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ASKEP KLIEN DENGAN

PARKINSON DISEASE
Parkinsonisme
• Sindrom ditandai tremor ritmik, bradikinesia, kekakuan otot,
hilangnya refleks postural
• Disebabkan defek jalur dopaminergik (produksi dopamin) yang
menghubungkan subtansi grisea dengan korpus striatum
• Hilangnya neuron-neuron yang mengandung dopamin di
subtansi nigra  dopamin sangat berkurang dalam
nigrostriatum  gangguan keseimbangan antara dopamin
(penghambat) dan asetilkolin (penyerang)
• Penyebab : idiopatik, pasca ensefalitis, induksi obat, keracunan
logam berat (timah, Mangan, Hg), dll
Penyebab
• Degenerasi sel-sel saraf di bagian otak tengah yang
mengendalikan gerakan tubuh
• Hilangnya neuron-neuron yang menghasilkan dopamin.
• Disfungsi ganglia basalis  degenerasi sel-sel yang
memproduksi dopamin di substantia nigra pars compacta
 konsentrasi dopamin otak rendah  aktivitas otak yang
abnormal
Faktor risiko:
• Usia, meningkat dengan bertambahnya usia, ≥ 60 tahun.
• Keturunan/gen. Anggota keluarga dengan parkinson
• Jenis kelamin. Laki-laki lebih berisiko
• Paparan toksin. Paparan herbisida/pestisida meningkatkan
risiko.
• Paparan lingkungan: pestisida, CO, mangan
Body movements are regulated by basal ganglia, whose cells require a proper
balance of two substances called dopamine and acetylcholine, both involved in the
transmission of nerve impulses.
SEREBELUM
• Terletak di bawah serebrum
• Pusat koordinasi gerakan dan penyesuaian postural
• Hambatan transmisi neurotransmiter dopamin di
serebelum  tidak adanya gerakan halus dan
terkoordinasi spt pada penyakit parkinson
Symptoms
• Berbeda pada tiap orang, dan berubah sesuai
perkembangan penyakit
• Gejala biasanya muncul antara usia 50-60 tahun.
Berkembang lambt, sering tidak disadari oleh keluarga
maupun pasien sendiri
• Terjadi gangguan pergerakan yang menjadi lambat
• Beberapa awalnya merasakan kelemahan, kesulitan
berjalan, kekakuan otot.
• Atau merasakan tremor pad akepala atau tangan
• Parkinson adalah gangguan progresif dan gejala secara
bertahap memburuk.
Manifestasi klinis
• Rigiditis (kekakuan)  bisa timbul deformitas
• Rigiditas pada tubuh  bungkuk, dagu lebih ke depan
daripada jari-jari kaki, berjalan dengan menyeret kaki,
tergesa-gesa, langkah makin lama makin cepat
• Tremor (terutama sewaktu istirahat)
Otot tegang, bersiap melakukan aktivitas bertujuan  tremor
bisa berhenti
Tremor tangan  pill rolling, akibat gerakan ritmis ibu jari
dan jari ke 2 dan ke 3
Tremor makin hebat jika pasien lelah, ketegangan emosi,
memusatkan perhatian pada tremor
• Akinesia  sulit memulai gerakan spontan/gerakan baru
• Bradikinesia  kelambatan yang abnormal pada gerakan
yang disengaja
• Pasien membutuhkan tenaga lebih banyak untuk mengangkat
lengan  cepat lelah dan mengeluh nyeri otot
• Manifestasi otonom  berkeringat,, sukar menelan,
konstipasi, gangguan kandung kemih
• Penglihatan kabur
• Gangguan saluran nafas  hipoventilasi, inaktivasi, aspirasi
makanan atau saliva
Manifesasi khas
• Tremor istirahat
• Wajah seperti topeng
• Kelainan postural dan gaya berjalan
• Mikrofragia
• Monoton
• Refleks glabela
The general symptoms of Parkinson's disease:
• Slowness of voluntary movements, especially in the initiation of
such movements as walking or rolling over in bed
• Decreased facial expression, monotonous speech, and
decreased eye blinking (kedipan mata)
• A shuffling gait (berjalan menyeret) with poor arm swing and
stooped posture (postur membungkuk)
• Unsteady balance; difficulty rising from a sitting position
• Continuous "pill-rolling" motion of the thumb and forefinger
• Abnormal tone or stiffness in the trunk and extremities
• speech may become soft or slurred (cadel, kurang jelas)
• Swallowing problems in later stages
• Lightheadedness or fainting when standing (orthostatic
hypotension)
• Tremor  pill-rolling tremor, tremor of hand when it is
relaxed (at rest).
• Slowed movement (bradykinesia)  steps may become
shorter, difficult to get out of a chair, drag feet, making it
difficult to move.
• Rigid muscles  can limit range of motion and cause
pain.
• Impaired posture and balance  stooped, balance
• Loss of automatic movements  decreased ability to
perform unconscious movements, including blinking,
smiling or swinging arms when walking.
• Speech changes  softly, quickly, slur or hesitate,
monotone
• Writing changes  hard to write, writing may appear
small
Complications
• Thinking difficulties: usually occur in the later stages of
Parkinson's disease
• Depression and emotional changes
• Swallowing problems
• Sleep problems and sleep disorders
• Bladder problems
• Constipation
Penatalaksanaan
• medications  control symptoms
• lifestyle changes: aerobic exercise.
• physical therapy that focuses on balance and stretching
• A speech-language pathologist may help improve speech
problems.

