Hypoparathyroidism & Hyperparathyroidism

After thyroid surgery, the nurse suspects damage or removal of the parathyroid glands when the patient develops a. muscle weakness and weight loss. b. hyperthermia and severe tachycardia. c. hypertension and difficulty swallowing. d. laryngospasms and tingling in the hands and feet.

Correct answer: d Rationale: Painful tonic spasms of smooth and skeletal muscles can cause laryngospasms that may compromise breathing. These spasms may be related to tetany, which occurs if the parathyroid glands are removed or damaged during surgery, which leads to hypocalcemia.

A patient is 6 hours post-opt from thyroid surgery. The patient's calcium level is 5 and phosphate level is 4.2. What physical signs and symptoms would NOT present with these findings? (Select-all-that-apply)* A. Bronchospasm B. Constipation C. Numbness and tingling in the face D. Positive Chvostek's Sign E. Absent Trousseau's Sign F. Hypertension

The answers are B, E, and F. In this scenario, the patient is at risk for HYPOparathyroidism, especially considering the lab levels. A normal calcium level is 8.9 to 10 mg/dL and phosphate level is 2.7 to 4.5 mg/dL. In HYPOparathyroidism, HYPOcalcemia and HYPERphosphatemia is present (which is the case here). Constipation, absent Trousseau's Sign, and hypertension are not seen in HYPOparathyroidism.

Phosphate is needed for:

bone health, nerve and muscle function...kidneys regulate its levels

What does a low calcium level in the body do?

it stimulates the parathyroid glands to release PTH which causes the kidneys to reabsorb calcium, excrete phosphate, and activate vitamin D which causes the small intestines to absorb more calcium from food. PTH also stimulates osteoclasts (break bone down) in bones which causes bone resorption and calcium is then released.

Treatment for hyperparathyroidism

*Parathyroidectomy: main treatment for primary cause (remove only the glands enlarged/adrenals)

Parathyroidectomy

*monitor respiratory status, semi-fowlers position, trach kit, suction, and oxygen at bedside *watch calcium level: decrease = tingling/numbness, excessive twitching, positive Trousseau's sign or Chvostek's *monitor laryngeal nerve damage = voice changes, hoarse, problems swallowing/speaking

Nursing interventions for hypoparathyroidism

*monitor: -Calcium and phosphate levels -airway (tetany) = trach kit, O2, and suction -seizures -ensure increased calcium (diary, green leafy veggies) and decreased phosphorus (soft drinks, meats, eggs) diet

Nursing Interventions for hyperparathyroidism

*monitor: VS, EKG, urine (strain), calcium and phosphorus levels, I & O, encourage fluids *diet low in calcium and high in phosphorus (watch phosphorus in renal patients)

The nurse is caring for a client who is diagnosed with hypoparathyroidism. The client will receive parathyroid gland replacement therapy. The nurse understands that this therapy accomplishes which of the following? Select all that apply. a. Activates vitamin D b. Promotes calcium reabsorption from the renal tubules c. Promotes calcium excretion from the kidneys d. Activates calcium absorption into bones e. Promotes calcium absorption from the GI tract

A.) PTH replacement therapy promotes increased calcium absorption. This is accomplished by enhanced calcium absorption from the GI tract, vitamin D activation, and reabsorption of calcium from the kidneys. B.)PTH replacement therapy promotes increased calcium absorption. This is accomplished by enhanced calcium absorption from the GI tract, vitamin D activation, and reabsorption of calcium from the kidneys. E.) PTH replacement therapy promotes increased calcium absorption. This is accomplished by enhanced calcium absorption from the GI tract, vitamin D activation, and reabsorption of calcium from the kidneys.

Calcium is needed for:

bone health, nerve & muscle contraction

Signs and symptoms of hyperparathyroidism

*Bone fracture: PTH causes excessive breaking down of bones = calcium leaks in blood = very fragile *Calculi: increase calcium levels = kidneys absorb calcium and form stones *Constipation: GI system smooth muscle slows down *GI problems: N & V, epigastric pain = due to increased gastric acid *Frequent urination: increased calcium causes kidneys to work harder (dehydration = concentrated urine) * EKG changes: short QT interval

Signs and symptoms of hypoparathyroidism

*Paresthesia (tingling on mouth, face, finger, toes) *Positive Trousseau's and Chvostek's sign *Tetany (severe) decreased calcium and increased phosphorus=involuntary muscle contraction and cramping which can lead to bronchospasm/seizure, laryngospasm, hands/foot spasms, EKG changes *Hypocalcemia and Hperphosphatemia

A client that is admitted after surgery to remove the parathyroid glands due to cancer. The nurse is assessing and knows to look for which of the following side effects? Select all that apply. a. Arrhythmias b. Excessive hunger c. Hyperactivity d. Seizures e. Tetany

A.)Hypoparathyroidism from the removal of parathyroid glands may cause arrhythmias due to the low calcium levels causing cell excitability. D.) Hypoparathyroidism from the removal of parathyroid glands may result in seizures from the low calcium causing increased cell excitability. E.)The client with the thyroid removed will have a decrease in calcium due to the low PTH levels, which may result in tetany.

