Research of Literature for Case Study #5
Primary Hyperparathyroidism
Carrie Virgil
Gillette College

Case Study #5 Primary Hyperparathyroidism
Introduction
Hyperparathyroidism is an endocrine disorder involving the parathyroid glands. According to Timby and Smith (2010), Hyperparathyroidism occurs when the parathyroid gland dysfunctions. Primary hyperparathyroidism and secondary hyperparathyroidism are two disorders that occur when the parathyroid gland dysfunctions (Timby and Smith, 2010). This case study will focus on primary hyperparathyroidism. Timby and Smith (2010) report that primary hyperparathyroidism occurs when excess parathormone is secreted from an enlarged parathyroid gland. Mayo Clinic (2011) notes the excess hormone results in increased phosphorus released in the urine and an excessive loss of calcium from the bones.
According to Mayo Clinic (2010), the excess calcium in the blood stream causes hypercalcemia, which can cause a variety of health problems. Timby and Smith (2010) confirm that hypercalcemia can depress the responsiveness of the peripheral nerves, which can result in fatigue and muscle weakness. Fuleihan and Silverberg (2012) report severe bone loss and kidney stones are major clinical manifestations of hyperparathyroidism. Primary hyperparathyroidism is diagnosed by an elevated PTH concentration or by a normal PTH concentration with an elevated serum calcium concentration (Fuleihan and Silverburg, 2012). Timby and Smith (2010) state a 24 hour urine test, skeletal radiographs, MRI and CT can be used to confirm the diagnosis.
Fuleihan and Silverburg (2012), contend that primary hyperparathyroidism is caused by a problem with one or more of the four parathyroid glands. The most common cause is a noncancerous growth called adenoma; hyperplasia of two or more parathyroid glands is the second most common cause (Mayo Clinic, 2011). Fuleihan and Silverburg (2012) point out that a malignant tumor can also cause hyperparathyroidism.
Psychobiological Findings in Case Study #5
Case study #5, a 60 year old woman, referred to as Mrs. X, is five years post-menopausal. The physician would expect to see muscle weakness, fatigue, hypotonic muscles, pain when weight bearing, and possible cardiac dysrhythmias (Timby and Smith, 2010). Mrs. X has had two episodes of kidney stones, which is caused by large amounts of phosphorus and calcium passing through the kidneys (Mayo Clinic, 2011). Mrs. X previously had a fractured wrist and ankle, which could be caused from excess calcium released from the bones, causing extremely weak bones. Fuleihan and Silverburg (2012), report that anorexia, nausea, constipation, polydipsia, and polyuria are other common side effects of primary hyperparathyroidism.
Mrs. X does not report to be on any medication for hyperparathyroidism; however, Mrs. X was treated by getting a parathyroidectomy. A parathyroidectomy removes one or more of the affected glands (Fuleihan and Silverburg, 2012). According to Mayo Clinic (2011), normally a patient requires calcium and vitamin D supplements after a parathyroidectomy. Medications that may treat hyperparathyroidectomy are calcimimetics, which mimic calcium in the blood so the parathyroid gland releases less parathyroid hormone and biophospahates, which prevent loss of calcium from the bones (Fuleihn and Silverburg, 2012). Hormone Replacement Therapy is also used for post-menopausal women to help the bones retain calcium and prevent osteoporosis (Mayo Clinic, 2011).
Depression is a common effect of hyperparathyroidism because of the severe fatigue and weakness. Many patients quit working and give up the activities they enjoy because of fatigue and weakness (Mayo Clinic, 2011). According to Fuleihan and Silverburg (2012), neuropsychiatric disturbances, such as, lethargy, psychosis, anxiety, decreased social interaction, and cognitive dysfunction has been recognized in patients with hyperparathyroidism. Mrs. X would be at an increased risk for depression due to feeling weak and not being able to do the things she enjoys doing.
If Mrs. X is unable to afford treatment for her hyperparathyroidism she could deteriorate quickly because of her high blood calcium. Mrs. X would have continued bone deterioration causing more broken bones, and more severe weakness and fatigue, which could also exacerbate her depression. Mrs. X’s lifespan would most likely be shortened if she could not afford to seek the necessary medical treatment she needs.
