Page 40 nursing.elitecme.com Complete Your CE Test Online - Click Here Several of these preceding complications are irreversible. Irreversible complications include[23] : ● ● Mental retardation in children. ● ● Stunted growth. ● ● Cataracts. ● ● Deposits of calcium in the brain that causes problems with equilibrium and seizures. Signs and symptoms Mild hypothyroidism may be asymptomatic. However, the disorder usually produces hypocalcemia and elevated phosphate levels that affect the central nervous system in particular and other body systems as well[5] . Characteristic signs of hypoparathyroidism as manifested by hypocalcemia are[5,6] : ● ● Tetany: Manifested by muscle hypertonia and tremors and spasmodic or uncoordinated movements triggered by attempts at voluntary movements. ● ● Chvostek’s Sign: Hyperirritability of the facial nerve manifested by a spasm of facial muscles, which occurs when muscles or branches of the facial nerve are tapped. ● ● Trousseau’s Sign: Carpopedal spasm (spasmodic contractions of the muscles of the hands and feet) triggered within three minutes after a blood pressure cuff is applied to the arm and inflated to 20 mmHg above patient’s systolic pressure. ● ● Laryngeal spasm. Additional clinical manifestations of hypoparathyroidism include [5,6,23] : ● ● Abdominal pain. ● ● Anxiety. ● ● Arrhythmias. ● ● Brittle nails. ● ● Cataracts. ● ● Depression. ● ● Dry, coarse skin. ● ● Dry, dull hair. ● ● Fatigue. ● ● Headaches. ● ● Memory problems. ● ● Mood swings. ● ● Muscles aches and cramps. ● ● Painful menstruation. ● ● Paresthesia (tingling or burning sensations in fingers, toes, and lips). ● ● Patchy loss of hair. ● ● Renal colic is there is a history of calculi. ● ● Weakness of tooth enamel causing decay and tooth loss. ● ● Weakness. Hypoparathyroidism alert! CNS signs and symptoms are exaggerated during pregnancy, infection, thyroid hormone withdrawal, before menstruation, hyperventilation, and right before menstruation[5] . Diagnosis Diagnosis is made on the basis of the patient’s history and physical, presenting signs and symptoms, and the results of specific diagnostic tests. These tests include[5,6] : ● ● Serum phosphorous level: Elevated. ● ● Serum calcium level: Hypocalcemia indicated by a serum calcium level of 7.5 mg/100 ml or less. ● ● Serum magnesium level: Decreased. ● ● Electrocardiogram (ECG): As a result of hypocalcemia ECG shows prolonged QT and ST intervals. ● ● Bone density: If hypoparathyroidism is chronic bone density may be increased. Diagnostic alert! Monitor patient for signs of heart block and decreased cardiac output due to prolongation of QT and ST intervals. Also monitor patients for signs of digoxin toxicity such as arrhythmias, nausea, fatigue, and vision changes since the reversal of hypocalcemia may quickly lead to digoxin toxicity[5,6] . Treatment and nursing considerations Early detection and treatment are essential if complications such as cataracts and brain calcifications are to be prevented[5] . Treatment alert! Cimetidine (Tagamet) interferes with normal parathyroid function, especially if renal failure is also a problem. Any interference with parathyroid function increases the risk of hypocalcemia[6] . Calcium absorption requires the presence of vitamin D. Therefore, treatment of hypoparathyroidism must include vitamin D along with the administration of supplemental calcium[5] . Intravenous calcium administration is needed in the presence of acute life-threatening tetany. The most effective calcium solution is ionized calcium chloride (10%). All intravenous calcium preparations are given slowly since it is a highly irritating solution that stings and causes thrombosis. The patient experiences burning flushing feelings of the skin and tongue. However, the intravenous calcium solution also seems to rapidly relieve feelings of anxiety[6] . Additional treatment measures include[5,6,23] : ● ● Vitamin D to promote calcium absorption. If patients are unable to tolerate the pure forms of vitamin D alternatives such as dihydrotachysterol (if liver and kidney functions are adequate) or calcitriol (if liver and kidney functions are compromised). ● ● Thiazide diuretic therapy. Thiazide diuretics can increase blood calcium levels. If patients do not respond to calcium administration thiazide diuretics may be added to the treatment regimen. Be sure that loop diuretics are not prescribed since these can actually decrease calcium levels. ● ● Correction of preexisting hypomagnesemia. ● ● Provision of a high-calcium, low-phosphorus diet. ● ● Sedatives and anticonvulsants may be administered to control spasms and tremors until calcium levels return to normal. Treatment alert! Chronic tetany requires life-long treatment with oral calcium and vitamin D supplements unless it is of a reversible form [5] . Nursing consideration: Nurses must provide very careful patient education regarding the importance of adhering to medication regimens. In cases where life-long treatment is necessary nurses must also be sure to provide emotional support and carefully monitor patients for adherence to their medication schedules. Patients with a history of tetany who are awaiting a diagnosis of hypoparathyroidism need to have a patent intravenous line. Intravenous calcium preparations, a tracheotomy tray, and endotracheal tube should be kept at the bedside of hospitalized patients so that swift intervention is possible in the event of laryngospasm[5] . Be alert for the onset of minor muscle twitching, which may signal the onset of tetany[5] . Parents should be taught how to plan a diet that is rich in calcium and low in phosphorus. High calcium foods include dairy products, green leafy vegetables, broccoli, kale, and fortified orange juice and breakfast cereals. Phosphorus-rich foods to avoid include carbonated soft drinks, meats, and eggs[23] . Additional patient education measures to be implemented include [5,6,23] : ● ● Always provide written as well as verbal instructions. Make sure that information is written in terms that the patients and families can understand and in a language with which they are comfortable.