Medications for hyperparathyroidism

Goal = decrease PTH, decrease Ca, keep patient hydrated *Calcimimetics "Sensipar": prescribed for patient with secondary cause...especially if they have chronic kidney disease (mimics role of calcium and deceives parathyroid gland there's enough calcium) take with food *Calcitonin: (injection or nasal) naturally produced by thyroid gland = lowers calcium suppresses osteoclasts and increases osteoblast activity and causes kidneys to excrete calcium *Loop diuretic "Lasix": decrease calcium levels by inhibiting calcium resorption in renal tubules (watch K+ levels)

The pathophysiology of hypoparathyroidism is associated with all of the following except: a. a lowered renal excretion of calcium b. an increase in the renal excretion of phosphate c. decrease in serum calcium d. an elevation of blood phosphate

The answer is B. an increase in the renal excretion of phosphate

The nurse is preparing to receive a postoperative client following parathyroidectomy surgery. The nurse is aware that which of the following are potential occurrences with this type of surgery? Select all that apply. a. Irritation of the thyroid gland b. Bleeding at the surgical site c. Removal of one or more parathyroid glands d. Postoperative hypercalcemic crisis e. Transplantation of parathyroid tissue in the forearm

The answer is A, B, C, and E. A parathyroidectomy is performed to remove diseased glands. There are 4 parathyroid glands, and a parathyroidectomy will involve the removal of 1 gland, or up to all of the glands. A.) Because the parathyroid glands are located behind the thyroid, this structure is at risk of irritation during surgery E.) When all parathyroid glands must be removed, some parathyroid tissue is transplanted to either the forearm or near the sternocleidomastoid muscle so that PTH will continue to be excreted. As with any surgery, bleeding at the surgical site can occur. The nurse will monitor the neck dressing for bleeding.

Causes of Hyperparathyroidism

*Primary: problem with parathyroid gland -noncancerous growth "Adenoma" (most common) -hyperplasia of gland -cancer growth *Secondary: disease causing parathyroid to mess up -chronic renal failure: overworks parathyroid (most common) -hypocalcemia: low levels overwork parathyroid -vitamin D deficiency: due to increased calcium (role in bone health, muscle and nerve function decrease)

Causes of hypoparathyroidism

*destruction/manipulation of parathyroid gland (most common) *thyroidectomy or treatment of cancer/neck throat (due to close proximity and sharing blood supply) *hypomagnesemia: low levels of magnesium inhibit PTH secretion *autoimmune: body produces antibodies to attack parathyroid *body resistant to PTH: parathyroid works great but kidneys and bones not receptive

The nurse is caring for a patient admitted with suspected hyperparathyroidism. Which signs and symptoms would represent the expected electrolyte imbalance (select all that apply.)? a. Nausea and vomiting b. Neurologic irritability c. Lethargy and weakness d. Increasing urine output e. Hyperactive bowel sounds

The answer is A, C, D. Hyperparathyroidism can cause hypercalcemia. Signs of hypercalcemia include muscle weakness, polyuria, constipation, nausea and vomiting, lethargy, and memory impairment. Neurologic irritability and hyperactive bowel sounds do not occur with hypercalcemia.

A physician orders Calcium Gluconate IV as treatment for a patient with hypoparathyroidism. The patient's calcium level is 5 mg/dL. Which of the following finding causes you to question this order?* A. The patient is taking Digoxin. B. The patient complains of muscle cramping and numbness in the face. C. The patient is taking Aluminum Carbonate. D. The patient's phosphate level is 7 mg/dL.

The answer is A. Calcium gluconate can increase Digoxin toxicity. Therefore, as the nurse you should clarify the order with the physician and make sure the physician is aware the patient is on Digoxin.

