Parkinsons Disease: Evaluation of Nursing Care

Table of Contents

Introduction
Main body
Conclusion
References:

Introduction

Nursing strategies are very influential in the management of patient care. Although the mode of their execution varies with the case, certain options need to be carefully considered as they may irk patients. Generally, patients with declined mental functions as observed in dementia, Alzheimers, Parkinsons disease may need to be thoroughly studied from the ground level to gain a better understanding of their pathophysiology that may facilitate efficient care delivery.

Main body

This would include history, clinical symptoms, drug therapy, and evidence-based nursing practice, etc. So, the present description is concerned with the evaluation of nursing care intended for Parkinsons disease. This disorder is most clinically characterized by rest tremor, bradykinesia, rigidity, and loss of postural reflexes. The secondary motor symptoms are hypomimia, dysarthria, dysphagia, micrographia, shuffling gait, festination, freezing, glabellar reflexes, and non-motor symptoms include autonomic dysfunction, cognitive/neurobehavioral abnormalities, sleep disorders, and sensory abnormalities such as anosmia, paresthesias, and pain (Jankovic, 2008).

These clinical features are problematic and may indicate that Parkinsons disease is a neurodegenerative disorder, as they are reported to involve the neuronal damage that contributes to poor mental functions in association with a variety of diagnostic manifestations (Pal & Netravathi, 2005).

It was also described that in Parkinsons disease degeneration of the central dopaminergic neurons in the substantia nigra, would lead to a depletion of dopamine (DA) in the striatum that causes bradykinesia, hypokinesia, rigidity, tremor, and postural instability (Wolters, 2006).

Lewy body pathology in the central dopaminergic system, noradrenergic, serotonergic, and cholinergic transmitter systems is considered as another vital pathological sign (Wolters, 2006).

In the present case, an 83-year-old male patient was admitted to a hospital ward via the emergency department.

The complaints at the time of admission were nausea, dark-colored brown fluids with blood clots, permanent indwelling urethral catheters (IDC) draining haematuria urine. His clinical profile revealed that he has a history of Parkinsons disease with dysphagia and depression. The other secondary complications were community-acquired Methicillin-resistant Staphylococcus aureus (MRSA), renal calculi, osteoporosis, recurrent urinary tract infection (UTI), constipation, Percutaneous Endoscopic Gastrostomy PEG tube, multiple skin tear, and conjunctivitis. The main reported problem of this patient was UTI which lead to renal calculi and PEG feeds.

It was revealed that the patient was on PEG feeds due to dysphagia.

The clinical complaints of this patient were in agreement with the well-known documented pathology of Parkinsons disease. Hence, the selection is appropriate.

So, from the diagnostic results, there is a need of developing awareness about dysphagia as it is characterized by discomfort in swallowing associated with a variety of medical and surgical complications. There are 9 clinical indicators of dysphagia reported. They are difficulty while keeping liquids in the mouth; coughing after drinking; shortness of breath while drinking; voice change after drinking; coughing after eating; shortness of breath after eating; food getting stuck in the mouth/throat when eating; voice change after eating; difficulty with saliva (Boczko, 2006). Hence, it may indicate that patients with dysphagia are likely to develop problems concerned with eating and drinking.

This was further strengthened by another report that described that patients with dysphagia may be at risk of aspirating food or saliva into the lungs, creating a potentially life-threatening medical condition (Brady, 2008). This could be due to the impairment of one of the 50 pairs of muscles involved in the complicated swallowing mechanism (Brady, 2008). Therefore, nurses should carefully evaluate the problems relevant to swallowing as they may lead to serious consequences.

Manor et al. (2007) described that underreporting of swallowing disturbances by Parkinsons disease patients may lead to delay in the diagnosis and treatment, alerting the physician to existing dysphagia only after the first episode of aspiration pneumonia. They evaluated a swallowing disturbance questionnaire (SDQ) for 33 PD patients and reported that SDQ would minimize errors concerned with the misdiagnosis of swallowing complaints.

This has indicated that SDQ may serve as a validated tool to detect early dysphagia in Parkinsons disease patients (Manor et al., 2007). The presence, severity, and differences in dysphagia in Parkinsons disease could be assessed by treatments focusing on vocal loudness, specifically Lee Silverman Voice Treatment (LSVT LOUD). Therefore, speech rehabilitation programs with the LSVT LOUD may be highly efficacious (Sapir, Ramig, & Fox, 2008).

Earlier workers described the electrophysiologic method that involves measuring the duration of laryngeal-pharyngeal mechanogram (LPM-D), duration of the inhibition of the cricopharyngeal muscle activity (CPEMG-ID), the interval between onset of Electromyography (EMG) activity of suprahyoid/submental muscles, and the onset of laryngeal-pharyngeal mechanogram (I-SHEMG-LPM), and swallowing reaction time (SRT) could help in assessing the presence, severity, and differences in dysphagia in Parkinson disease, Parkinson variant of multiple system atrophy (MSA-P) (Alfonsi et al., 2007).

Therefore, the problem of dysphagia in Parkinsons disease can be better solved by efficiently considering these strategies in a multi-disciplinary approach.

