PARATHYROID HORMONES

The parathyroid glands are four tiny glands, located in the neck, that control the body's
calcium levels. Each gland is about the size of a grain of rice (weighs approximately 30
milligrams and is 3-4 millimeters in diameter) (Clark, Payne, Warrick et al 2017). The
parathyroids produce a hormone called parathyroid hormone (PTH) which is an antagonist to
calcitonin; it maintains normal blood levels of calcium and phosphate. According to Fan,
Hanai, (2017), besides bone, the target organs of parathyroid hormone are the small intestine
and kidneys. These small glands are easily overlooked and can be removed inadvertently
during thyroid surgery. Inadvertent surgical removal is the most common cause of
hypoparathyroidism PTH raises the blood calcium level by:

1. Breaking down the bone (where most of the body's calcium is stored) and causing calcium
release

2. Increasing the body's ability to absorb calcium from food

3. Increasing the kidney's ability to hold on to calcium that would otherwise be lost in the
urine.

PARATHYROID FUNCTION

Parathormone, the protein hormone from the parathyroid glands, regulates calcium and
phosphorus metabolism in which calcium and phosphorus is the chief material that gives
hardness and strength to your bone and teeth is also needed for muscle and nerve to function
properly. Phosphate is also needed for the production of energy within the body. Increased
secretion of parathormone results in increased calcium absorption from the kidney, intestine,
and bones, thereby raising the blood calcium level. Some actions of this hormone are
increased by the presence of vitamin D. Parathormone also tends to lower the blood
phosphorus level. Excess parathormone can result in markedly elevated levels of serum
calcium, a potentially life-threatening situation. When the product of serum calcium and
serum phosphorus (calcium × phosphorus) rises, calcium phosphate may precipitate in
various organs of the body and cause tissue calcification. The serum level of ionized calcium
regulates the output of parathormone. Increased serum calcium results in decreased
parathormone secretion, creating a negative feedback system.
TYPES OF DISORDERS OF THE PARATHYROID

1. Hyperparathyroidism
2. Hypoparathyroidism

HYPERPARATHYROIDISM

Hyperparathyroidism is where the parathyroid glands produce too much PTH(Parathyroid

hormone). This causes blood calcium levels to rise (hypercalcaemia) and blood phosphorus
levels to fall (hypophosphataemia).
PATHOPHYSIOLOGY

In primary hyperparathyroidism due to adenomas, the normal feedback on parathyroid

hormone production by extracellular calcium seems to be lost, resulting in a change in the set
point (Helme, Lulsegged, & Sinha, 2011).. However, this is not the case in primary
hyperparathyroidism from parathyroid hyperplasia. An increase in the cell numbers is
probably the cause. The chronic excessive reabsorption of calcium from bone caused by
excessive parathyroid hormone can result in osteopenia. In severe cases, this may result in
osteitis fibrosa cystica, which is characterized by subperiosteal resorption of the distal
phalanges, tapering of the distal clavicles, salt-and-pepper appearance of the skull, and brown
tumors of the long bones. This is not commonly seen now. In addition, the chronically
increased excretion of calcium in the urine can predispose to the formation of renal stones.

ETIOLOGY

There are two main types of hyperparathyroidism. They are:

Primary –when one or more of the parathyroid glands is enlarged or overactive, for reasons
explained below, and the abnormality causing it is within the gland itself

Secondary – when nothing is wrong with the gland, but there's a condition, such as kidney
failure or vitamin D deficiency, that lowers calcium; the body reacts by producing extra
parathyroid hormone to stop calcium levels from falling to a very low level

Hyperparathyroidism is usually the result of hyperplasia or a benign tumour of the

parathyroid glands, or it may be hereditary. Some cancers can also make a substance that
mimics parathyroid hormone and causes hypercalcemia. Secondary hyperparathyroidism
occurs when the parathyroid secrete excessive parathyroid hormone in response to low serum
calcium levels. Serum calcium may be reduced in kidney disease because of the kidney’s
failure to activate vitamin D, which is necessary for absorption of calcium in the small
intestine
CLINICAL MANIFESTATION

Hyperparathyroidism doesn't always cause symptoms. It's often diagnosed while having a
blood test for another unrelated problem. The patient may have no symptoms or may
experience signs and symptoms resulting from involvement of several body systems. Apathy,
fatigue, muscle weakness, nausea, vomiting, constipation, hypertension, and cardiac
dysrhythmias may occur; all are attributable to the increased concentration of calcium in the
blood. Psychological manifestations may vary from irritability and neurosis to psychoses
caused by the direct effect of calcium on the brain and nervous system. An increase in
calcium produces a decrease in the excitation potential of nerve and muscle tissue. The
formation of stones in one or both kidneys, related to the increased urinary excretion of
calcium and phosphorus, is one of the important complications of hyperparathyroidism and
occurs in 55% of patients with primary hyperparathyroidism.

Renal damage results from the precipitation of calcium phosphate in the renal pelvis and
parenchyma, resulting in renal calculi (kidney stones), obstruction, pyelonephritis, and renal
failure. Musculoskeletal symptoms accompanying hyperparathyroidism may result from
demineralization of the bones or bone tumours composed of benign giant cells resulting from
overgrowth of osteoclasts. The patient may develop skeletal pain and tenderness, especially
of the back and joints; pain on weight bearing; pathologic fractures; deformities; and
shortening of body stature. Bone loss attributable to hyperparathyroidism increases the risk
for fracture. The incidence of peptic ulcer and pancreatitis is increased with
hyperparathyroidism and may be responsible for many of the gastrointestinal symptoms that
occur.

