Parathyroid Gland

Hyperparathyroidism

Hyoparathyroidism

Overivew the parathyroid glands

• Is located in the neck in the posterior aspect of the thyroid gland• Secretes parathormone, regulates calcium & phosphorus metabolism• Increased parathormone: increased absorption of calcium from kidney,

intestine, bones---increased serum calcium level• Its action increases by the presence of Vitamin D• Tends to decrease phosphorus blood level• Ca ions regulate the hormone; as serum Ca increases secretion of

parathormone decreases• Excess parathormone— increased Calcium; a life-threatening condition• When Ca & phosphorus serum level increases—calcium phosphate

precipitate in various organs—tissue calcification

Hyperparathyroidism

• Is characterized by bone decalcification & renal calculi• Primary occurs in women more than men; in 50% no symptoms • Secondary occurs in chronic renal failure called renal rickets; as a result

of phosphorus retention, increased stimulation of parathyroid gland Manifestations: signs-related to increased serum calcium involve several

body systems:• Apathy, fatigue, muscle weakness, nausea/vomiting, constipation,

hypertension, dysrhythmias; all are related to increased blood Ca• Psychological changes: irritability—neurosis—psychosis; as a result of

direct effect of Ca on brain; increased Ca ions—decreased excitation • Kidney stones• Musculoskeletal symptoms; demineralization: skeletal pain in the back,

joint pain on weight bearing; pathological fracture; deformities

Medical management

• Diagnosis: elevated Ca & parathormone in blood plus other tests Parathyroidectomy Surgery may be delayed for asymptomatic patients with mildly elevated

Ca Hydration therapy : because of kidney involvement• Fluid intake of 2 liters is encouraged;• Cranberry juice is recommended to reduce urinary pH• Thiazide diuretics are avoided –they decrease renal excretion of Ca• Avoid dehydration; seek help for vomiting, diarrhea

Medical management

Mobility is encouraged; walking Stressed bone release less Ca Bed rest increases Ca excretion and risk of renal calculi Oral phosphates lower Ca but long-term use is not recommended ,

because of formation of calcium-phosphate complex Diet & medication: Meet the nutritional needs avoid diet with restricted or excess Ca In peptic ulcer give antacids; protein to offset anorexia Management of constipation Improve appetite Prune juice, stool softeners, physical activity, fluid intake to offset

constipation

Nursing management

• Help patients and families deal with their feelings; to understand the psychological changes

• Promote adherence to medical management: hydration, diet, mobility• Monitor for signs of tetany , a post operative complication of

parathyroidectomy• Read self-care check list CHART 42-9 P. 1274.

Hypercalcemic crisis: a life-threatening situation due to extreme elevation of serum Ca; 15mg/dL, 3.7 mmol/L

• Including neurologic, cardiovascular, renal changes• Management: IV hydration, diuretics, phosphate therapy• Calcitonin or dialysis may be used in emergency situation

Hypoparathyroidism

• The cause: Inadequate secretion of parathormone due to surgery

• Less common cause: atrophy of the gland

• Parathormone deficiency—increased serum phosphate

• Absence of parathormone, there is Hypocalcemia & hyperphosphatemia Decreased absorption of intestinal Ca Decreased resorption of Ca from bones and renal tubules

Hypoparathyroidismdiagnosis

Clinical manifestations• Irritability of the neuromuscular system• Tetany: a general muscle hypertonia, with tremor & spasmodic or

uncoordinated contractions• Latent tetany: numbness, tingling & cramps in the extremities, stiffness

in hands & feet • Overt tetany: bronchospasm, laryngeal & carpopedal spasm, dysphagia,

dysrhythmias; hypotension Positive Trousseau’s sign; positive chvostek’s sign Blood tests: Ca level is 5-6 mg/dl--tetany; elevated phosphate level• X-ray: increased bone density

