Caring for Patients with Neurological Disorders

Caring for Patients with Neurological Disorders

Shaneka Dumas MSN, RN

Objectives

• Identify/Interpret clinical cues of
• Parkinson’s Disease
• Huntington Disease
• Make informed clinical decisions
• Apply collaborative and holistic nursing interventions
• Evaluate and adjust interventions for optimal outcomes
• Educate patients and families on treatment information

Parkinson’s Disease (PD)

The Basics of PD

• A slow-progressing neurological disorder affecting movement
• Common in men around 50 yrs old but as early as 30
• Caused by reduced dopamine levels due to
• Age / Genetics
• Environment

• PD diagnosed through patient history and two major symptoms
• Treatment aims at symptom control and independence

(Hinkle, 2021)

The Key Symptoms of PD

Bradykenisa

Rigidity

Instability

Tremor

(Hinkle, 2021)

Additional Symptoms and Complications in PD

Dysphagia

Psychiatric Changes

AutonomicSymptoms

Hypokinesia

Complications

(Hinkle, 2021)

Key Considerations for Levodopa

• Most effective treatment for PD
• Carbidopa is often added to enhance effectiveness
• Patients may experience on-off syndrome
• Adverse effects of levodopa include
• N/V and/or decreased appetite
• Hypotension
• Dystonia
• Dyskinesia within 5-10 yrs
• Confusion

(Hinkle, 2021)

Additional Medications to Manage PD

MAOIs

Antiviral

Anticholinergics

Other Meds

(Hinkle, 2021)

Nursing Interventions for Improving Mobility and Self-Care

• Walk with proper posture, arm swinging, and heel-toe
• Walking to music or metronome for sensory reinforcement
• Use warm baths, massage, and stretching to relax muscles
• Modify the environment and provide adaptive devices

(Hinkle, 2021)

Nursing Interventions for Improving Nutrition and Swallowing

• Consider supplemental feedings and consult with a dietitian
• Promote upright sitting position to reduce aspiration risk
• Offer semisolid thick-liquid diet
• Teach swallowing strategies
• Encourage use of assistive devices
• Electric warming trays
• Stabilized plates
• Non-spill cups
• Utensils with built-up handles

(Hinkle, 2021)

Nursing Interventions for Enhancing Communication and Coping

• Remind patients to
• Face the listener
• Pronounce words clearly
• Speak in short sentences
• Provide a small electronic amplifier for hearing difficulties
• Assist patients in setting achievable goals
• Promote independence
• Avoid doing tasks for the patient solely for time-saving purposes

(Hinkle, 2021)

A 79-year-old client diagnosed with Parkinson's Disease. Client lives with his daughter and her family, who are his main caregivers at home. The patient has been prescribed levodopa. The nurse anticipates the medication regimen is effective when assess which of the following? Select all that apply.

Improved motor coordination and decreased tremors

Increased ability to perform activities of daily living independently

Enhanced facial expression and reduced masking of emotions

Diminished rigidity and improved range of motion

Heightened cognitive function and improved memory

submit

(Hinkle, 2021)

A 79-year-old client diagnosed with Parkinson's Disease. Client lives with his daughter and her family, who are his main caregivers at home. The patient has been prescribed levodopa. The nurse anticipates the medication regimen is effective when assess which of the following? Select all that apply.

Improved motor coordination and decreased tremors

Increased ability to perform activities of daily living independently

Enhanced facial expression and reduced masking of emotions

Diminished rigidity and improved range of motion

Heightened cognitive function and improved memory

Rationale: Levodopa effectively manages motor symptoms of Parkinson's disease by replenishing dopamine levels. It improves motor coordination, reduces tremors, enhances independence in daily activities, facial expression, and range of motion, and diminishes rigidity.

(Hinkle, 2021)

Huntington’s Disease (HD)

The Basics of HD

• Hereditary condition causing cell death in the striatum, cortex, and cerebellum
• Causes progressive involuntary choreiform movement and dementia
• Affects approximately 1 in 10,000 men or women at midlife, regardless of race
• Results from a genetic mutation in the Huntington gene (HTT)
• CAG (amino acids) repeating on HTT gene
• Genetic testing identifies disease development
• Genetic counseling is crucial

(Hinkle, 2021)

Key Symptoms of HD

• Rapid, purposeless movements affecting the entire body (chorea)
• Slurring and incoherent speech, swallowing, and gait
• Dementia
• Irritability, depression, apathy, anxiety, psychosis, or euphoria
• Determine age of onset, typically between 35 and 45
• Slow decline, emaciation, and exhaustion despite increased appetite

(Hinkle, 2021)

Complications of HD

Heart Failure

Pneumonia

Infection

Falls

Malnutrition and Choking

Common causes of death

(Hinkle, 2021)

Enhancing Mealtime Experiences for HD Patients

Snacks

During Meals

Before Meals

(Hinkle, 2021)

Medication Management of HD

Mental Health

Rigidity

Chorea Symptoms

(Hinkle, 2021)

Enhancing Education and Support for HD

• Address the coping mechanism and risk of suicide
• Tailor patient and family education to individual needs and changes experienced
• Consider speech therapist consultation for alternative communication strategies
• Discuss potential use of PEG tube for nutritional support in advanced stages
• Offer family support for coping with emotional, physical, social, and financial challenges
• Schedule regular follow-up visits to alleviate fear of abandonment

(Hinkle, 2021)

Menu

Which nursing interventions are indicated or contraindicated for a patient with Huntington's disease? Select all that apply.

Contraindicated

Indicated

Encouraging physical activity and exercise

Promoting a low-protein diet

Providing emotional support and counseling

Administering antipsychotic medications

Accept

(Hinkle, 2021)

Which nursing interventions are indicated or contraindicated for a patient with Huntington's disease? Select all that apply.