When high calcium levels do cause symptoms, they can be mild or general and include:

 Depression
 Fatigue
 Feeling thirsty and passing a lot of urine
 Feeling sick and losing your appetite
 Muscle weakness
 Constipation
 Tummy pain
 Loss of concentration
 Mild confusion
  Left untreated, high blood levels of calcium can cause:
 Vomiting Muscle spasms
 Bone pain or tenderness
 Irregular heart beat
 High blood pressure
 Drowsiness
 Dehydration
 Confusion

Risk factor of hyperparathyroidism

Those that may be at an increased risk of primary hyperparathyroidism include:

 A woman who has gone through menopause

 Someone who has had prolonged, severe calcium or vitamin D deficiency
 Someone who has a rare, inherited disorder, such as multiple endocrine neoplasia,
type I, which usually affects multiple glands
 Someone who has had radiation treatment for cancer that has exposed your neck to
radiation
 Someone who has taken lithium, a drug most often used to treat bipolar disorder.

PREVENTION

Early and aggressive management of hypertension can help avoid chronic kidney disease and
the secondary hyperparathyroidism that frequently results. Likewise, diabetes requires
aggressive, optimal management to reduce complications. Weight management and proper
nutrition could help prevent the huge burden of type 2 diabetes and the resulting kidney
damage and secondary hyperparathyroidism.

Prevention of hyperparathyroidism in chronic renal failure requires aggressive phosphorus

management early in the progression of renal failure and adequate replacement of the active
form of vitamin D (1,25-dihydroxyvitamin D). Calcium levels can be managed in the dialysis
fluid of the patients requiring dialysis. Low-phosphorus diets and the use of phosphorus-
binding drugs that prevent enteral absorption can help limit hyperphosphataemia.
Phosphorus binders containing aluminium are avoided as they can be toxic to the skeleton

TEST AND DIAGNOSIS

Blood tests

If the result of a blood test indicates the person has elevated calcium in the blood, the doctor
will likely repeat the test to confirm the results after the person has not eaten for a period of
time (fasted).

A number of conditions can raise calcium levels, but the doctor can make a diagnosis of
hyperparathyroidism if blood tests show there is elevated parathyroid hormone.

Bone mineral density test (bone densitometry). The most common test to measure bone
mineral density is dual energy X-ray absorptiometry, or a DXA scan. This test uses special
X-ray devices to measure how many grams of calcium and other bone minerals are packed
into a segment of bone.

Urine tests. A 24-hour collection of urine can provide information on how well your kidneys
function and how much calcium is excreted in your urine.

This test may help in judging the severity of hyperparathyroidism or diagnosing a kidney
disorder causing hyperparathyroidism. If a very low level of calcium in the urine is found,
this may indicate a condition that doesn't require treatment.

Imaging tests of kidneys. The doctor may order X-rays or other imaging tests the abdomen to
determine if you have kidney stones or other kidney abnormalities

COMPLICATIONS OF HYPERPARATHYROIDISM

Complications of hyperparathyroidism are primarily related to the long-term effect of too

little calcium in your bones and too much calcium circulating in your bloodstream. Common
complications include:
Osteoporosis.: The loss of calcium often results weak, brittle bones that fracture easily
(osteoporosis).

Kidney stones: The excess of calcium in your blood may lead to excess calcium in your
urine, which can cause small, hard deposits of calcium and other substances to form in your
kidneys. A kidney stone usually causes significant pain as it passes through the urinary tract.

Cardiovascular disease: Although the exact cause- and-effect link is unclear, high calcium
levels are associated with cardiovascular conditions, such as high blood pressure
(hypertension) and certain types of heart disease.

Neonatal hypoparathyroidism: Severe, untreated hyperparathyroidism in pregnant women

may cause dangerously low levels of calcium

MEDICAL MANAGEMENT

The insidious onset and chronic nature of hyperparathyroidism and its diverse and commonly
vague symptoms may result in depression and frustration. The family may have considered
the patient’s illness to be psychosomatic. An awareness of the course of the disorder and an
understanding approach by the nurse may help the patient and family to deal with their
reactions and feelings. The recommended treatment of primary hyperparathyroidism is the
surgical removal of abnormal parathyroid tissue. In some patients without symptoms and
with only mildly elevated serum calcium levels and normal renal function, surgery may be
delayed and the patient followed closely for worsening of hypercalcemia, bone deterioration,
renal impairment, or the development of kidney stones.

HYDRATION THERAPY

The kidney involvement is possible patients with hyperparathyroidism are at risk for renal
calculi. Therefore, fluid intake of 2,000 mL or more is encouraged to help prevent calculus
formation. Cranberry juice is suggested because it may lower the urinary pH. It can be added
to juices and ginger ale for variety. The patient is instructed to report other manifestations of
renal calculi, such as abdominal pain and hematuria. Thiazide diuretics are avoided because
they decrease the renal excretion of calcium and further elevate serum calcium levels.
Because of the risk of hypercalcemic crisis, the patient is instructed to avoid dehydration and
to seek immediate health care if conditions that commonly produce dehydration (e.g.,
vomiting, diarrhoea) occur.

MOBILITY

Mobility of the patient, with walking or use of a rocking chair for those with limited mobility,
is encouraged as much as possible because bones subjected to normal stress give up less
calcium. Bed rest increases calcium excretion and the risk for renal calculi. Oral phosphates
lower the serum calcium level in some patients. Long term use is not recommended because
of the risk for ectopic calcium phosphate deposits in soft tissues.

