A 60-year-old woman, church secretary, is diagnosed with primary hyperparathyroidism. Three years ago she started having the following symptoms; two episodes of kidney stones, a fractured wrist and a fractured ankle, and reports of feeling weak when she is walking. Treatment at the time consisted of hydration and diuretics. She has been doing well until now. Ms. Thompson presents to the endocrinologist’s office with a serum calcium was 12. 4 mg/dL and the urine calcium is elevated. Today she is being evaluated for a parathyroidectomy.
Hyperparathyroidism having too much parathyroid hormone in the bloodstream due to over excretion of the body’s parathyroid glands located in the neck. The parathyroid glands secrete parathyroid hormone, which helps maintain a correct balance of calcium in the bloodstream and in tissues tha depend on calcium for proper functioning. There are two types of hyperparathyroidism, primary and secondary. In primary hyperparathyroidism, an enlargement of one or more of the parathyroid glands causes excessive secretion of the hormone PTH, causing high levels of calcium in the blood, hypercalcemia, which can cause a wide range of health problems.
Surgery is the most common treatment for primary hyperparathyroidism by taking out the parathyroid gland, parathyroidectomy. Secondary hyperparathyroidism occurs as a result of another disease that initially causes low levels of calcium in the body and over time, which leads to over secretion of the parathyroid hormone levels to occur. Neither of which are generally causes by genetic disposition (Timby, pg845). Hyperparathyroidism is caused by bodily issues that increase the production of parathyroid hormone.
The parathyroid glands are responsible for maintaining levels of both calcium and phosphorus in your body by increasing or decreasing the secretion of parathyroid hormone as needed. The body loves to maintain homeostasis, so, for the most part; the body balances the levels out well. When calcium levels in your blood fall too low, your parathyroid glands increase the secretion of PTH to rebalance the levels. PTH raises calcium levels by drawing calcium from your bones and increasing the amount of calcium absorbed from your small intestine.
When blood calcium levels are too high, the parathyroid glands decreased the secretion of PTH. However, one or more of these glands can produce too much hormone causing unusually high levels of calcium and low levels of phosphorus in your blood. Calcium aids in the communication of signals in nerve cells, and it is involved in muscle contraction, with the aide of another mineral, phosphorus (Stalberg, 2007). . Expected Psychobiological Findings Hyperparathyroidism is usually detected before signs or symptoms of the disorder become more obvious to the patient.
When symptoms do occur, they are the outcome of in other organs or tissues that are having issues because sickness or disease causing malfunction due to high calcium levels in the blood and urine or too little calcium in bones. Symptoms can be so minute that a person may not think twice about them, or they may be severe and obstruct a person’s day-to-day living The signs and symptoms can range from; brittle bones, excessive urination, abdominal pain, depression or forgetfulness, bone and joint pain, and nausea and vomiting.
A patient with hyperparathyroidism may present with loss or decrease in muscle tone, weakness, and fatigue, due to increased calcium in the blood, which depresses the responsiveness of the peripheral nerves. The patient may have skeletal pain and tenderness with any weight baring activity, the bones may also break easily (little to no trauma) from becoming so demineralized from the calcium not staying in the bones and being pulled into the blood stream. Also, with the increase of phosphorus and calcium in the blood, passing through the kidneys, the patients are likely to develop stones in the urinary ract, pyelonephritis, and uremia (Timby 2014, p. 845).
As said in the case study, this patient is already had past fractures of her wrist and ankle, kidney stones, and pain with weight baring activity as simple as walking. Her signs are more obvious and symptoms she cannot ignore. Treatment After diagnosis have been made by testing calcium and phosphate levels, which will be elevated, a 24 urine calcium test will show increased urine calcium levels, a skeletal radiograph showing calcium loss from bones, and possibly an MRI showing a parathyroid adenoma (tumor or growth), the treatment will more then likely be a parathyroidectomy.