Medications for hypoparathyroidism

*goal = increase calcium and decrease phosphorus *IV calcium (if very low): Calcium gluconate (watch for Digoxin toxicity) *oral calcium with vitamin D (watch for GI upset, constipation, renal calculi, and flank pain) *Calcium supplements interfere with absorption of iron and thyroid medications *Phosphate binders: decrease phosphate through excretion of phosphorus in stool (take after meal = aluminum carbonate) *Parathyroid hormone replacement: natpara (injection) (monitor calcium levels, GI issues, N & V, paresthesia)

When the patient with parathyroid disease experiences symptoms of hypocalcemia, what is a measure that can be used to temporarily raise serum calcium levels? a. administer IV normal saline b. have patient rebreathe in a paper bag c. administer oral phosphorus supplements d. administer furosemide as ordered

The answer is B. Rebreathing in a paper bag promotes carbon dioxide retention in the blood, which lower pH and creates an acidosis. An acidemia enhances the solubility and ionization of calcium, increasing the proportion of total body calcium available in physiologically active form and relieving the symptoms of hypocalcemia.

A patient hospitalized with hypoparathyroidism is about to order lunch. Which food selection is best for this patient based on their dietary needs at this time?* A. Baked chicken, green beans, and boiled potatoes B. Broccoli salad, cottage cheese, and peaches C. Roast beef, carrots, and pinto beans D. Hamburger, fries, and sorbet

The answer is B. Remember green leafy vegetables and cheeses are high in calcium. Therefore, B is the correct answer. All the other options are high in either protein, carbs, or fiber.

The nurse is caring for a client that was diagnosed with primary hyperparathyroidism. Her vital signs are the following: blood pressure 172/94 heart rate 82 temperature 98.9F Respirations 16 Which of the following orders should the nurse implement first? a. Normal saline IV 120/hr continuous b. Give levothyroxine PO daily c. Give stat calcium PO to client d. Confirm surgical consent is present for the removal of the parathyroid gland

The answer is D. The nurse should confirm surgical consent was obtained for the removal of the parathyroid glands. Primary hyperparathyroidism is treated by the surgical removal of the parathyroid glands, as there is not an underlying cause.

The nurse is caring for a patient after a parathyroidectomy. The nurse would prepare to administer IV calcium gluconate if the patient exhibits which clinical manifestations? a. Facial muscle spasms and laryngospasms b. Tingling in the hands and around the mouth c. Decreased muscle tone and muscle weakness d. Shortened QT interval on the electrocardiogram

The answer is A. Nursing care for a patient after a parathyroidectomy includes monitoring for a sudden decrease in serum calcium levels causing tetany, a condition of neuromuscular hyperexcitability. If tetany is severe (e.g., muscular spasms or laryngospasms develop), IV calcium gluconate should be administered. Mild tetany, characterized by unpleasant tingling of the hands and around the mouth, may be present but should decrease over time without treatment. Decreased muscle tone, muscle weakness, and shortened QT interval are clinical manifestations of hyperparathyroidism.

The healthcare provider notifies the nurse that they are testing for hyperparathyroidism. Which of the following tests should the nurse expect to see in the client's orders? a. PTH level b. Creatinine level c. TSH level d. Blood glucose level

The answer is A. PTH levels may be drawn to help diagnose hyperparathyroidism, which causes excessive PTH.

A patient is recovering from a thyroidectomy. The patient starts to complain of tingling and numbness in the face, toes, and fingers. Which of the following findings below warrants attention?* A. Ca+ level: 6 mg/dL B. Na+ level: 145 mg/dL C. K+ level: 3.5 mg/dL D. Phosphate level: 4.3 mg/dL

The answer is A. Patients who've had a thyroidectomy are at risk for HYPOparathyroidism, and the symptoms listed in the question are classic signs of hypocalcemia. A normal calcium level is 8.6 to 10.0 mg/dL. Therefore, due to the patient's signs and symptoms and low calcium level of 6 mg/dL this warrants a nursing intervention.

A client is admitted with complications due to hypoparathyroidism. The nurse is aware that which of the following treatments should be implemented? a. 1 tablet calcium PO BID b. Potassium phosphate rider OT c. 1 gram phosphorous packets QID with meals and at bedtime d. 200 units calcitonin daily

The answer is A. The client with hypoparathyroidism has decreased PTH, therefore a decrease in calcium in the body. It would be appropriate and necessary to give the client a calcium PO.

The nurse is preparing a client for a parathyroidectomy. Which of the following is an appropriate teaching point? a. There may be pain with talking the first few days following surgery b. Postoperatively, you will need to be placed in the supine position c. After removal of the parathyroid, calcium supplements will no longer be necessary d. A positive Rovsing's sign indicates hypocalcemic crisis

The answer is A. The parathyroid is located behind the thyroid gland in the neck. Because surgery involves manipulation to the area, there is a risk of injury to the nerves that innervate the vocal chords. The client may experience a hoarse voice or pain with talking for the first day or two.