DIET AND MEDICATIONS

Nutritional needs are met, but the patient is advised to avoid a diet with restricted or excess
calcium. If the patient has a coexisting peptic ulcer, prescribed antacids and protein feedings
are necessary. Because anorexia is common, efforts are made to improve the appetite. Prune
juice, stool softeners, and physical activity, along with increased fluid intake, help to offset
constipation, which is common postoperatively.

Preoperative and postoperative care is similar to that of the patient undergoing thyroid
surgery, with special attention paid to calcium and PTH levels. The patient will likely be on
calcium and vitamin D supplements following surgery. A new procedure, called minimally
invasive radio-guided parathyroidectomy, can be done under local anaesthesia through a
small incision.

NURSING MANAGEMENT

Nursing management is very important in the care of every patient. Nursing management of a
patient with hyperparathyroidism using nursing care plan approach.

Assess the patient for symptoms related to hypercalcaemia, including muscle weakness,
lethargy, bone pain, anorexia, nausea, vomiting, behavioural changes, and renal insufficiency.
Monitor serum calcium levels as ordered.
 NURSING DIAGNOSIS

 Activity Intolerance related to body weakness evidenced by patient’s inability to carry

out activities of daily living.
 Imbalanced Nutrition less than body requirement related to loss of appetite evidenced
by weight loss.
 Risk for injury (fracture, complication of hypercalcaemia) related to calcium
imbalance

NURSING CARE PLAN OF A PATIENT WITH HYPERPARATHYROIDISM

s/n NURSING OBJECTIVE IMPLEMENTATION SCIENTIFIC EVALUATION

DIAGNOSIS RATIONALE
1. Activity 1. Patient will 1.assess patient level of 1. Assessing Patient carried out
intolerance related be able to weakness patient level of activities of daily living
to fatigue carry out weakness will within 3 days of nursing
evidenced by activities of help in the intervention.
patient inability to daily living treatment
carry out activities within 3-4 planning.
of daily living days of nursing
intervention.
2. Give bed bath and 2.This will help
encourage patient to to improve
participate in self-care patient personal
as patient is carried hygiene and
along. improve passive
and active
exercise
 3. Encourage patient to 3.This will help
do recreational exercise in-patient
such as reading rehabilitation
newspaper, playing process
chess, ludo game, cards
and etc.
4. This will help
4. Serve meal and give
to allay pain
prescribed medication.
thereby aiding
healing process.

2. Imbalanced Patient’s 1. Check patient’s 1. This will help Patient’s appetite

nutrition less than appetite will weight weekly. to provide a improved throughout the
body requirement improve base line data period of hospitalization.
related to loss of throughout the
appetite period of 2.Give appetizers 2. This will help
evidenced by loss hospitalization. to stimulate
of weight. patient eating
habit
3. Serve attractive 3. This will help
adequate diet. to improve the
patient’s eating
appetite.

4.Give prescribed 4. This will help

medications .e.g in weight
multivitamins gaining process.

3. Risk for injury Patient will not 1.Assess level of risk 1. Assessing Patient showed no sign(s)
(fracture, show any signs for injury in patient. patient’s level of of injury throughout the
complications of of injury risk for injury period of hospitalisation.
hypercalcemia.)R throughout the helps in
elated to calcium period of precaution
imbalance. hospitalisation planning.

2.Place patient in a
2. Placing
comfortable position
patient in a
comfortable
position helps to
prevent injury

3.Use bed side rails

3. Using bed
side rails helps
to prevent fall.

4. Make patient
4. This helps to
environment tidy and
prevent the
safe from harmful
patient from any
objects
forms of injury.
HYPOPARATHYROIDISM

The most common cause of hypoparathyroidism is inadequate secretion of parathyroid

hormone after interruption of the blood supply or surgical removal of parathyroid gland tissue
during thyroidectomy, parathyroidectomy, or radical neck dissection. According to Levine,
Bilezikian, Clarke (2015), atrophy of the parathyroid glands of unknown cause is a less
common cause of hypoparathyroidism. Hypoparathyroidism means the parathyroid glands
produce too little PTH (Parathyroid hormone). This causes blood calcium levels to fall
(hypocalcaemia) and blood phosphorus levels to rise
(hyperphosphataemia).Hypoparathyroidism may be transient, congenital/genetically inherited
or acquired.

PATHOPHYSIOLOGY

The ionized calcium concentration in the extracellular fluid (ECF) remains nearly constant, at
a level of approximately 1mM. Ionized calcium in the ECF is in equilibrium with ionized
calcium in storage pools such as bone, proteins in the circulation, and within the intracellular
fluid. The intracellular fluid concentration of calcium is more than 10,000-fold lower than in
the ECF. The maintenance of ionized calcium concentrations in the intracellular and
extracellular fluids is highly regulated and modulates the functions of bone, renal tubular
cells, clotting factors, adhesion molecules, excitable tissues, and a myriad of intracellular
processes.

An extracellular calcium-sensing receptor has been isolated from parathyroid, kidney, and
brain cells. The extracellular calcium-sensing receptor is G protein coupled. Mutations in the
extracellular calcium-sensing receptor have been demonstrated to result in hypercalcemic or
hypocalcemic states. Normally, the extracellular calcium-sensing receptor is extremely
sensitive and responds to changes in the ECF calcium ion concentration as small as 2%.
ETIOLOGY

The most common causes of hypoparathyroidism are heredity and the accidental removal of
the parathyroid glands during thyroidectomy. In about 12% of people undergoing surgery it
lasts for only a short time, with less than 3% having permanent hypoparathyroidism. Because
of the proximity of the glands to the thyroid, it is sometimes difficult to avoid removing them.
Hypoparathyroidism also occurs following purposeful removal of the parathyroid glands for
hyperparathyroidism or cancer. Another cause is hypomagnesemia, which impairs secretion
of PTH. Hypomagnesemia can occur with chronic alcoholism or certain nutritional problems.