Medical management

Iv calcium gluconate• If irritability & seizures do not decrease immediately—sedative agents,

pentobarbital may be given• Parenteral parathormone for hypoparathyroidism with tetany—monitor

for allergic reaction & serum Ca Quiet environment: no noise, bright light, sudden movement• In respiratory distress: tracheostomy, mechanical ventilation,

bronchodilators Diet: high in Ca low in phosphorus Avoid milk products, egg yolk, spinach, although high in Ca• Oral Ca gluconate may be given as supplements• Aluminum hydroxide gel to bind with phosphorus; given after meals• Vit D to enhance absorption of intestinal Ca

Nursing management

• Focuses on

Close monitoring of signs of hypocalcemia, tetany; post thyroidectomy

Keep Ca gluconate and IV equipment at bed side; In case of cardiac disorder, or digitalis; the drug should be given slowly with cautious

Ca & digitalis increase systolic contraction—fatal dysrhythmias;

Cardiac patients require close monitoring

Adrenal glandoverview

• 2 adrenal glands, each attaches to upper portion of each kidney• Adrenal cortex secretes steroid; adrenal medulla, at the center, secretes

catecholamines• Hypothalams—pituitary—adrenal axis regulates hormone secretion Adrenal medulla—catecholaminses• Regulate metabolic pathway• Prepare for fight-or-flight response Adrenal cortex—• Glucocorticoids—glucose elevation; inhibit inflammatory response• Mineralocorticoids—aldosterone—promote reabsorption of Na• Androgen: sex hormone—male gender

Pheochromocytoma

Benign tumor in the adrenal gland, medulla; Cause cured hypertension• Symptoms depend on proportion of epinephrine & norepinephrine• The typical triad of symptoms is headache, diaphoresis, palpitations• Hypertension & cardiovascular disturbances are common Diagnoses: signs of SNS over-activity + elevation Bp• Associated with five Hs: hypertension, headache, hyperhidrosis,

hypermetabolism, hyperglycemia• Blood tests: catecholamine & metanephrine, a metabolite of

Cateholamines

Medical management

Management: may need ICU; bed rest—head of the bed elevated• Drug therapy: adrenergic blocking agents—phentolamine, muscle

relaxant—nitroprusside,• Phenoxybenzamine, alpha blocking agent, to maintain normal Bp; to

prepare for surgery• Calcium channel blocker, Procardin, to prevent cardiac complications• Surgical management: adrenalectomy Pre-operative Maintain normal Bp; Maintain well-hydration Manipulation of adrenal gland—release of catecholaminse—increased

Bp---nitroprusside during or after surgery Postoperative: corticosteriods replacement; hypotension, hypoglycemia

Addison’s disease

• Adrenocortical insufficiency Causes: autoimmune; surgical removal; infection-tuberculosis; sudden

cessation of exogenous corticosteroids Clinical manifestations:• Muscle weakness, anorexia, fatigue, dark pigmentation of mucous

membrane & skin; hypotension, low blood glucose;• Mental changes: depression, apathy, confusion• Sodium depletion & severe dehydration• Mental status changes: apathy, confusion Addison’s crisis: cyanosis & circulatory shock; with• Nausea, headache, abdominal pain, confusion & restlessness• Even overexertion; exposure to cold, infection, decreased salt intake.

Lead to circulatory collapse

Medical management

Diagnosis: serum cortisol and ACTH; hypoglycemia, hyponatremia; hyperkalemia

Management of collapse: IV cortisone & 5% glucose / saline Vasopressin if hypotension persists• reccumbent position with leg elevated; Antibiotics may be needed• Assess for other stressors; increases cortisone dose• Oral fluid once tolerated / decrease IV fluids gradually• Lifelong replacement of corticosteroids & mineralocorticoids may be

needed• Added salt with GI losses

Nursing management

• Assessing the patient: focus on symptoms of fluid imbalances; Bp with position changes; Changes in weight, muscle weakness, fatigue; any illness and stress• Managing Addison’s crisis Assess S&S of collapse Avoid physical & psychological stressors : cold exposure, overexertion,

infection, emotional stress Prepare for IV fluid, electrolytes• Restoring fluid balance Diet & fluid to maintain fluid & electrolyte Add salt in GI disturbances, and in hot weather

Nursing management

Written instructions about hormonal replacement and modifications based on changes; as prescribed

