully chews and swallows each bite before offering the next, preventing food bolus accumulation and potential aspiration.
- Offer small sips of liquids between bites of food, rather than large gulps, to improve swallowing control and coordination.
3. Implement strategies to manage drooling (sialorrhea).
Rationale: Excessive drooling is common in PD due to impaired muscle control and swallowing dysfunction. Drooling can complicate swallowing further and increase aspiration risk. Discuss and administer anticholinergic medications, such as glycopyrrolate or atropine eye drops (used off-label orally), as prescribed to help reduce saliva production and manage drooling.
4. Encourage and facilitate swallowing exercises.
Rationale: Swallowing exercises, guided by a speech-language pathologist, can strengthen the muscles involved in swallowing and improve swallowing coordination. Following a swallowing evaluation and SLP instructions, encourage the patient to perform prescribed exercises, such as tongue and jaw thrusts, to enhance muscle strength and swallowing function.
5. Select food consistencies that are easy to swallow and minimize aspiration risk.
Rationale: Dietary modifications are crucial for safe swallowing. Offer foods that are easy to swallow and less likely to cause aspiration. Prioritize foods that are not dry, crumbly, or require extensive chewing. Soft, moist foods like oatmeal, scrambled eggs, pureed fruits and vegetables, and well-moistened pasta are generally easier to swallow and safer for patients with dysphagia.
Risk for Injury
Motor symptoms of Parkinson’s disease, including muscle rigidity, postural instability, and bradykinesia, significantly increase the risk of falls and injuries. These motor impairments compromise balance, coordination, and reaction time, making individuals with PD more vulnerable to accidents.
Nursing Diagnosis: Risk for Injury
Related Factors:
- Underlying disease process of Parkinson’s Disease.
- Muscle rigidity and stiffness.
- Postural instability and impaired balance.
- Bradykinesia (slowed movement).
- Neurobehavioral manifestations (e.g., cognitive changes, impulsivity).
Evidenced By:
- Risk diagnoses do not have “evidenced by” statements because the problem has not yet occurred. Nursing interventions are focused on prevention.
Expected Outcomes:
- The patient will remain free from injuries throughout their care, demonstrating a safe environment and effective preventive measures.
- The patient and/or caregiver will verbalize and demonstrate understanding and implementation of injury prevention strategies to minimize risks in the home and community.
Nursing Assessment:
1. Assess the severity of motor symptoms and their impact on mobility.
Rationale: The degree of motor impairment directly correlates with injury risk. Thoroughly assess and document the severity of rigidity, bradykinesia, tremors, balance issues, and gait abnormalities. Evaluate for “freezing” episodes, uneven gait patterns, and slowed movements, as these factors significantly increase the risk of falls and injuries. This assessment informs the development of a tailored injury prevention plan.
2. Assess ambulation, movement patterns, and gait characteristics.
Rationale: Parkinson’s disease often manifests in characteristic gait abnormalities. Observe and document the patient’s gait, noting for a slow, shuffling pattern, reduced arm swing, and decreased smoothness of movement. These gait deviations predispose individuals to falls and highlight the need for specific mobility interventions and environmental modifications.
3. Monitor blood pressure, particularly with positional changes (orthostatic blood pressure).
Rationale: Orthostatic hypotension, a drop in blood pressure upon standing, is common in PD due to reduced levels of the neurotransmitter norepinephrine. This blood pressure dysregulation increases the risk of dizziness, lightheadedness, and falls, especially when changing positions. Regularly monitor blood pressure in lying, sitting, and standing positions to identify orthostatic hypotension and implement preventive measures, such as slow positional changes and fall precautions.
Nursing Interventions:
1. Provide clear instructions and guidance during ambulation.
Rationale: Specific ambulation techniques can improve safety and reduce fall risk. When assisting with walking, instruct the patient to take deliberate, conscious steps, widen their stance for better balance, and lift their feet slightly to avoid shuffling and tripping. Verbal cues and guidance promote safer ambulation.
2. Encourage the patient to maintain an upright posture during activities.
Rationale: An upright posture enhances stability and balance, reducing the risk of falls and injuries. The stooped posture common in PD shifts the center of gravity forward, compromising balance and increasing fall susceptibility. Encourage and assist the patient in maintaining an upright posture during walking and other activities to improve stability and awareness of surroundings.
3. Educate on the proper use of assistive devices for mobility.
Rationale: Assistive devices, such as walkers and canes, provide external support and enhance mobility and safety. Instruct the patient and caregivers on the correct selection, fitting, and safe use of prescribed assistive devices. Ensure devices are readily available and used consistently to promote independence and reduce fall risk.
4. Promote and encourage regular exercise participation.
Rationale: Regular physical activity is crucial for maintaining balance, flexibility, and strength in PD, thereby reducing the risk of injuries. Encourage participation in exercises tailored for PD, such as Tai Chi, yoga, walking programs, and stationary cycling. These activities improve motor function, balance, and coordination, contributing to fall prevention and overall well-being.
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.