Other causes include:

Destruction of the parathyroid glands by the immune system in people with autoimmune
diseases, where the body mistakenly attacks its own tissues

Radiation therapy to the neck for thyroid cancer

CLINICAL MANIFESTATION

Hypercalcemia causes irritability of the neuromuscular system and contributes to the chief
symptom of hypoparathyroidism—tetany. Tetany is a general muscle hypertonia, with tremor
and spasmodic or uncoordinated contractions occurring with or without efforts to make
voluntary movements. Symptoms of latent tetany are numbness, tingling, and cramps in the
extremities, and the patient complains of stiffness in the hands and feet. In overt tetany,
thesigns include bronchospasm, laryngeal spasm, carpopedal spasm (flexion of the elbows
and wrists and extension of the carpophalangeal joints), dysphagia, photophobia, cardiac
dysrhythmias, and seizures. Other symptoms include anxiety, irritability, depression, and
even delirium. ECG changes and hypotension also may occur.

The symptoms of hypoparathyroidism vary depending on the cause, the speed at which the
condition develops and the effectiveness of treatment.

People who develop hypoparathyroidism quickly (for example, after neck surgery) can have
the following symptoms:

 A tingling sensation in the hands or feet or around the mouth (paraesthesia )

  Unusual muscle movements, such as jerking, twitching or muscle spasms
 Muscle cramps
 People with long-lasting (gradually developing) hypoparathyroidism caused by other
medical conditions can also have:
 Eye problems, particularly cataracts
 Dry, thick skin
 Coarse hair that breaks easily and can fall out
 Fingernails that break easily, with ridges that go from left to right.

Factors that may increase the risk of developing hypoparathyroidism:

 Recent neck surgery, particularly if the thyroid was involved

 A family history of hypoparathyroidism
 Having certain autoimmune or endocrine conditions, such as Addison's disease — a
condition characterized by a deficit in hormone production by the adrenal glands

PREVENTION

There are no specific actions you can take to prevent hypoparathyroidism. However, if you're
scheduled to have thyroid or neck surgery, talk to your surgeon for assurance that steps will
be taken to avoid damage to your parathyroid glands during the procedure.

If you've had surgery involving your thyroid or neck, be alert for signs and symptoms that
could indicate hypoparathyroidism, such as a tingling or burning sensation in your fingers,
toes or lips, or muscle twitching or cramping. When they occur, your doctor may recommend
prompt treatment with calcium and vitamin D to minimize the effects of the disorder.
COMPLICATIONS:

Tetany. These cramp-like spasms of the hands and fingers may be prolonged and painful.
Tetany may also include muscle discomfort and twitches or spasms of the muscles of the
face, throat or arms. When these spasms occur in the throat, they can interfere with
breathing, creating a potential emergency.

Paresthesias. These are characterized by sensory symptoms of odd, tingling sensations or

pins and needles feelings in the lips, tongue, fingers and feet.

 Loss of consciousness with convulsions (grandmal seizures).

 Malformation of the teeth, affecting dental enamel and roots.
 Impaired kidney function.
 Heart arrhythmias and fainting, even heart failure.
 Stunted growth (short stature)
 Slow mental development (or mental retardation) in children
 Calcium deposits in the brain, which can cause balance problems and seizures
 Cataracts

DIAGNOSTIC TESTS

A positive Trousseau’s sign or a positive Chvostek’s sign suggests latent tetany. Trousseau’s
sign is positive when carpopedal spasm is induced by occluding the blood flow to the arm for
3 minutes with a blood pressure cuff. Chvostek’s signis positive when a sharp tapping over
the facial nerve just in front of the parotid gland and anterior to the ear causes spasm or
twitching of the mouth, nose, and eye.The diagnosis of hypoparathyroidism often is difficult
because of the vague symptoms, such as aches and pains. Therefore, laboratory studies are
especially helpful. Tetany develops at serum calcium levels of 5 to 6 mg/dL(1.2 to 1.5
mmol/L) or lower. Serum phosphate levels are increased, and x-rays of bone show increased
density. Calcification is detected on x-rays of the subcutaneous or Para spinal basal ganglia of
the brain.
Medical history

The doctor who suspects hypoparathyroidism begins by taking a medical history and asking
about your symptoms, such as muscle cramps or tingling of your toes, fingers or lips. He or
she will want to know whether you've had recent surgeries, particularly operations involving
the thyroid gland or your neck.

Physical exam

The doctor will conduct a physical examination, looking for signs that suggest
hypoparathyroidism, such as facial muscle twitching.

Blood tests

Blood tests, and the following findings may indicate hypoparathyroidism:

A low blood-calcium level

A low parathyroid hormone level

A high blood-phosphorus level

A low blood-magnesium level

The doctor may also order a urine test to determine whether the body is excreting too much
calcium.

In diagnosing children, doctors check to see whether tooth development is normal and
whether they have met developmental milestones.