Mineralocorticoid--Florinef; corticosteroids—prednisone• Improving activity tolerance Avoid unnecessary activity Detect signs of infection or other stressors• Teaching self—care Explicit information about lifelong replacement; proper dosage;

modification during stressors; Modification of fluid intake Inform other healthcare provider about using cortisone—bracelet Instruct about S&S of excessive—edema & Wt gain or inadequate

replacement—hypotension & Wt loss:

Cushing’s syndrome

• Results from Adrenocortical activity• Cause:• Corticosteroid medication; adrenal hyperplasia• Secondary to tumor of pituitary gland • Symptoms are related to overproduction of corticosteroids; androgen Arrest of growth, obesity, musculoskeletal changes Glucose intolerance; hyperglycemia Central obesity with a fatty, buffalo hump, heavy trunk with thin

extremities, weakness & lassitude Sleep disturbances; fragile skin—ecchymosis Protein catabolism—muscle weakness, osteoporosis, kyphosis Moon faced oiliness and acne

Cushing’s syndrome

• excessive adrenocortical activity• Central-type obesity; buffalo hump• Skin is thin, fragile, ecchymosis• Moon faced; glucose intolerance In women Virilization: appearance of masculine traits—hirsutism; breast

atrophy, menses cease• Mood & mental changes; psychosis; Distress & depression• Visual disturbances in pituitary tumor• Diagnosis Overnight dexamethasone suppression test Increased serum sodium and blood glucose Blood & urinary cortisol 24-hour urinary free cortisol level Read chart 42-12;P. 1282.

Cushing’s syndrome Medical management

In pituitary tumor• Surgical removal—transsphenoidal hypophysectomy Adrenal insufficiency may appear 12-48 hours postoperatively Replacement of hyrdocortisone for several months Life long replacement in bilateral adrenalectomy Radiation therapy Adrenalectomy in primary adrenal hypertrohpy If caused by corticosteroid medication reduce dosage to minimum

Nursing diagnoses

• Risk for injury related to weakness• Risk for infection related to altered protein metabolism and

inflammatory process• Self-care deficit• Impaired skin integrity• Disturbed body image• Disturbed thought process

Nursing actions

• Decreasing risk of injury Protective environment to prevent fall & fracture Assistance in activities Diet recommended: high in protein, calcium, Vit D to minimize muscle

wasting• Decreasing risk of infection Avoid unnecessary exposure to those with infection Assess for subtle changes of infection—anti-inflammatory effect of

corticosteroids may mask signs of inflammation & infection

Nursing actions

• Preparing for surgery, adrenaloectomy Insulin and medications for ulcer are initiated if needed Monitor glucose level before and after surgery Monitor stool for blood Consider other symptoms—obesity—instruction for breathing exercise

• Encouraging rest & activity Encourage moderate activity Help patients to plan & space rest periods Promote relaxing, quiet environment for rest & sleep

Nursing action

• Promoting skin integrity• Meticulous skin care to prevent traumatizing the fragile skin• Avoid adhesive tape• Assist patients to change position• Assess skin & bony prominences

• Improving body image Assure that most of physical symptoms disappear in time Manage weight gain & edema--low CHOs, low salt diet; high

protein diet may reduce some of symptoms

Nursing actions

Improving thought process• Explain about causes of psychological instability—help coping with

mood swings• Report psychotic behaviors• Encourage verbalization of feelings

• Monitoring & managing potential complications Addisonian crisis Adverse effects of adrenocortical activity: assess fluid & electrolyte

status; blood glucose monitoring Teaching patient self-care: READ CHART 42-13, P. 1284 AND THE ENTIRE

NURSNG CARE PLAN , P. 1282-1284.

CORTICSTEROIDS THERAPY

• ARE USED FOR:• Adrenal insufficiency• Suppressing inflammation & autoimmune reaction• Controlling allergic reaction• Reducing rejection in transplantation ( read table42-5, P.1285)• Helps patients to tolerate stress

• Major side effect: suppression of pituitary & adrenal gland• Used to treat acute conditions, bronchial spasm; outer eye infection• Also, in Dermatologic disorders• Reduced gradually; do not miss a scheduled dose