Penatalaksanaan : Levodopa dan karbidopa


Antikolinergik, antihistamin  menghambat impuls saraf
yang dirangsang asetilkolin yang menyebabkan tremor,
rigiditas, bradikinesia
Pengobatan
• Tujuan: meningkatkan dopamin
Carbidopa-levodopa
• Menuju ke otak diubah menjadi dopamin
• Levodopa dikombinasikan dengan karbidopa (Rytary, Sinemet), untuk
melindungi konversi levodopa menjadi dopamin terlalu awal yang terjadi di
luar otak, sehingga mengurangi efek samping seperti nausea.
MAO-B inhibitors
• selegiline (Eldepryl, Zelapar), rasagiline (Azilect)
• Menghambat enzim monoamine oxidase B (MAO-B)  mencegah pemecahan
dopamin otak
Catechol-O-methyltransferase (COMT) inhibitors
• Entacapone (Comtan)
• Memblok enzim yang memcah dopamin
Anticholinergics
• benztropine (Cogentin) or trihexyphenidyl.
• Mengontrol tremor
Amantadine
• Mengurangi gejala jangka pendek pada parkinson awal, ringan
Surgical procedures
• Deep brain stimulation can stabilize medication fluctuations,
reduce or halt involuntary movements (dyskinesias), reduce
tremor, reduce rigidity, and improve slowing of movement

