Hyperparathyroidism

Nursing Considerations-Associated Nursing Procedures

12- or 24-hour timed urine collection Blood pressure assessment IV bag preparation IV bolus injection IV pump use Nutritional screening Oral drug administration Pain management Postoperative care Preoperative care Pulse assessment Respiration assessment Straining urine for calculi Surgical wound dressing application Urine specimen collection, random Venipuncture

Nursing Considerations-Nursing Diagnoses

Activity intolerance Acute pain Anxiety Decreased cardiac output Disturbed body image Excess fluid volume Fear Imbalanced nutrition: Less than body requirements Ineffective coping Risk for injury

Overview-Causes

Adenoma Chronic renal failure (secondary hyperparathyroidism) Decreased intestinal absorption of vitamin D or calcium Dietary vitamin D (secondary hyperparathyroidism) sor calcium deficiency Genetic disorders Idiopathic Ingestion of drugs such as phenytoin Laxative ingestion Multiple endocrine neoplasia Osteomalacia

Nursing Considerations-After Parathyroidectomy

Airway patency Surgical site Neuromuscular function, especially increased neuromuscular irritability Renal function Fluid balance status Signs and symptoms of hypercalcemia and hypocalcemia Serum calcium levels Complications Neck edema Chvostek's sign Trousseau's sign

Diagnostic Test Results-Laboratory

Alkaline phosphatase level increases. Serum PTH level increases. Serum calcium level increases; levels may be low-normal (secondary hyperparathyroidism). Serum phosphorus level decreases. Urine calcium levels increase.

Treatment-Activity

As tolerated

Treatment-Severe Hypercalcemia

Bisphosphonates, such as alendronate sodium, to reduce bone turnover and maintain bone density Calcimimetics, such as cinacalcet, to decrease calcium and PTH levels Loop diuretics, such as furosemide, to treat hypercalcemia in patients who are well-hydrated

Overview

Characterized by a greater than normal secretion of parathyroid hormone (PTH), one of the two major hormones that modulates calcium and phosphate homeostasis; stimulates intestinal absorption of calcium and acts on bone to release calcium Classified as primary or secondary

Treatment-Medications

I.V. normal saline solution for symptomatic hypercalcemia to expand extracellular volume and promote calcium excretion Estrogen therapy, such as conjugated estrogen (for postmenopausal women with mild hypercalcemia) Bisphosphonates, such as alendronate sodium, to increase bone density and assist with lowering serum calcium levels Vitamin D analogs or calcimimetics, such as cinacalcet (secondary hyperparathyroidism or patients with hypercalcemia unable to undergo surgery), to suppress parathyroid hormone release Vitamin D supplementation if the patient has vitamin D deficiency

Treatment-General

In primary disease, treatment to decrease calcium levels In renal failure, dialysis In secondary disease, treatment to correct underlying cause of parathyroid hypertrophy

Overview-Pathophysiology

In primary hyperparathyroidism, one or more of the parathyroid glands enlarges (usually due to an adenoma or gland hyperplasia), disrupting the normal feedback mechanism and causing an inappropriately high PTH secretion in relation to serum calcium concentration. In secondary hyperparathyroidism, the parathyroid gland responds appropriately to a reduced level of extracellular calcium; PTH concentrations rise and calcium is mobilized by increasing intestinal absorption. The glands become hyperplastic due to long-term stimulation and release of PTH.

Treatment-Diet

Increased oral fluid intake Restricted calcium intake if hypercalcemia is severe

Nursing Considerations-After Parathyroidectomy

Maintain a patent airway; keep a tracheotomy tray and endotracheal tube setup at the bedside. Maintain seizure precautions. Place the patient in semi-Fowler's position. Support the patient's head and neck. Have the patient ambulate as soon as possible.