Contraindicated

Indicated

Encouraging physical activity and exercise

Promoting a low-protein diet

Providing emotional support and counseling

Administering antipsychotic medications

Physical activity and exercise are indicated as they help maintain mobility and overall well-being in patients with Huntington's disease. Emotional support and counseling are essential to address the psychological and emotional needs associated with the disease. However, a low-protein diet is not indicated for Huntington's disease, as patients require adequate nutrition. The use of antipsychotic medications should be carefully assessed as they can potentially exacerbate movement disorders associated with the disease, but they may be necessary for managing symptoms such as psychosis or agitation in certain situations.

(Hinkle, 2021)

Before Meals

• Administer phenothiazines (chlorpromazine) before meals to calm patient(s)
• Talk to the patient before mealtime for relaxation and social interaction
• Use a warming tray to keep food warm
• Find the best feeding position for the patient and keep them upright
• Show and explain the food's appearance and temperature

SSRIs, TCAs, and antipsychotics may help control psychiatric symptoms

Dysphagia

Difficulty in swallowing due to the degeneration of muscles in the throat.

More than 50% of patients report choking, along with changes in vision and sense of smell

During Meal Interventions

• Use a long-handled spoon and apply slight pressure on the middle of the tongue
• Wait for the patient to chew and swallow bite-sized portions
• For swallowing difficulties:
• Apply gentle deep pressure around the patient’s mouth
• Rub fingers in circles on the cheeks and then down each side of the patient’s throat
• Perform abdominal thrust in the event of choking

Anticholinergic Agents

Help Control The Tremor

Benztropine mesylate (Cogentin)

• Counteracts the action of acetylcholine

• Narrow-angle glaucoma contraindicated
• Side effects similar to Artane

Trihexyphenidyl hydrochloride (Artane)Side effects

• Blurred vision
• Flushing
• Rash
• Gastric/urinary retention
• Confusion

Bradykinesia

an overall slowing of active movement

• PD patients may take longer to complete activities due to slowed movement
• Can significantly affect a patient's daily life and independence

Amantadine Hydrochloride

Reduces Key Symtoms

• Common side effects to monitor for
• Psychiatric disturbances: mood changes, confusion, depression, hallucinations
• Lower extremity edema
• Nausea
• Epigastric distress
• Urinary retention
• Headache
• Visual impairment

Complications

are often related to disorders of movement

• Increased risk for respiratory and urinary tract infections
• Skin breakdown and injury from falls
• Adverse effects from medications
• Dyskinesia (impaired ability to execute voluntary movements)
• Akathisia (fidgeting when overmedicated)
• Urge to move, difficulty sitting still, restlessness, pacing, rocking, leg shifting
• Orthostatic hypotension

Medication Management of Chorea

• Benzodiazepines potential side effects
• Potential side effects:
• Sedation
• Drowsiness
• Dizziness
• Impaired coordination

• Tetrabenazine reduces dopamine in the brain
• Potential side effects:
• Sedation
• Parkinsonism
• Akathisia
• Depression

Overmedication leads to dangerous akathisia (motor restlessness)

Increase the duration of action of carbidopa or levodopa

After carbidopa or levodopa loses effectiveness

• Bromocriptine mesylate
• Pergolide

iEntacapone

• Tolcapone

Hypokenesia

the on-off "freezing" phenomenon

• Masklike and expressionless face
• Decreased frequency of blinking
• Dysphonia

• Shuffling walk
• Decreased arm swing,
• Micrographia (small handwriting)

Rigidity

affects the arms, legs, face, and overall posture

• Resistance to passive limb movement
• Jerky movements when an extremity is moved passively
• Often referred to as lead-pipe or cogwheel movements.

Monoamine oxidase inhibitors (MAOIs)

inhibit the breakdown of dopamine

• Common side effects to monitor for
• Agitation
• Dizziness
• Nausea
• Headache
• Rhinitis
• Back pain
• Stomatitis
• Orthostatic hypotension
• Insomnia

Give Between-Meal Feedings

• Constant movement expends more calories
• Patients often have voracious appetites, particularly for sweets
• Encourage a high calorie diet

develops due to postural and gait problems

Instability

• Forward-bent posture and shuffling gait increases fall risk
• Caused by the forward flexion of the neck, hips, knees, and elbows

• Difficulty in pivoting can result in a loss of balance

Progressive decline in motor and respiratory functions increases the vulnerability to respiratory infections and subsequent complications

Tremors

• Rhythmic, slow turning motion involving the forearm and the hand
• Involves pronation and supination
• Repeated action of the thumb against the fingers (rolling a pill between the fingers)

can be severe and significantly impact quality of life

Psychiatric Changes

• High prevalence of depression and anxiety
• Dementia and delirium
• Cognitive decline
• Often severe in long-term PD patients.
• Hallucinations and psychosis
• Auditory and visual hallucinations can occur
• Associated with depression, dementia, lack of sleep, or medication side effects

Prevention and Intervention

• Pad the sides and head of the bed
• Use padded heel and elbow protectors
• Keep the skin meticulously clean and lotion as needed
• Use soft sheets and bedding
• Encourage ambulation with assistance to maintain muscle tone

Levodopa provides temporary relief of rigidity

are related to the effect of PD on the basal ganglia

Autonomic Symptoms

• Uncontrolled sweating and drooling due to impact on ANS control
• Sudden, repeated bouts of redness and warmth in the skin (Paroxysmal flushing)
• Orthostatic hypotension
• Gastric and urinary retention
• Constipation
• Sexual dysfunction can manifest as reduced sexual desire or performance issues