Lifestyle
Healthy eating
• eating foods high in fiber (serat) and drinking an adequate
amount of fluids (cairan) can help prevent constipation
• A balanced diet also provides nutrients, such as omega-3 fatty
acids
Exercise/olahraga
• increase muscle strength, flexibility and balance; improve well-
being and reduce depression or anxiety
Avoiding falls: avoid carrying things while walking, avoid walking
backward
Daily living activities: occupational therapist
Alternative medicine: massage, acupuncture, yoga , music or art
therapy, pet therapy
Nursing Care Plans
• The nursing goals for patients with Parkinson’s Disease
include improving functional mobility, maintaining
independence in performing ADLs, achieving optimal bowel
elimination, attaining and maintaining acceptable nutritional
status, achieving effective communication, and developing
positive coping mechanisms
Disturbed Thought Process
• May be related to: parkinsonian medications,
psychological causes, depression, incorrect belief system
• Possibly evidenced by: inaccurate interpretation of
environment, inappropriate thinking, memory impairment,
inability to perform activities as before
Desired Outcomes
• Patient will identify factors that elicit depressive reactions
and use techniques that will effectively reduce the amount
and frequency of these episodes.
• Patient will be compliant with the therapeutic regimen.
Nursing Interventions Rationale
Depression is a common among PD patients, whether it’s
Assess patient for depressive a reaction to the disorder or related to biochemical
behaviors, causative events, and abnormality is uncertain. Identify specific problems and
orient patient to reality as allow for the establishment of a plan of care. Reality
warranted. orientation helps patient to be aware of self and
surroundings.
Establishes a trusting relationship and permits patient to
discuss topics that can help the patient deal with in
appropriate ways. PD patients often feel embarrassed
Use nonjudgmental attitude
apathetic, bored, and lonely that may be brought about by
toward patient and actively listen
physical slowness and the great effort that even small
to his feelings and concerns.
tasks require. Encourage and assist the patient in every
effort possible to carry out the tasks involved in meeting
their own daily needs to remain independent.
Identify patient’s medications Assists with identification of any misuse of drugs and side-
currently being taken. effects that may precipitate depressive symptoms.
Patients who are depressed and who have already thought
Assess patient for potential for
about a suicide plan are serious and need emergency
suicide and suicidal ideation.
help.
Antidepressants and other psychoactive medications may
Monitor vital signs every 4 hours result in cardiovascular and cerebrovascular insufficiency.
and prn. Amantadine (Symmetrel) can cause psychiatric
disturbances, mood changes, hallucinations.
Impaired Verbal Communication
• May be related to: physical barrier from hypertonicity from parkinsonism, rigidity of
facial muscles, depression medications
• Possibly evidenced by: confusion, anxiety, restlessness, flight of ideas, inability
to speak, Stuttering (gagap), impaired articulation, difficulty with phonation,
inability to name words, inability to identify objects, difficulty comprehending
communication, dyslalia, dysarthria, inappropriate verbalizations, aphasia,
dysphasia, apraxia, slurred, slow monotonous speech, high-pitched rapid speech,
repetitive speech, facial muscle rigidity
• Desired Outcomes
• Patient will be able to have effective speech and understanding of communication,
or will be able to use another method of communication and make needs known.
• Patient will be able to use assistive devices and techniques to improve ability to
communicate.
• Patient will be able to speak in an understandable way possible when necessary.
• Patient will be able to understand communication.
• Patient will be able to exhibit minimal frustration and anxiety with speech attempts.
• Patient will be able to make needs known utilizing nonverbal methods if required.
• Family will be compliant and supportive of patient’s attempt at communication.
Nursing Interventions Rationale
Assess the patient’s ability to speak, language deficit,
Speech disorders are present in most
cognitive or sensory impairment, presence of aphasia,
patients with Parkinson’s disease, this helps
dysarthria, aphonia, dyslalia, or apraxia. Presence of
identify problem areas and speech patterns
psychosis, and/or other neurologic disorders affecting
to help establish a plan of care.
speech.

Instruct patient to make a conscious effort to speak


slowly, with deliberate attention to what they’re
This helps establish a clear method of
speaking. Remind the patient to face the listener,
communication and speaking to the patient.
exaggerate the pronunciation of words, speak in short
sentences, and take a few breaths before speaking.

Indicates that feelings or needs are being


Monitor the patient for nonverbal communication, such expressed when speech is impaired.
as facial grimacing, smiling, pointing, crying, and so Excessive mumbling, striking out, or non
forth; encourage use of speech when possible. verbalization clues may b e the only method
left for the patient to express discomfort.
Attempt to anticipate patient’s needs. Helps to prevent frustration and anxiety.
Clarity, brevity, and time provided for
When communicating with patient, face patient and
responses promotes the opportunity for
maintain eye contact, speaking slowly and enunciating
successful speech by allowing patient time to
clearly in a moderate or low-pitched tone.
receive and process the information.
Reduces unnecessary noise and distraction
Remove competing stimuli, and provide a calm,
and allows patient time to decrease
unhurried atmosphere for communication.
frustration.
Use simple, direct questions requiring one- Promotes self-confidence of the patient who is
word answers. Repeat and reword questions if able to achieve some degree of speech or
misunderstanding occurs. communication.
Provide a small electronic amplifier if
Helpful if the patient has difficulty being heard.
necessary.
Encourage patient to control the length and
Helps to promote speech in the presence of
rate of phrases, over articulate words, and
dysarthria.
separate syllables, emphasizing consonants.

