by Cathy Parkes September 21, 2020
In this article, we explain HYPO- and HYPERparathyroidism for nurses and nursing students. These are disorders that result from improper amounts of parathyroid hormone (PTH) in the body. Knowing the pathophysiology, symptoms, diagnosis and treatment for these two disorders will be key in your Med-Surg exams as well as your nursing practice.
These disorders are covered in our Medical-Surgical Flashcards (Endocrine system).
In video 2 of our Med-Surg Endocrine system playlist, we taught you about the parathyroid glands.You have four parathyroid glands, and they are right next to/on top of the thyroid gland. You can think of the parathyroid glands as bedazzling the thyroid gland. The parathyroid glands’ main function is to release parathyroid hormone (PTH).
Remember that the endocrine system and its negative feedback loops seek homeostasis with different hormone levels, wanting to get levels not too high, not too low, but just right (think of the baby bear in Goldilocks and the Three Bears).
PTH’s goal is to keep calcium at the appropriate level by increasing it, and it does this in three ways:
Hypoparathyroidism is decreased or insufficient secretion of PTH. Since PTH’s main function is to increase calcium levels in the body, when the parathyroid glands are functioning normally, calcium will be at the correct level. When PTH is too low, blood calcium levels will also be low.
Hypoparathyroidism most often occurs after damage to the parathyroid glands during a thyroidectomy. A thyroidectomy is that complete or partial removal of the thyroid gland that we discussed in our last article. If you remember how the parathyroid glands are bedazzling the thyroid, and know that they are about as small as grains of rice, and they can be really hard to avoid during that thyroidectomy surgery, so sometimes they get accidentally damaged, or even removed.
The signs and symptoms of hypoparathyroidism are the signs and symptoms of hypocalcemia (low calcium levels), which include numbness, tingling around the mouth, muscle twitching, GI upset, and positive Chvostek’s and Trousseau’s signs. Hypocalcemia can result in more severe side effects too, like seizures, dysrhythmias, and tetany.
Tetany is a symptom marked by involuntary contraction and spasming of the muscles. Tetany is not related to tetanus, which is an infectious disease that we get vaccinated against. The two do share the same root, “tet,” which means tension (as in a muscle).
The lab values that you need to know about for hypoparathyroidism are:
The normal level of calcium (Ca) in the blood is 9 - 10.5 mg/dL. Calcium levels under 9 mg/dL can indicate hypocalcemia.
Hyperphosphatemia is a lab value you should be familiar with for your nursing exams. The normal level of phosphorus (P) in the blood is 3.0 - 4.5 mg/dL. Phosphorus levels above 4.5 mg/dL can indicate hyperphosphatemia.
Hyperphosphatemia can also be caused by kidney disease, and its symptoms are the same as hypocalcemia: muscle spasms, numbness, tingling.
Calcium and phosphorus have an inverse relationship in the body. When we have high levels of calcium, we have low levels of phosphorus, and when we have low levels of calcium, we have high levels of phosphorus. That’s why the symptoms of hyperphosphatemia and hypocalcemia are the same.
There are several medications that can be used to treat hypoparathyroidism, including vitamin supplements. A patient with hypoparathyroidism can be given calcium gluconate, which is usually administered with a vitamin D supplement because vitamin D is essential for allowing absorption of calcium. Phosphate binders can also be given, to help bring the phosphorus levels down.
When you have a patient with hypoparathyroidism, you may need to implement seizure precautions because of the risk of seizures associated with hypocalcemia. You will follow your facility’s procedure, but that usually includes padding the side-rails of the bed and making sure oxygen equipment is available.
A patient with hypoparathyroidism will need a high-calcium, low-phosphorus diet, and can be given their phosphate binders with their meals.
Hyperparathyroidism is a disorder of the parathyroid glands resulting in hypersecretion, or excess secretion, of parathyroid hormone (PTH) resulting in excess blood calcium levels.