The cultural considerations for Mrs. X would be treating her overall physical and mental health because of her age. The healthcare professionals would need to assess if Mrs. X is still working or if she is retired or forced to retire because of her health. If Mrs. X could not afford treatment the healthcare professionals should assist her in locating the necessary help.
Nursing Diagnosis
A priority nursing diagnosis for Mrs. X is activity intolerance related to bone pain, neuromuscular deficits, and fatigue. Long term goals for Mrs. X would be for her to participate willingly in necessary activities and to also resume activities she enjoys doing. I would like to see this patient involved in a long term exercise plan to build up her muscle strength, her energy level and decrease depression symptoms.
Short term outcomes for Mrs. X include: Involvement in an exercise program or rehabilitation program at a minimum of 3 days a week for 1 hour a day. Mrs. X verbalizing, prior to leaving the hospital, the understanding of the importance of maintaining an exercise or rehabilitation program is to help her activity level and overall physical and mental health. Help Mrs. X to find ways to maintain desired activity level by forming a list of alternative ideas to accomplish tasks, such as resting between activities and walking in a mall instead of outside in the case of inclement weather.
Interventions
Provide the client with passive range of motion exercises post-surgery to keep the joints flexible to make it easier to resume activity. Assess current activity level by interviewing the client, observing the client during activity and have the client do an exercise tolerant test on a treadmill, prior to discharge from the hospital. This information will provide a baseline for comparison and ability to track changes. Implement safety precautions, by keeping the bed in the low position, having client call for assistance prior to getting up, and removing any tripping hazards. This will prevent the client from falling and causing injury that will set her activity level back. Implement the physical therapy program with the patient and other health care team members prior to discharge. The coordination of a program will enhance the likelihood of success.
Teach the client how to do range of motion exercises prior to discharge to keep the joints moving freely, which will make mobility easier. Teach the client the importance of resting between strenuous activities and spacing out activity. This will help the client to avoid fatigue while still accomplishing the necessary activities. Work with the client to identify obstacles to activity and write a list of possible solutions to those obstacles. This will help the client to see other avenues to accomplish tasks.
The client may be put on calcium and vitamin D after the parathyroidectomy. If Mrs. X is put on the supplements explain why she is on them and teach the importance of keeping her doctor appointments to get her calcium levels checked. This will ensure that she has adequate calcium but not too much calcium in her bloodstream. Refer Mrs. X to programs in the community that provide exercise programs, such as the senior citizen center and the recreation center. Also Refer Mrs. X to programs that offer other assistance, such as home care services, etc.
The goals for Mrs. X would be evaluated by verbalization from Mrs. X that she is willing to incorporate an ongoing exercise plan in her life. I would also observe Mrs.X’s behavior when she verbalizes to see if she makes eye contact, has relaxed body language, and is agreeable to the changes she needs to make for her overall health. I would also evaluate her outcomes by her willingness to participate in the activities and participation of making a list of alternate ideas to perform activity.
Conclusion
It is important for the patient with hyperparathyroidism to find ways to help with the weakness and fatigue. Making improvements in the way they perform the activities of daily living can help with the fatigue and also help their outlook on life. Whether the treatment the client receives for hyperparathyroidism is surgery or medication it is crucial the client keeps their doctor appointments to manage the disorder and its symptoms (Mayo Clinic, 2012).

References
Doenges, M., Moorhouse, M., & Murr, A.(2010). Nurses Pocket Guide Diagnoses, Prioritized Inteventions, and Rationales, Activity Intolerance (pp.73-76). Philadelphia, PA: F.A. Davis Company.
Fuleihan, G., & Silverberg, S.(2012), Diagnosis and Differential Diagnosis of Primary Hyperparathyroidism. Retreived March 11, 2013, from UpToDate database.
Mayo Clinic Staff (2011, May). Hyperparathyroidism. Retrieved from http://www.mayoclinic.com/health/hyperparathyroidism/DS00396
Timby, B. & Smith, N.(2010).Introduction Medical-Surgical Nursing, Caring for Clients with Disorders of the Endocrine Systems (p.771). Philadelphia, PA: Lippincott Williams & Williams.