Assessment-Physical Findings

No specific physical findings; most commonly asymptomatic If symptomatic: hypertension, bradycardia conjunctival calcium deposits muscle weakness and atrophy hypotonia psychomotor disturbances stupor and, possibly, coma skin necrosis subcutaneous calcification hypertension, bradycardia conjunctival calcium deposits muscle weakness and atrophy hypotonia psychomotor disturbances stupor and, possibly, coma skin necrosis subcutaneous calcification

Nursing Considerations-Nursing Interventions

Obtain baseline serum potassium, calcium, phosphate, and magnesium levels before treatment and as ordered throughout therapy. Provide at least 3 qt (3 L) of fluid per day; if I.V. fluids are used, ensure patent I.V. access. Institute safety precautions to reduce the risk of injury. Schedule frequent rest periods, and assist with energy conservation measures. Cluster nursing care activities to promote rest. Provide comfort measures, including helping the patient turn and reposition every 2 hours and supporting the affected extremities with pillows. Administer prescribed drugs, such as loop diuretics and bisphosphonates; avoid the use of loop diuretics in patients with hypocalcemia. Assist with activities of daily living, such as bathing and dressing, if bone pain is present. Offer emotional support. Help the patient adopt a positive self-image and develop effective coping strategies. Prepare the patient and family for surgery, if indicated.

Overview-Complications

Osteoporosis Subchondral fractures Traumatic synovitis Renal calculi and colic Renal insufficiency and failure Cholelithiasis Cardiac arrhythmias Vascular damage Hypertension Heart failure Muscle atrophy Depression Hypoparathyroidism (after surgery) Recurrent laryngeal nerve damage (after surgery)

Assessment-History

Possibly asymptomatic Recurring nephrolithiasis Polyuria Hematuria Chronic lower back pain Easy fracturing Osteoporosis Constant, severe epigastric pain that radiates to the back Abdominal pain Anorexia, nausea, and vomiting Constipation Polydipsia Muscle weakness, particularly in the legs Lethargy Personality disturbances Depression Overt psychosis Cataracts Anemia

Overview-Incidence

Primary hyperparathyroidism can occur at any age but the great majority of cases occur in individuals over age 45. Women are affected twice as commonly as men, probably because the increase in bone resorption that follows menopause unmasks parathyroid gland hyperactivity. Patients may have a history of irradiation to the head and neck, on average 20 to 40 years before the development of hyperparathyroidism. Females are three times more likely to develop primary hyperparathyroidism than males.

Treatment-Surgery

Removal of diseased gland (considered only proven curative treatment)

Nursing Considerations-Monitoring

Vital signs Intake and output Serum calcium levels Respiratory status Cardiovascular status

Diagnostic Test Results-Imaging

X-rays show diffuse bone demineralization, bone cysts, outer cortical bone absorption, and subperiosteal erosion of the phalanges and distal clavicles in primary disease. Technetium-99m (99m Tc) sestamibi imaging, ultrasonography, computed tomography, and magnetic resonance imaging scanning help identify enlargement and abnormally functioning areas.

Patient Teaching-General

disorder, diagnosis, possible causes, and treatment prescribed medications, including drug names, dosages, rationales for use, schedule of administration, and possible adverse effects signs and symptoms of hypercalcemia and hypocalcemia, including the need to notify a practitioner if any occur signs and symptoms of tetany, respiratory distress, and renal dysfunction need for periodic blood tests to evaluate electrolyte levels need to contact a practitioner before using any over-the-counter medications and to avoid calcium-containing antacids and thiazide diuretics importance of wearing medical identification jewelry surgical site care, if appropriate signs and symptoms of complications associated with surgery, such as infection and bleeding, and the need to contact a practitioner if any occur importance of adherence to follow-up, including laboratory testing to evaluate the condition and effectiveness of therapy.

Nursing Considerations-Expected Outcomes

perform activities of daily living without excessive fatigue express feelings of increased comfort and decreased pain verbalize strategies to reduce anxiety maintain adequate cardiac output express positive feelings about self maintain normal fluid volume express fears and concerns maintain adequate nutrition and hydration demonstrate adaptive coping behaviors remain free from injury and complications.