MEDICAL MANAGEMENT

The goal of therapy is to raise the serum calcium level to 9 to 10 mg/dL(2.2 to 2.5 mmol/L)
and to eliminate the symptoms of hypoparathyroidism and hypercalcemia. When
hypercalcemia and tetany occur after a thyroidectomy, the immediate treatment is to
administer calcium gluconate intravenously. If this does not decrease neuromuscular
irritability and seizure activity immediately, sedative agents such as pentobarbital may be
administered. Parenteral parathormone can be administered to treat acute hypoparathyroidism
with tetany. The high incidence of allergic reactions to injections of parathormone, however,
limits its use to acute episodes of hypercalcemia. The patient receiving parathormone is
monitored closely for allergic reactions and changes in serum calcium levels. Because of
neuromuscular irritability, the patient with hypercalcemia and tetany requires an environment
that is free of noise, drafts, bright lights, or sudden movement. Tracheostomy or mechanical
ventilation may become necessary, along with bronchodilating medications, if the patient
develops respiratory distress.

Therapy for the patient with chronic hypoparathyroidism is determined after serum calcium
levels are obtained. A diet high in calcium and low in phosphorus is prescribed. Although milk,
milk products, and egg yolk are high in calcium, they are restricted because they also contain
high levels of phosphorus. Spinach also is avoided because it contains oxalate, which would
form insoluble calcium substances. Oral tablets of calcium salts, such as calcium gluconate, may
be used to supplement the diet. Aluminium hydroxide gel or aluminium carbonate (Gelusil,
Amphojel) also is administered after meals to bind phosphate and promote its excretion through
the gastrointestinal tract. Variable dosages of a vitamin D preparation—dihydrotachysterol (AT
10 or Hytakerol), ergocalciferol (vitamin D), cholecalciferol (vitamin D)—are usually required
and enhance calcium absorption from the gastrointestinal tract. Thiazide diuretics may also be
used because they reduce the amount of calcium excreted in the urine. Magnesium is given if
hypomagnesemia is present.

NURSING MANAGEMENT

Nursing management of the patient with possible acute hypoparathyroidism includes the
following:

 Care of postoperative patients having thyroidectomy, parathyroidectomy, and radical

neck dissection is directed toward detecting early signs of hypercalcemia and
anticipating signs of tetany, seizures, and respiratory difficulties.
 Calcium gluconate is kept at the bedside, with equipment necessary for intravenous
administration. If the patient has a cardiac disorder, is subject to dysrhythmias, or is
receiving digitalis, calcium gluconate is administered slowly and cautiously.
 Calcium and digitalis increase systolic contraction and also potentiate each other; this
may produce potentially fatal dysrhythmias. Consequently, the cardiac patient
 requires continuous cardiac monitoring and careful assessment. An important aspect
of nursing care is teaching about medications and diet therapy. The patient needs to
know the reason for high calcium and low phosphate intake and the symptoms of
hypercalcemia and hypercalcemia.

ASSESSMENT/DATA COLLECTION

Assessment; past and present history are taken and head to toe general physical appearance
examination are done; checking the head for any coarseness of the hair, a tingling sensation
in the hand or feet or around the mouth (paraesthesia).especially hyperparathyroidism caused
by other medical conditions can also have eye problem, so check the eye particularly for
cataracts, and also assess for unusual muscle movements, such as jerking, twitching or
muscle spasm.

Assessment continues using Gordon’s typology of 11 functional health patterns

Health perception and health management: data collection is focused on the person’s
perceived level of health and well-being, and on practices for maintaining health

Nutrition and metabolism: assessment is also focused on the pattern of food and fluid
consumption relative to metabolic need. Problems related to fluid balance, tissue integrity,
and host defences may be identified

Elimination: data collection is also focused on excretory patterns (bowel, bladder, skin).
Excretory problem such as incontinence, urinary retention, constipation may be identified.

Activity and exercise: assessment is focused on the activities of daily living requiring energy
expenditure, the status of major body systems involved with activity and exercise is
evaluated.

Cognition and perception: assessment is focused on the ability to comprehend and use
information

Sleep and rest: assessment is focus on the person’s sleep, rest and relaxation process.

Self-perception and self-concept: assessment is focused on the person’s attitudes toward self,
including identity and sense of self- worth.
Roles relationship: assessment is focused on the person’s roles in the world and relationships
with others. Satisfaction with roles, role strain, or dysfunctional relationship may be further
evaluated

Sexuality and reproduction: assessment is focused on the person’s satisfaction or

dissatisfaction with sexuality patterns and reproductive functions. Concern with sexuality
may be identified.

Coping and stress tolerance: assessment is focused on the person’s perception of stress and on
his or her coping strategies are evaluated, and symptoms of stress are noted.

Values and belief: assessment is focused on the person’s values and belief (including spiritual
beliefs).

The patient at risk for hyperparathyroidism should be closely monitored for symptoms of
tetany. If you suspect tetany, check for Chvostek’s and Trousseau’s signs. Monitor
respirations closely for stridor, a sign of laryngospasm.

NURSING DIAGNOSIS

 Acute pain related to disease process as evidenced by patient’s verbalization.

 Anxiety related to unknown outcome of the illness as evidenced by patient asking too
many questions.
 Risk for injury related to tetany.

EXPECTED OUTCOME

The patient’s pain will be alleviated after 10-15 minutes of nursing intervention

The patient’s anxiety will be allayed; psychotherapy will be given and significant others will
be carried along

The patient will remain free from injury; signs of tetany will be recognized and treated
quickly.
PLANNING AND IMPLEMENTATION

 Make be and place patient in a comfortable position.

