Endocrinology

Parathyroid Gland
Parathyroid
 Anatomy
Parathyroid Hormone
 Parathyroid hormone is the most important
endocine regulator of calcium and
phosphorous concentration in the extracellular
fluid.
 This hormone is secreted from cells of the
parathyroid glands and finds its major target
cells in bone and kidney.
Physiologic Effect of Parathyroid
hormone
 The effect of Parathyroid hormone goes with
the principle of negative feedback system, if
calcium ion concentrations in extracellular
fluid fall below normal, bring them back
within the normal range.
 In conjunction with increasing calcium
concentration, the concentration of phosphate
ion in blood is reduced.
Physiologic Effect of Parathyroid
hormone
 Mobilization of calcium from bone: Although
the mechanisms remain obscure, a well-
documented effect of parathyroid hormone is
to stimulate osteoclasts to reabsorb bone
mineral, liberating calcium into blood.
Physiologic Effect of Parathyroid
hormone
 Enhancing absorption of calcium from the
small intestine:
 Parathyroid hormone stimulates this process,
by stimulating production of the active form
of vitamin D in the kidney. Vitamin D induces
synthesis of a calcium-binding protein in
intestinal epithelial cells that facilitates
efficient absorption of calcium into blood.
Physiologic Effect of Parathyroid
hormone
 Suppression of calcium loss in urine:
 Parathyroid hormone puts a brake on
excretion of calcium in urine, thus conserving
calcium in blood. This effect is mediated by
stimulating tubular reabsorption of calcium.
 Another effect of parathyroid hormone on the
kidney is to stimulate loss of phosphate ions in
urine.
Physiologic Effect of Parathyroid
Hormone
Hyperparathyroidism
Hyperparathyroidism results from
excessive secretion of parathyroid
hormone (PTH). PTH promotes bone
resorption, and hypersecretion leads to
hypercalcemia and hypophosphatemia.

In primary hyperparathyroidism: one or

more parathyroid glands enlarge and
increase PTH secretion, most commonly
caused by a single adenoma, but this may
be a component of multiple endocrine
neoplasia (all four glands usually
involved).
Hyperparathyroidism
 In secondary hyperparathyroidism, a
hypocalcemia-producing abnormality outside
the parathyroids causes excessive
compensatory production of PTH. Causes
include: rickets, vitamin D deficiency, chronic
renal failure, and osteomalacia due to
phenytoin (Dilantin).
Pathophysiology
 Signs and symptoms
Nervous system
- Apathy
- Psychological changes from irritability,
neurosis to psychosis
Cardiovascular system
- forceful cardiac contraction
- cardiac dysrhythmias
- hypertension
 Signs and Symptoms
Renal System
- Polyuria
- nephrocalcinosis
- Kidney stones/renal calculi 55% of patients
with primary hyperparathyroidism
 Skeletal System

- skeletal pain and tenderness

- pain on weight bearing
- shortening of body stature
Signs and symptoms
 Musclular System
- fatigue
- decrease muscle tone
- muscle weakness
 GIT

- peptic ulcer
- pancreatitis
- abdominal pain ranging to the back
- nausea and vomiting
 Diagnostic Findings
 Radioimmunoassay (confirms the diagnosis)
 X-rays showing diffused demineralization of bones
 Spectrophotometry
 Ultrasound, MRI, thallium scan, and
 fine-needle biopsy have been used to evaluate the
function of the parathyroids and to localize
parathyroid cysts, adenomas, or hyperplasia.
 Treatment
 Surgery
- The recommended treatment of primary
hyperparathyroidism is the surgical removal of
abnormal parathyroid tissue.
 The nursing management of the patient
undergoing parathyroidectomy is essentially the
same as that of a patient undergoing
thyroidectomy.
 Nursing management
 Increased fluid intake (3-4L/day).
- to reduce risk of stone formation in the
kidneys and relieve thirst due to polyuria.
 Acid-ash fruit juices (prune juice, cranberry
juice) ascorbic acid.
- acidic urine inhibits stone formation in the
kidneys. This will also prevent constipation to
patient.
 Protect from injury to prevent fracture.
 Normal saline IV.

- Ca excretion is promoted by Na excretion

 Nursing management
 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.
Bedrest increases calcium excretion and the risk for
renal calculi
Nursing management
 Dietand Medication
- Low Ca diet
- Antacid to peptic ulcer
- Thiazide diuretics are avoided because
they decrease the renal excretion of calcium
and further elevate serum calcium levels.
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.
Pathophysiology
Signs and symptoms
 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.
Signs and symptoms
 Inovert tetany, the signs 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.
Diagnostic findings
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 sign is 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.
Diagnostic findings
 Tetany develops at 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 paraspinal basal ganglia of
the brain.
Treatment
 The goal of therapy is to raise the serum
calcium level to 9 to10 mg/dL (2.2 to 2.5
mmol/L) and to eliminate the symptoms of
hypoparathyroidism and hypocalcemia.
 If unrelieved, seizure may occur, Penobarbital
may be given to sedate the patient.
 Parenteral parathormone can be administered
to treat acute hypoparathyroidism with
tetany.
Treatment
 Tracheostomy or mechanical ventilation may
become necessary, along with bronchodilating
medications, if the patient develops
respiratory distress.
 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.
Treatment
 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. Aluminum hydroxide gel or aluminum
carbonate (Gelusil, Amphojel) also is
administered after meals to bind phosphate
and promote its excretion through the
gastrointestinal tract.
treatment
 VitaminD preparation—dihydrotachysterol (AT
10 or Hytakerol), ergocalciferol (vitamin D),
cholecalciferol (vitamin D)—are usually
required and enhance calcium absorption from
the gastrointestinal tract.
 Nursing management
Care of postoperative patients having
thyroidectomy, parathyroidectomy, and
radical neck dissection is directed toward
detecting early signs of hypocalcemia and
anticipating signs of tetany, seizures, and
respiratory difficulties.
Prepare Tracheostomy set if Laryngospasm
occurs.
Nuesing management
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.Safety precautions for
possible seizure
Nursing management
 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.
 Safety precautions for possible seizure
Think About This
“ A bar of iron costs $5, made into
horseshoes its costs is $12, made into
neddles its costs is $3,500, made into
balance springs for watches, its worth
is $300,000. Your value is developed
as you go through refinement and fire
of adversity.”