The primary cause of hyperparathyroidism is an adenoma (benign tumor) on the parathyroid gland that causes excess secretion of PTH. Remember that a primary cause is when the problem is local to the organ in question and not caused by something somewhere else in the body.
A secondary cause of hyperparathyroidism is kidney disease. With kidney disease, calcium levels are low. This is because healthy kidneys help activate vitamin D (which helps calcium absorption) and remove extra phosphorous (which allows more calcium in the blood). When kidneys are diseased, they can’t perform that function as well, and the body is not able to get calcium levels up where they should be, resulting in hypocalcemia.
But remember, PTH’s job is to get calcium to a normal level. So in response to calcium being low, the parathyroid glands go into overdrive producing excess PTH.
The signs and symptoms of hyperparathyroidism are the signs and symptoms of hypercalcemia, which includes fatigue, muscle weakness, bone pain and deformities (because calcium is being pulled out of bones), nausea and vomiting, weight loss, constipation, hypertension, kidney stones, depression or other behavioral changes and dysrhythmias.
The lab values that you need to know about for hyperparathyroidism are:
The normal level of calcium (Ca) in the blood is 9 - 10.5 mg/dL. Calcium levels over 10.5 mg/dL can indicate hypercalcemia.
The normal level of phosphorus (P) in the blood is 3.0 - 4.5 mg/dL. Phosphorus levels below 3 mg/dL can indicate hypophosphatemia.
These labs are covered in our Lab Values flashcards, which help you keep the most important labs for your exams all in one place.
For patients with hyperparathyroidism, there are several types of treatments available, including medications to control symptoms, as well as surgical interventions.
One medication option is the loop diuretic Lasix (furosemide), which helps increase the excretion of calcium through urine, and bring blood calcium levels down. Another is calcitonin, which prevents calcium extraction from bones by inhibiting osteoclast activity, and increases kidney excretion of calcium. And finally, patients can be given phosphates to bring their phosphorus levels up.
Calcitonin helps tone down calcium in the blood!
Need help remembering these medications for Med-Surg or Pharm? They’re covered in our Pharmacology flashcards for nursing students so you can memorize them easily.
Surgery might be needed if the patient has an adenoma on their parathyroid gland (that primary cause of the disorder). The surgery to remove the parathyroid glands is called a parathyroidectomy, which is thankfully a pretty easy one to remember!
Fragile; handle with care! If you have a patient with hyperparathyroidism, you will want to implement safety precautions. This patient is literally fragile— their excess levels of PTH causes calcium to be pulled out of the bones. Remember how we need calcium to build strong bones? Well, without the needed calcium, this patient’s bones are weak and brittle. If they were to fall, there could be some tragic consequences. You will want to provide for patient safety, assist the patient with ambulation, and make sure they don’t fall!
A patient with hyperparathyroidism should eat a low-calcium, high-phosphorus diet, and increase their fluid intake to prevent constipation and the risk of kidney stones.
Cathy’s teaching on these disorders is intended to help prepare you for Medical-Surgical nursing exams. The Medical-Surgical Nursing video series is intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI and NCLEX.
In this video, we are going to talk about hypoparathyroidism and hyperparathyroidism. If you are following along with cards, I'm on card 41.
Before we get into those two disorders, let's do a quick review of the parathyroid glands. So there are four of them, and they are right next to the thyroid gland. It actually looks like the thyroid gland has been bedazzled with parathyroid glands, if you take a look at a picture.
These parathyroid glands release PTH. PTH causes increased calcium levels in the bloodstream, and it does this three ways. One is it pulls calcium out of the bones into the bloodstream. It also causes increased reabsorption of calcium at the kidneys, and it causes increased absorption of calcium in the intestines, and that's how it brings those calcium levels up in the bloodstream.
With hypoparathyroidism, we have decreased or insufficient secretion of PTH, and this causes those calcium levels to go down, because those parathyroid glands are not working correctly.