Impaired verbal communication results in


patient’s feeling of isolation, despair,
Avoid rushing the patient when struggling to depression, and frustration. Compassion
express feelings and thoughts. helps to foster a therapeutic relationship and
sense of trust and is important for continuing
communication.

Instruct patient and/or SO regarding need to Helps promote communication with sensory or
use glasses, hearing aids, dentures. other deficits.

Instruct patient and/or SO in the performance


Promotes facial expressions used to
of facial muscle exercises, such as smiling,
communicate by increasing muscle
frowning, sticking tongue out, moving tongue
coordination and tone.
from side to side and up and down.
Impaired Physical Mobility
May be related to: Parkinson’s disease, tremors, rigidity,
bradykinesia
Possibly evidenced by: Inability to move at will, weakness,
immobility, gait disturbances, balance and coordination
deficits, difficulty turning, decreased reaction time, postural
disturbances, shuffling gait (cara berjalan)
Desired Outcomes
• Patient will maintain functional mobility as long as possible
within limitations of disease process.
• Patient will have few, if any, complications related to
immobility.
Nursing Interventions Rationale
Instruct patient with techniques that Rocking from side to side helps to start the leg
initiate movement. movement.
Instruct patient to get out of chair by
moving to edge of seat, placing Parkinson disease causes rigidity tremors,
hands on arm supports, bending bradykinesia and may result in difficulty getting
forward, and then rocking to a out of a chair.
standing position.
Balance may be adversely affected because of
the rigidity of the arms that prevents them from
swinging when walking normally. A special
Teach the patient to concentrate on
walking technique must be learned to offset the
walking erect and use a wide-based
shuffling gait and the tendency to lean forward. A
gait.
conscious effort must be made to swing the
arms, raise the feet while walking, and use a
heel-toe placement of the feet with long strides.

Instruct patient to perform daily Exercise prevents contractures that occur when
exercise that will increase muscle muscles are not used, improves coordination
strength: walking, riding a stationary and dexterity, and reduces muscular rigidity.
bike, swimming, and gardening are Adherence to exercise and walking program
helpful. helps delay the progress of the disease.
Teach patient to sit in chairs with backs
Help with rising from a sitting position
and arm rests; use elevated toilet seats
and prevent falls.
or sidebars in the bathroom.

Recommend that sexual relations be


Parkinson’s causes bradykinesia which
planned for when the medication is
can impair intimacy.
active.

Instruct patient to raise head of bed and


make position changes slowly. Teach
These measures reduce orthostatic
patient to dangle legs a few minutes
hypotension.
before standing. Avoid dehydration and
maintain adequate dietary salt.

May be helpful in developing an


individualized exercise program and
Refer patient to a physical therapist.
can provide instruction to the patient
and caregiver on exercising safely.

Helps relax muscles and relieve painful


Provide warm baths and massages.
muscle spasms that accompany rigidity.
Risk for Injury
• May be related to: medications, hallucinations, bradykinesia
• Risk factors: confusion, disorientation, altered mobility, agitation,
physical discomfort, involuntary movements, loss of postural
adjustment, loss of balance, loss of arm swinging movement,
shuffling gait, slowness of movement, orthostatic hypotension,
activity intolerance, hallucinations, tremors, muscle rigidity
Desired Outcomes
• Patient will remain safe from environmental hazards resulting from
cognitive impairment.
• Family will ensure safety precautions are instituted and followed.
• Patient will remain in a safe environment with no complications or
injuries obtained.
• Family will be able to identify and eliminate hazards in the patient’s
environment.
Nursing Interventions Rationale
Assess ambulation and movement. Aids in planning of interventions.