 Give psychotherapy and give health education to the patient and significant others
 Give prescribed analgesic to alleviate pain.
 Monitor for signs of tetany and report immediately to RN or physician so treatment
can be instituted quickly.
 Make sure a tracheostomy set, endotracheal tube, and intravenous calcium are
available for emergency use if laryngospasm occurs.
 Consult a dietitian for high-calcium diet teaching. The patient may need a lifelong
high-calcium diet.
 Teach the patient about the importance of diet and medication therapy, and follow-up
laboratory testing. The patient needs to understand self-care for follow-up at home.

EVALUATION

Patient’s pain was alleviated within 11 minutes of nursing intervention.

Patient’s anxiety was allayed throughout hospitalization.

Injury was prevented through early recognition and reporting of signs and symptoms of
tetany. The patient should be able to describe correct treatment and self-care measures for
home.
 NURSING CARE PLAN OF A PATIENT HYPOPARATHYROIDISM

s/n Nursing diagnosis Objective Implementation Scientific rationale evaluation

1. Acute pain related Patient’s pain will 1. Assess patient’s 1. Assessing patient’s Patient’s pain was
to disease process as be allayed within level of pain using level of pain will help the allayed within 12
evidenced by 10-20 minutes of a pain rating scale nurse know the minutes of
patient’s Nursing of 1-10. level/severity of pain. nursing
verbalization. intervention. intervention.
2. Make bed and
2. This will promote the
place patient in a
comfort of the patient.
comfortable
position.

3.Give 3. This will help in

psychotherapy and relaxing the patient and
nurse patient in a promote sleep/rest.
quiet environment.

4. Serve meal and

give prescribed 4. This will help to allay
analgesic. pain thereby aids healing
process.

2. Anxiety related to Patient’s anxiety 1. Create a good 1. This will help in Patient’s anxiety
unknown outcome will be allayed rapport with the gaining patient’s trust was allayed
of the illness as though out the patient. and listening ear. throughout the
evidenced by period of 2. This will help in period of
2.Give
patient asking too hospitalization. allaying patient’s anxiety hospitalization.
psychotherapy
many questions.

3. Give health 3. This will aid in giving

education on the the patient better

patient’s condition understanding about

his/her condition.
 4. This will help the
4. Get significant
patient feel better and the
others involved and
patient will know he/she
provide emotional
is not alone.
support.

5. This will help the

5 .Introduce patient patient know some

to the ward. people have been through

the same and they
became better with time.
3. Risk for injury Patient will be 1.Assess patient’s 1. This will help in Patient was free
related to tetany. free from injury level of risk for taking proper precautions from injury
throughout the injury in preventing injury. throughout the
period of period of
hospitalization. hospitalization.
2. Treat pressure 2. This will help in
areas and turn preventing pressure sore
patient often. from developing.

3. This helps to promote

3.Place patient in a
comfort and rest.
comfortable
position

4. Use bed side 4. This will help to

rails. prevent fall.

5. Tidy patient’s 5. This helps to prevent

environment and
the patient from any
keep it free from forms of injury.
slippery objects or
object that can
cause fall or injury.
 REFERENCES

Brunner & Suddarth’s. Textbook of Medical Surgical Nursing Tenth Edition

Famakinwa T.T. A Synopsis of Medical Surgical Nursing.

Linda S.W., & Paula D.H. Understanding Medical Surgical Nursing Third Edition

Medscape retieved from http://emedicine.medscape.com/article/122207-overview#a6

Mustapha R.O. Anatomy and Physiology in Health and Illness.

Nanda Nursing Intervention http://nanda-

nursinginterventions.blogspot.com.ng/2012/09/hyperparathyroidism-definition-etiology.html
retrieved Tuesday Septemb
HYPERTHYROIDISM

Hyperthyroidism is a common endocrine disorder. It is a form of thyrotoxicosis resulting

from an excessive synthesis and secretion of endogenous or exogenous thyroid hormones by
the thyroid (Bahn, Burch, Cooper, et al, 2011).

The most common causes are:

- Grave’s disease
- Toxic multinodular goiter
- Toxic adenoma
- Thyroiditis
- Excessive ingestion of thyroid hormone

Grave’s disease is the most common cause of hyperthyroidism. It is an autoimmune disorder

that results from an excessive output of thyroid hormones caused by abnormal stimulation of
the thyroid gland by circulating immunoglobulins. This disease affects women eight times
more frequently than men, with onset usually between the second and fourth decades
(Papadakis et al 2013)

CLINICAL MANIFESTATION

Patients exhibit a characteristic group of signs and symptoms. The presenting symptom is
often nervousness. These patients are often emotionally hyperexcitable irritable and
apprehensive, they cannot sit quietly, the suffer from palpitations and their pulse is
abnormally rapid at rest as well as on exertion. They tolerate heat poorly.

A fine tremor of hands may be observed. Patients may exhibit opthalmopathy such as
exopthalmos (abnormal protrusion of one or both eyeballs) which produces a startled facial
expression.

Other manifestations include increased appetite, increased dietary intake, weight loss,
fatigability and weakness, amenorrhea, changes in bowel function. Atrial fibrillation occurs
in 15% of in older adult patients with new onset hyperthyroidism (Porth and Matfin, 2009).

The course of the disease may be mild, characterized by remissions and exacerbations and
terminate with spontaneous recovery in a few months of years. It may also progress
relentlessly, with the untreated person becoming emaciated, intensely nervous, delirious and
even disorcented, eventually the heart fails.
Symptoms of hyperthyroidism may occur with the release of excessive amounts of thyroid
hormone as a result of inflammation after irradiation of the thyroid or destruction of thyroid
tissue by tumor. Long standing use of thyroid hormone (in the treatment of hypothyroidism)
in the absence of close monitoring may be a cause of hyperthyroidism.