Next, swallowing discomfort may also commonly contribute to malnutrition and dehydration, because the reduction in the overall oral intake may enhance the bodily demands of food and water. Hence, nutrition is the other important parameter to consider. Wolfrath et al. (2006) evaluated the use of nutritional supplements in Parkinsons disease patients to determine the prevalence of their use and the associated side effects.

It was revealed that Vitamin E was the most commonly used in nutritional supplements and its awareness in Parkinsons disease patients was warranted to avoid dangerous side effects and drug interactions (Wolfrath et al.,2006). This was later strengthened by another report that emphasized patients with Parkinsons disease to consume a balanced diet about adequate intake of dietary fiber, fluids, and macro-and micronutrients (Evatt et al., 2007).

They also stressed obtaining data regarding patients nutritional history and anthropomorphic measures (height and weight), clinical trials of antioxidant vitamins; as nutritional requirements may change with Parkinsons disease progression or after surgical therapy for Parkinsons disease (Evatt et al., 2007).

Hence, it seems that nutritional therapy is important for patients with Parkinsons disease.

In the present case of an 81-year-old man, nutritional history was not considered. This may give an incomplete clinical profile. Hence, while securing information from the medical records, health care providers should gather nutritional history without fail.

Therefore, diet would be given prior importance in patients with Parkinsons disease to avoid serious consequences of inadequate nutrition such as malnutrition and constipation.

Patients with dysphagia and bradykinesia may need appetite-inducing foods that can be chewable and swallowed easily. To avoid constipation, the diet should contain adequate roughage and fruits. Before serving on a warmed plate the food should be cut into pieces.

Next, time planning and management is a crucial factor. Eating six small meals a day may lessen exhausting than taking three large meals. The nutritional management of Dysphagia would be beneficial provided there is proper monitoring of food and its composition. In case of insufficient nutritional intake, parenteral fluids may serve as the best option. Therefore, regular assessment of the patients nutritional status and intake, by a dietitian is an added advantage.

In the present case, since the patient has Dysphagia, he may not take food orally as he may encounter swallowing or eating problems. Hence, the patient needs to rely on PEG feeds.

PEG stands for Percutaneous (through the skin) Endoscopic (via an endoscope) Gastrostomy (to the stomach). PEG constitutes a tube meant for placing directly the stomach through the abdominal wall (www.oralcancerfoundation.org). Patients on PEG feeds need to be assessed to determine their nutritional needs, the number of calories, protein, and fluids as well as the most appropriate nutritional formula and how much of that formula would be required each day. (www.oralcancerfoundation.org). There is also a need to check for the problems associated with their usage. These include gastric hemorrhage, peristomal leakage, and infection, stomal leaks, tube extrusion or migration, aspiration, and fistula formation. Aspiration is considered a common complication and is reported to occur when food is inhaled into the lungs (www.oralcancerfoundation.org).

Since the patient on PEG feeds may become susceptible to the above-mentioned side effects, a follow-up is strictly recommended.

Lowry and Johnston (2007) reported that there is an inadequacy in the follow-up of patients discharged from the hospital following the commencement of PEG tube feeding.

It was revealed from a postal questionnaire that only a significant proportion of patients/carers had been trained regarding PEG tube care. Therefore, there is a great need to improve the PEG follow-up service (Lowry & Johnston, 2007). This might enable the dietician to better understand the clinical symptoms and recommend changes in the formula if the patient is

lactulose intolerant, change tubing every 24hours, without violating the manufacturers guidelines. This could also minimize constipation, diarrhea, and vomiting associated with bacterial contamination.

Next, the patient has a urinary tract infection (UTI) in addition to a syndrome of complications associated with Parkinsons disease. So, the complexity of the case has increased and probably this could have made him hospitalized and rely on equipment such as indwelling urethral catheters (IDC) in addition to PEG feeds. But, indwelling urethral catheters are reported to contribute to the risk of UTI which is the most common hospital-acquired infection (Schumm & Lamm, 2008). These workers have emphasized the reliability of silver alloy indwelling catheters as they are believed to possess minimum side effects(Schumm & Lamm, 2008).

Hence, it can be inferred that there may be a more severe UTI in the present case associated with the permanent IDC and nurses should make use of silver-coated IDC to prevent the further spread of UTI. Previously, it was described that the incidence of UTI is due to the formation of biofilm on both the internal and external surface of IDC; because of the protection offered by the biofilm against antimicrobials and the host immune response (Nicolle, 2005).

Here, it may reflect that the old patient may not be having sufficient immunity to withstand the effect of IDC-induced UTI. So, his immune system needs to be stimulated to counteract the infections by either diet supplementation or appropriate medication. Hence, the recommended interventions for nurse care are relevant clinical trials to define the optimal antimicrobial regimens and the development of biomaterials resistant to biofilm formation, for the management of catheter-acquired UTI especially, in older populations. (Nicolle, 2005). Therefore, nursing staff should assess the outcomes of residents with UTI round the clock.

Conclusion

In conclusion, the neurodegenerative disorder, Parkinsons disease was found associated with a spectrum of complications in an 81-year-old man. Special evidence-based nursing attention is warranted to circumvent the major problems of dysphagia and UTI. Nutrition may offer a safe and reliable therapy. The efficacy of hospital devices such as PEG tubing and IDC should be carefully understood by the nursing staff and made applicable to old patients with appropriate case history, as they are reported to further aggravate the problem of side effects.

References:

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