If the hyperparathyroidism is secondary to a deficiency, the treatment is to correct cause of vitamin D deficiency with sodium and phosphate supplements (Timby 2014, p. 845). In the case study, this patient’s treatment consists of diuretics and hydration, which are not the appropriate medications for her condition. The diuretic can cause her to become severely dehydrated, and also cause her to pull even more calcium from her bones as she already has an elevated urine calcium level.
A person can have anywhere from one to 10 parathyroid glands, four is typical. The preoperative step is finding out how many parathyroid glands the patient has and how many of those need to be removed due to the adenoma. The surgeon will always try to leave at least one of the parathyroid glands or some of the tissue, if it is still viable, to function normally in the future. The nursing preoperative care would include a full assessment for a baseline and reassessment postop, and listening to the patient and giving psychological support (Walker, 2016).
Nursing Considerations Postoperatively the major nursing considerations are maintaining fluid balance, pain control, wound care, and reassessing the patient head to toe. Pain control assessments are necessary to keep the patients pain under control while also monitoring for respiratory depression. Wound care is not only to help the healing process and prevent infection, but also an important time to talk to the patient about how they feel, showing empathy and support. The scar on their neck can alter their self-image and how they feel.
The surgery can result in damage to the laryngeal nerve and paralysis of vocal cords, causing there to be a definite need of psychological care (Parathyroid Surgery Basics, 2016). The priority nursing diagnosis for this patient is risk for hypocalcemia related to removal of the parathyroid gland. The nurse needs to observe for hypocalcemia, signs including tetany (muscle spasm), positive Trousseau’s sign (using a blood pressure cuff, waiting 3 minutes, and the hand will spasm), and Chvostek’s sign (tapping the facial nerve and the patient will smile and jaw may lock) (Parathyroid Surgery Basics, 2016).
The short term goals for this patient will be to keep the head elevated, even after going home, to decrease swelling, and the patient should have a tracheostomy kit at the bed side. The patient should avoid straining (with a bowel movement or lifting), and maintain follow up appointments for long term monitoring of calcium levels. These lead to the long-term goals of proper healing with out infection and swelling of the throat during the two week period before the stitches are removed. With the priority diagnosis in mind, the priority long term goal would be to maintain calcium levels, measured at follow up appointments, long term.
Outlook on Life Hyperparathyroidism can put a downward spiral on a patient’s outlook on life in many ways. This patient in particular is a church secretary; this means a lot of busy work. With her weakened skeletal system she has already endured two fractures, one of the wrist, and the other of the ankle. It is hard to go and do any sort of activities, even work, if they are constantly afraid they will fracture of break another bone. In addition to her skeletal pain, she has also been having issues with kidney stones.
Not only do these inflict pain, but also constant need to urinate even if she doesn’t have to go. This can also add to frustration in daily living activities if she feels the need to stay close to the bathroom all the time she will not want to participate in activities outside her home, and possibly not even her work. All of there combined can cause a patient to be depressed, withdrawn, and all around sad. Cultural Considerations and Socioeconomic Status The main thing with any cultural considerations and health care is the cost.
There is the cost of the surgery, medications, and care after the surgery during the healing process. Though this case study does not mention her particular religion or ethnicity that can also play a factor in what a patient may decide with their healthcare plan of action. This patient being a church secretary, just a guess, probably does not have the best income and may not have health coverage. These costs can add up quickly when the surgery, hospital stay, and postoperative medications are considered.
She may need extra medications such as stool softeners to help her from straining, nausea medications, etc, that are not free, and are quite expensive without medical coverage. The best route to take with this patient would to get her in contact with the correct hospital employees, such as HR and Billing to help her know her options and if she qualifies for any additional help with consideration to her age and economic status. Conclusion Hypothyroidism is an endocrine disorder that manifests in numerous body systems due to an increased amount of calcium in the blood stream.
The patient in the case study was properly diagnosed; however, she was not prescribed the correct medication of a diuretic. Most cases are treated surgically by removing the adenoma by parathyroidectomy in primary hyperparathyroidism, or by correcting the cause in secondary with sodium and phosphate supplements. This patient with Hyperparathyroidism can most certainly have an altered outlook on life and have problems due to socioeconomic standing that should be discussed with her.