Assessment and diagnostic findings

The thyroid gland invariably is enlarged to some extent. It is soft and may pulsate, a thrill can
often be palpated and a bruit is heard over the thyroid arteries (Hogan-Quigley et al., 2012).
These are signs of greatly increased blood flow through the thyroid gland. In advanced cases,
the diagnosis is made on the basis of the symptoms, a decrease in serum ISH, increased free
T4 and an increase in radioactive iodine uptake

MEDICAL MANAGEMENT

Appropriate treatment depends on the underlying cause and often consists of a combination
of therapies, including antithyroid agents, radioactive iodine and surgery. Treatment of
hyperthyroidism is directed toward reducing thyroid hyperactivity to relieve symptoms and
preventing complications.

The 3 treatments RADIOACTIVE IODINE THERAPY, ANTI-THYROID MEDICATIONS

AND SURGERY) share the same complications relapse or recurrent hypertheroidism and
permanent hypothyroidism

Pharmacologic Therapy

2 forms of pharmacotherapy are available for treating hyperthyroidism and controlling

excessive thyroid activity:

 Antithyroid medications that interfere with the synthesis of thyroid hormones and
other agents that control manifestation of hyperthyroidism

Surgical Management

Surgery to remove thyroid tissue was once the main method of treating hyperthyroidism.
Today, surgery is reserved for special circumstances eg in pregnant women who are allergic
to antithyroid medications. Surgery for treatment of hyperthyroidism is performed soon after
they thyroid function has returned to normal (4-6 weeks)
NURSING PROCESS

The Patient with Hyperthyroidism

ASSESSMENT

The health history and examination focuse on symptoms related to accelerated or exaggerated
metabolism. These include the patient’s and family’s reports of irritability and increased
emotional reaction and the impact that these changes have had on the patient’s interactions
with family, friends and co-workers. The history includes other stressors and the patient’s
ability to cope with stress.

The nurse initially and periodically assesses the patient’s nutritional status and the presence
of symptoms related to the hypermetabolic state (which may affect the cardiovascular system
including heart rate and rhythm, blood pressure, heart sounds and peripheral palses).

Emotional changes are associated with hy0erthyroidism, the patient’s emotional state and
psychological status are evaluated as well as symptoms of irritability, anxiety, sleep
disturbances, lethargy etc.

DIAGNOSIS

 Imbalanced nutrition: less than body requirements related to exaggerated metabolic

rate
 Situational low self-esteem related to changes in appearance and excessive appetite
 Risk for imbalanced body temperature

PLANNING AND GOALS

The goals may be improved nutritional status, improved self-esteem, maintenance of normal
body temperature.

NURSING INTERVENTIONS

Improving Nutritional status: Hyperthyroidism affects all body systems including GI system.
The appetite is increased but may be satisfied by several well-balanced meals of small size,
even up to 6 meals a day. Foods and fluids are selected to replace fluid lost through diarrhea
and the control the that results from increased peristudis. Rapid movement of food through
the GIS may result in nutritional imbalance and weight lost.
High-Calorie, high protein foods and encouraged: To reduce diarrhea, stimulants like coffee,
alcohol, tea, cola and discouraged.

Nurses’ role: Weight and dietary intake are recorded to monitor nutritional status.

Enhancing Coping Measures: The patient needs reassurance that the emotional reactions
being experienced are as a result of the disorder and that with effective treatment the
symptoms will be controlled.

Nurses role: The nurse encourages relaxing activities that will not overestimate the patient. It
is important to balance periods of activity with rest.

3. Improving Self-Esteem: The patient is likely to experience changes in appearance,

appetite and weight. These factors along with the patient is inability to cope well with family
and the illness may result in loss of self esteem.

Nurses role: The nurse conveys an understanding of the patient’s concern about these
problems and promotes the use of effective coping strategies. The nurse should inform
caregivers and family to avoid commenting on the patient’s large dietary intake

4. Maintaining Normal Body temperature: The patient with hyperthyroidism usually finds
a normal room temperature too warm because of an exaggerated metabolic rate and
increased heat production.

Nurses Role: Cool baths and cool/cold fluids may be provided. Bedding and clothing should
be changed as needed.

Monitoring and Managing Potential Complications:

To nurse’s role include:

 Close monitoring of patient for signs and symptoms indicative of thyroid storm.
 Cardiac & respiratory functions are assessed by measuring vital signs and cardiac
output; electrocardiographic (ECG) monitoring, arterial blood gases and pulse
oximetry.
 IV fluids may be necessary to maintain blood glucose levels and replace lost fluid
EVALUATION

Expected patient outcomes may include:

1. Improved nutritional status

- Reports adequate dietary intake and decreased hunger
- Avoids the use of alcohol and other stimulants
- Reports decreased episodes of diarrhea
2. Demonstrates effective coping methods in Dealing with family, friends, co-workers
- Explains reasons for irritability
- Avoids stressful vents and people
- Participates in relaxing non-stressful activities
3. Achieves increased self esteem
- Describes feelings of loss of control
- Verbalizes feelings about self and illness
4. Absence of complications
- Serum thyroid hormone and TSH levels within normal limits
- Vital signs, pulse oximetry within normal limits
- Status importance of regular follow-up