And the main cause of this issue is that during a thyroidectomy, which is removal of the thyroid gland, we have nicked and damaged those parathyroid glands, and when we damage them, they don't produce their PTH, and causes those calcium levels to come down.
In terms of signs and symptoms of this disorder, if we have hypoparathyroidism, we're basically going to see the same signs and symptoms we would see for someone who has hypocalcemia, so low levels of calcium. So this includes muscle cramps, numbness and tingling, a positive Chvostek's sign, as well as a positive Trousseau's sign. We may also see tetany or seizures and possibly dysrhythmias as well.
In terms of labs, when we have hypoparathyroidism we will have decreased PTH. So decreased parathyroid hormone.
In addition, we will have hypocalcemia, so levels of calcium will be under 9.
And then we will have hyperphosphatemia. So you may recall, when we have high levels of calcium, we'll have low levels of phosphorous, and the opposite is true too. If we have high levels of phosphorous, we have low levels of calcium. They have this inverse relationship. So with this disorder, we'll have hypocalcemia, but hyperphosphatemia.
In terms of treatment, we would provide a patient with this disorder with calcium gluconate, so we want to try to get those calcium levels up. We would give them calcium as well as Vitamin D supplements because Vitamin D is essential to allow for the absorption of calcium. And then we can also give them phosphate binders to help bring those phosphorous levels down.
In terms of nursing care, we're going to want to implement seizure precautions because of the risk of seizures. So we're going to pad those side-rails of the bed and make sure we have oxygen equipment available at the bedside, etc.
We're going to provide the patient with a high-calcium, low-phosphorous diet.
And then also give the patient phosphate binders with their meals.
Now let's talk about hyperparathyroidism. This is where we have hypersecretion, excess secretion, of PTH from the parathyroid glands.
And this may be due to primary or secondary causes. The primary cause would be an adenoma which is a benign tumor on the parathyroid gland that causes excess secretion of PTH.
One of the secondary causes of hyperparathyroidism would be kidney disease. So with kidney failure or kidney disease, we have hypocalcemia. So our calcium levels are very low. And the parathyroid glands, they sense that and they're trying to compensate. So they pump out all this extra PTH to bring up those calcium levels. And in the process, when we have all that PTH, that pulls calcium out of the bones, into the bloodstream. And those levels just keep coming up.
In terms of labs, we would see high levels of PTH, high levels of calcium, and low levels of phosphorus.
For signs and symptoms, the signs and symptoms of hyperparathyroidism are going to be consistent with the signs and symptoms of hypercalcemia. So this includes fatigue, muscle weakness. We also may see bone pain and deformities, because we're pulling all that calcium out of the bones. Nausea and vomiting, weight loss, constipation, hypertension as well as kidney stones and dysrhythmias are also possible side effects.
In terms of treatment, medications we can use include furosemide, which is Lasix. That helps to increase excretion of calcium, and bring those blood levels down. We can also give a patient calcitonin. So if you recall, calcitonin helps to tone down calcium levels in the bloodstream. And then we can also give the patient phosphates to help bring those phosphorus levels up.
Surgery may also be needed if the patient has an adenoma. If they have the primary cause of hyperparathyroidism. So they may need a parathryoidectomy, so removal of the parathyroid gland.
And then in terms of nursing care, we're going to want to implement safety precautions for this patient, because the excess levels of PTH is causing calcium to be pulled out of the bones, those bones are going to be really weak and fragile. And so if that patient were to fall, then it could be really tragic. So we're definitely going to want to provide for patient safety, assist the patient with ambulation, make sure they do not fall.
We also want to provide the patient with a low-calcium, high-phosphorus diet, and increase their fluid intake as well, to help prevent that constipation as well as the risk for kidney stones.
Hopefully this video has been helpful. In my next video, we will talk about diabetes in depth. Thank you so much for watching and take care!
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