Instruct patient to swing arms and lift These action assist gait and prevent
heels during ambulation. falls.

To prevent the crossing of one leg


Teach patient to turn in wide arcs. over the other, which could cause a
fall.

Remind patient to maintain an upright Stooped posture may cause the


posture and look up when walking. patient to collide with objects.

Instruct a wide-based gait To improve balance.

Teach range of motion exercises and Exercising increases flexibility and


stretching to be performed daily. improves strength and balance.
Ineffective Coping
• May be related to: progressive chronic disease, depression, lack
of coping skills, physical or emotional impairment caused by
normal aging changes or parkinsonism, changes in lifestyle
• Possibly evidenced by: verbalization of inability to cope,
inappropriate coping strategies, social withdrawal, irritability,
aggressiveness, hostility, changes in communication pattern,
inability to ask for help, fatigue, increased illness, poor
concentration, decreased problem-solving skills, risk-taking
behaviors, poor-self esteem, insomnia
Desired Outcomes
• Patient will exhibit improvement in emotional well-being.
• Patient will use acceptable strategies to cope with problems, and
will have improved sense of self-worth.
• Patient will be able to access support systems, community
resources, or counselors to assist in achieving adequate coping
skills.
Nursing Interventions Rationale
Provide care for patient using same Provides for continuity of care and the
personnel whenever possible. establishment of a trusting relationship.
Allows patient time to express extreme and
powerful emotional feelings, and with
discussion, patient can begin to comprehend
Provide uninterrupted time to be spent with
the personal meaning attached to recent
patient, and encourage him to express
events and develop a reasonable
feelings and concerns.
assessment of the situation in order to
identify a plan to deal constructively with the
situation.
Dependency on the nurse decreases self-
Assist patient only when necessary. Offer
esteem. Encouraging desired behaviors
positive feedback for independent behavior.
promotes effective coping.
Encourage patient to make choices about his Reduces helplessness and enhances sense
care. of self-esteem.
Helps set boundaries for manipulative
Identify expectations from patients for
behavior. Manipulation by the patient reduces
behavior and what consequences will occur if
sense of insecurity by increasing feeling of
limits are not honed.
power.
A sense of responsibility needs to be
Assist patient to identify behavior and
developed before any changes can
accept responsibility for actions.
occur.
Identify patient’s positive qualities and Patient will have less need for
accomplishments and assist patient to manipulative behavior if self-esteem is
recognize these traits. increased.
Congratulate the patient when he or she
Helps reinforce positive behavior.
uses effective coping strategies.
Encourage patient to utilize community
resources, support systems, Helps to maintain effective coping skills.
counselors, and family and friends.
Instruct patient/family in appropriate Provides knowledge and identifies
coping strategies. alternatives to inappropriate behavior.
Instruct patient and/or family regarding May be required to continue complete
need for support groups and/or appropriate care and enable patient to
counseling. effectively maintain coping skills.
Deficient Knowledge
• May be related to: lack of knowledge about Parkinson’s disease, stigma
of disease, difficulty understanding the disease process, lack of coping
skills, cognitive impairment
• Possibly evidenced by: verbalization of questions, verbalization of
incorrect information, noncompliant, presence of preventable
complications, inability to follow instructions, inappropriate behavior,
agitation, depression, withdrawal, apathy, restlessness (gelisah)
Desired Outcomes
• Patient and/or family will be able to exhibit understanding of disease
process, medication regimen, and treatment plan of care.
• Patient will be able to accurately verbalize understanding of
parkinsonism and its treatment regimen.
• Patient will be able to comply with medication regimen and notify
physician if patient experiences untoward side effects.
• Patient and/or family will be able to identify and demonstrate safety
precautions to prevent injury.
• Patient and/or family will be able to identify need for long-term goals and
potential for end-of-life decisions to be made.
Nursing Interventions Rationale
Provides baseline of understanding from which to
Assess patient’s understanding of
establish a plan of care. New information can be
disease process. Consider the older
used the patient’s existing knowledge base and life
patient’s life experiences.
experience.
Elderly patients may not be aware of old
Educate patient and/or SO about information and the stigma that was attached to PD
Parkinson’s disease, signs and and dementia, and will require re-education
symptoms, treatments and prevention of regarding current treatments. Reduction of
complications. Limit length of teaching extraneous stimuli assists with learning and the
sessions and provide quiet and ability to process new information without
productive environment for each session. distraction. Short sessions allow patient to learn at
own speed and prevent information overload.
Surgical options may be required to replenish
Prepare patient for surgery as indicated. dopamine, improve dyskinesias and rigidity, or to
treat disabling drug-resistant tremors.
The patient can adjust the schedule to produce
Advise the patient to take the anti-
peak effect of the drug when mobility is mostly
parkinsonism drugs on schedule.
needed.
Provides knowledge and facilitates compliance with
Instruct patient and/or SO regarding
treatment regimen. Provides for timely identification
medications and need for compliance with
of serious adverse effect from medication regimen
dosage, scheduling, and physician follow-
to allow physician to be notified postdischarge from
up.
hospital.
Anticholinergic drugs (diphenhydramine, trihexyphenidyl,
procyclidine) can cause sedation, confusion, and urinary
retention.
Dopaminergic drugs (carbidopa-levodopa) can cause nausea,
Instruct family regarding side anorexia, confusion, psychotic disturbances, dyskinesia, and
effects of medications and nightmares.
when to notify the physician. Dopamine agonists (bromocriptine) can cause nausea, vomiting,
confusion, hallucination, dyskinesia and hypotension.
MAOIs (selegiline) can cause nausea, insomnia, and confusion.
Amantadine can cause urinary retention, increased intraocular
pressure, and confusion.