NURSING CARE PLAN FOR A PATIENT WITH HYPERTHYROIDISM

S/N Date/Time Nursing Nursing Nursing Order Scientific Evaluation

Diagnosis Objectives rationale

1 Imbalanced Patient’s - Check/measure - To check if Patient

nutrition: weight will patient’s patient’s showed
less than increase or be weight weight gain improve
body maintained regularly and or loss nutritional
requirements without record on - To provide status and
related to excess fluid appropriate the nutrients reported
exaggerated gain chart the patient decreased
metabolic throughout the - Provide foods needs for episodes of
rate. period of and fluids with body diarrhea
hospitalization high-calorie metabolic
and high- processes.
 protein content - To reduce
- Advice patience fluid lost by
on abstinence diarrhea
from stimulants
like alcohol and
coffee to
diarrhea
2 Situational Patient will - Establish good - To provide Patient
low self- verbalize nurse-patient answers to verbalized
esteem improved relationship any an
related to feelings about - Encourage concerns improvement
changes in self and illness patient to and alleviate in feelings
appearance during the express any anxiety about self
and period negative about and illness
excessive hospitalization feelings about disease
appetite illness and self. condition
- Encourage - To provide
patant to share support for
concerns with the patient
family from love
members and ones in the
spouse hospital and
post
hospitalizati
on

NURSING PROCESS – The Patient With Pneumonia

Assessment

Nursing assessment is critical in detecting pneumonia. Fever, chills, or night sweat in a

patient who also has respiratory symptoms should alert the nurse to the possibility of bacterial
pneumonia.
Respiratory assessment further identifies the clinical manifestations of pneumonia: Pleuritic –
type pain, fatigue, tachypnea, use of accessory muscles for breathing, bradycardia or relative
bradychardia, coughing and purulent sputum.

The nurse monitors the patient for the following: Changes in temperature and pulse, amount,
odor and color of secretions, frequency and severity of cough, degree of tachypnea or
shortness of breath, changes in physical assessment findings (primarily assessed by
inspecting and auscultating the chest) and changed in chest x-ray findings.

DIAGNOSIS

Based on the assessment data, major nursing diagnosis may include the following:

- Infective airway clearance related to copious tracheobronchial secretions

- Fatigue and activity intolerance related to impaired respiratory function
- Risk for deficient fluid volume related to fever and a rapid respiratory ate
- Imbalanced nutrition: Less than body requirements
- Deficient knowledge about the treatment regimen and preventive measure.

PLANNING AND GOALS (NURSE’S ROLES)

1. Improving Airway Patency

Removing secretions is important because retained secretions interfere with gas exchange and
may slow recovery. The nurse must encourage hydration (2-3L/day) because, adequate
hydration thins and loosens pulmonary secretions. Humidification may be used to loosen
secretions and improve ventilation. A high humidity faamask delivers warm, humidified air
to the tracheobronchial tree, helps liquidify secretions and relieves tracheobronchial irritation.

To improve airway patency, the nurse encourages the patient to perform an effective, direct
cough which includes correct positioning, a deep inspiratory maneuver, etc.

In some cases, the nurse may assist the patient by placing both hands on the lower rib cage
(either anterior or posterior) to focus the patient on a slow deep breath and then manually
assisting the patient by applying constant, external pressure during the expeiratory phase.

The nurse also administers oxygen therapy as prescribed. The effectiveness of oxygen
therapy is monitored by improvement in clinical signs and symptoms, patient comfort and
inadequate oxygenation values as measured by pulse oximetry.
2. Promoting Rest

The nurse encourages the debilitated patient to rest and avoid overexertion and possible
exacerbation of symptoms. The patient should assume a comfortable position to promote rest
and breathing (eg Semi-Fowler’s position) and should change positions frequently to enhance
secretion clearance and pulmonary ventilation and perfusion.

3. Promoting fluid intake: The respiratory ate of patients with pneumonia increases
because of the increased workload imposed by labored breathing and fever. An increase
respiratory ate leads to an increase in insensible fluid loss during exhalation and can lead to
dehydration. Therefore, unless contraindicated, increased fluid intake (at least 2l/day) is
encouraged. Hydration must be achieved more slowly and carefully in patients with pre
existing such as heart failure
4. Maintaining Nutrition: Many patients with shortness of breath and fatigue have a
decreased appetite. Fluids with electrolytes (Commercially available drinks) man help
provide fluid, calories and electrolytes. In addition, IV fluids and nutrients may
beadministered.
5. Promoting Patients’ knowledge: The patient and family are instructed about the
cause of pneumonia, management of symptoms need for follow-up. The patient must be
given explanations in simple and terms to aid understanding and also on the importance of
management strategies and adherence to them during and after hospitals stay.

EVALUATION

Expected patient outcomes may include the following:

1. Demonstrates improved airway patency as evidenced by adequate oxygenation by

pulse oximetry
2. Rests and conserves energy by limiting activities and remaining in bed while
symptomatic
3. Maintains adequate hydration as evidenced by an adequate fluid intake and urine
output and normal skin turgor
4. Verbalizes increased knowledge about management strategies
5. Complies with management strategies
6. Consumes adequate dietary intake as evidenced by maintenance or increase in body
weight without excess fluid gain.
References
(2017). Retrieved 7 March 2017, from Medscape retieved from
http://emedicine.medscape.com/article/122207-overview#a6
Brunner, O., Conze, W., & Koselleck, R. (2004). Geschichtliche
Grundbegriffe (10th ed.). Stuttgart: Klett-Cotta.