The nurse is giving discharge instructions to a client with hypoparathyroidism. Which of the following should be included in education about items to avoid consuming? a. Pork chops b. Orange juice c. Kale d. Spinach

The answer is A. They are in the meat category which should be avoided due to high phosphorus levels.

What is an appropriate nursing intervention for the patient with hyperparathyroidism? a. pad side rails as seizure precaution b. increase fluid intake to 3000 to 4000 mL daily c. maintain bed rest to prevent pathologic fractures d. monitor the patient for Trousseau's and Chvostek's signs

The answer is B. A high fluid intake is indicated in hyperparathyroidism to dilute the hypercalcemia and flush the kidneys so that calcium stone formation is reduced. Seizures are not associated with hyperparathyroidism. The patient with hyperparathyroidism is at risk for pathologic fractures resulting from decreased bone density, but mobility is encouraged to promote bone calcification. Impending tetany of hypoparathyroidism after parathyroidectomy can be noted with Trousseau's and Chvostek's signs.

A nurse is caring for a client with hypoparathyroidism. The nurse knows that which of the following supplements might be administered to a client for treatment of hypoparathyroidism? a. Phosphorus b. Calcium c. Thiamine d. Folic acid

The answer is B. Hypoparathyroidism is treated with calcium supplements due to the low PTH levels caused by hypoparathyroidism. Low PTH causes hypocalcemia in the blood.

A client with hyperparathyroidism from a tumor is told that the healthcare provider wants to remove the parathyroid glands. The client asks the nurse what will happen if the parathyroid glands are removed. Which of the following is an appropriate answer by the nurse? a. "You will need to take phosphorus supplements for the rest of your life" b. "You will have low blood calcium levels, so it will be important to take calcium supplements" c. "You will be at a higher risk for kidney stones, so you will need to monitor your urine" d. "There won't be any changes in your symptoms or treatment"

The answer is B. The removal of the parathyroid glands will result in no PTH production. PTH facilitates the movement of calcium from the bones, intestinal reabsorption, and kidney retainment. The lack of PTH will result in decreased calcium levels, so the client will require calcium supplements.

Which of the following patients are MOST at risk for hypoparathyroidism?* A. A 75 year-old female who is diabetic and takes Os-Cal daily. B. A 59 year-old male with a Mg+ level of 0.9 mg/dL. C. A 85 year-old female complaining of flank pain and constipation. D. A 19 year-old male with a Ca+ level of 8.9 mg/dL.

The answer is B. This patient is experiencing HYPOmagnesemia which is a cause of HYPOparathyroidism and is most at risk for developing this condition.

You are providing discharge teaching to a patient who is prescribed calcium supplements with vitamin D for treatment of hypoparathyroidism. Which of the following statements by the patient warrants you to re-educate the patient on how they should take this medication?* A. "I will also make sure I eat foods rich in calcium, such as dairy and green leafy vegetables while I'm taking this medication." B. "A side effect of this medication is constipation. Therefore, I should drink plenty of fluids." C. "I will take my calcium supplements in the morning when I take my Synthroid." D. All the statements above are correctly stated by the patient.

The answer is C. Calcium supplements should NOT be taken at the same time as iron or thyroid hormones (Synthroid) because it affects absorption. Therefore, this medications should be taken at separate times.

A patient is prescribed Fosamax (Alendronate). The patient is about to be discharged and you observe the patient taking the medication. Which of the following findings requires you to re-educate the patient on how to take this medication?* A. The patient takes the medication on an empty stomach. B. The patient takes the medication with water. C. The patient sits up for 10 minutes after taking the medication. D. The patient waits 30 minutes after taking Fosamax before taking the prescribed vitamins and antacids.

The answer is C. Fosamax should be taken on an empty stomach, with a full glass of water, with no other medications for at least 30 minutes (especially antacids or vitamins), and the patient should sit-up for 30 minutes after taking it. Fosamax can cause serious throat and stomach ulcers and taking it with a full glass of water and sitting-up afterwards helps prevents this.

A nurse is reviewing discharge education with a client. Which of the following should the nurse provide to the client diagnosed with hyperparathyroidism? a. Eat foods high in calcium b. Limit water intake c. Avoid foods high in calcium d. Avoid foods high in phosphorus

The answer is C. Hyperparathyroidism causes increased PTH which causes excessive calcium release from the bones into the blood, so the client should avoid foods that are high in calcium.

A patient is recovery from a parathyroidectomy. Which of the following findings causes concern and requires nursing intervention?* A. The patient is in Semi-Fowler's position. B. The patient's calcium level is 8.9 mg/dL. C. The patient's voice is hoarse. D. The patient is drowsy but arouses to name.