Provide time for questions and


concerns to be voiced, and
Provide for correction of misinformation and written materials
answer questions honestly.
allow for documentation to assist with care once patient is
Give patient and/or family
discharged.
written materials to refer to
later.

Disease is chronic and patient will eventually become severely


Instruct patient and/or family
impaired. Issues that may occur in the future (tube feedings,
regarding need for long-term
DNR, etc) should be discussed to enable patient and family to
planning and potential for end-
make informed choices while the patient is capable of
of-life care decisions.
understanding the severity of the condition.
Imbalanced Nutrition: Less Than Body Requirements
• May be related to: facial rigidity, use of antiparkinsonian
drugs, inability to take in enough food, aging process
• Possibly evidenced by: inadequate food intake, weight
loss, decreased peristalsis, muscle mass loss, decreased
muscle tone, nausea, abdominal distention, lack of interest
in food, rigidity of facial muscles
Desired Outcomes
• Patient will have adequate nutritional intake with no weight
or muscle mass loss.
• Patient will maintain adequate nutritional status with use of
nutritional support, and will experience no complications
from support.
• Patient will show no signs of malnutrition status.
Nursing Interventions Rationale

To provide information regarding


Assess patient’s ability to eat. factors associated with reduced
intake of nutrients.

Weigh patient daily, on the same Provides information about weight


scale and same time if possible. loss or gain.
Patients with PD may have
difficulty maintaining their weight
as eating becomes a very slow
Provide an unhurried environment
process, requiring concentration
during meal time.
due to a dry mouth from
medications and difficulty chewing
and swallowing.
To assess whether caloric indicate
Monitor weight on a weekly basis.
is adequate.
Other Nursing Care Plans
• Self-care deficits (feeding, dressing, hygiene, and
toileting) related to tremors and motor disturbances.
• Constipation related to medications and reduced physical
activity.
• Impaired Swallowing