The answer is C. Patients who've had a parathyroidectomy are at risk for laryngeal nerve damage. Therefore, the nurse should monitor the patient for signs and symptoms of this which would include a hoarse voice, difficulty swallowing, or speaking. The nurse should intervene by notifying the physician.

The nurse is caring for a client with hyperparathyroidism. The nurse knows that the client is at risk for other comorbidities. The nurse is aware that which of the following is a high risk for this client? a. Gastritis b. Diabetes c. Coronary artery disease d. Crohn's disease

The answer is C. The client with hyperparathyroidism is at higher risk for coronary artery disease due to the increased calcium levels causing calcium deposit buildup in the blood, which may end up blocking off the main arteries supplying the heart.

A patient with hypoparathyroidism resulting from surgical treatment of hyperparathyroidism is preparing for discharge. What should the nurse teach the patient? a. milk and milk products should be increased in the diet b. parenteral replacement of parathyroid hormone will be required for life. c. calcium supplements with vitamin D can effectively maintain calcium balance d. bran and whole grain foods should be used to prevent GI effects of replacement therapy

The answer is C. The hypocalcemia that results from PTH deficiency is controlled with calcium and vitamin D supplementation and possibly oral phosphate binders. Replacement with PTH is not used because of antibody formation to PTH, the need for parenteral administration, and cost. Milk products, although good sources of calcium, also have high levels of phosphate, which reduce calcium absorption.

One of the most important frequently occurring complications of hyperparathyroidism is: a. peptic ulcer b. pancreatitis c. kidney stones d. pathological fractures

The answer is C. kidney stones

A nurse is assigned a client with the diagnosis of hypoparathyroidism. The nurse knows that which of the following would be expected in the client's test results? a. High PTH level b. Low phosphorus level c. High calcium level d. Low calcium level

The answer is D. The client with hypoparathyroidism has low calcium levels due to the lack of PTH.

This medication is used to treat hyperparathyroidism in patients with chronic renal failure. It works by mimicking the role of calcium in the blood and tricks the parathyroid gland into stop secreting PTH (parathyroid hormone). Which of the following medications does this describe below?* A. Calcitonin B. Fosamax C. Lasix D. Sensipar

The answer is D. The description in this question describes the action of Calcimimetics. Sensipar is the only Calcmimetic in this option.

A patient who recently had a calcium oxalate renal stone had a bone density study, which showed a decrease in her bone density. What endocrine problem could this patient have? a. SIADH b. hypothyroidism c. cushing syndrome d. hyperparathyroidism

The answer is D. The patient with hyperparathyroidism may have calcium nephrolithiasis, skeletal pain, decreased bone density, psychomotor retardation, or cardiac dysrhythmias among other manifestations.

A patient is diagnosed with hyperparathyroidism. Which of the following signs and symptoms would you NOT find in this patient? Select all that apply:* A. Calcium level 6 mg/dL B. Bone fracture C. Positive Trousseau's Sign D. Tingling and numbness of lips and fingers E. Calcium level of 15 mg/dL F. Phosphate level 1.2 G. Renal calculi

The answers are A, C, and D. This question wants to know what you will NOT see in hyperparathyroidism. So, you will need to select the options that won't happen. A patient with HYPERparathyroidism will NOT have a calcium level of 6 mg/dL (it will be high), positive Trousseau's sign (this happens in cases of LOW calcium) along with tingling/numbness of lips/fingers. Therefore, you can expect the patient to present with signs and symptoms of HYPERcalcemia. They will have a high calcium level and low phosphate level. A normal calcium level is 8.9 to 10 mg/dL and phosphate level is 2.7 to 4.5 mg/dL. Therefore, the patient would have possible bone fractures, calcium level greater than 10 mg/dL, hypophosphatemia, and possible renal calculi (kidney stone). All the other options are present in HYPOparathyroidism.

A patient has been diagnosed with hypoparathyroidism. What manifestations should the nurse expect to observe? Select all that apply a. skeletal pain b. dry, scaly skin c. personality changes d. abdominal cramping e. cardiac dysrhythmias f. muscle spasms and stiffness

The answers are: B, C, D, E, and F. In hypoparathyroidism the patient has inadequate circulating parathyroid hormone (PTH) that leads to hypocalcemia from the inability to maintain serum calcium levels. With hypocalcemia there is muscle stiffness and spasms, which can lead to cardiac dysrhythmias and abdominal cramps. There can also be personalty and visual changes and dry, scaly skin.

Hyperparathyroidism

excessive secretion of PTH by parathyroid glands (Hypercalcemia and Hypophosphatemia)

Hypoparathyroidism

low production of PTH (parathyroid hormone)