ASKEP

HIPOPARATIROIDISME
HIPERPARATIROIDISME
Nilai normal parathormon (PTH): 10 - 65
picograms per milliliter (pg/mL)
Nilai normal kalsium serum: 9-11 mg/dl
Nilai normal fosfor serum: 2,5-4,5 mg/dl
(1.7-2,6 mEq/L)
 EFEK HORMON PARATIROID (PTH)
• bekerja langsung pada tulang  meningkatkan resorpsi
tulang dan memobilisasi kalsium dari tulang ke dalam darah
 meningkatkan kalsium plasma.
• meningkatkan reabsorpsi kalsium di tubulus distal
• Menurunkan reabsorbsi fosfat di tubulus proksimal ginjal
(efek fosfaturik)  meningkatkan ekskresi fosfat dalam urin
 menurunkan fosfat plasma.
• meningkatkan pembentukan 1,25 dihidroksikolekalsiferol
(metabolit vitamin D yang secara fisiologis aktif)
meningkatkan absorpsi Ca2+ dari usus
• Role of calcium: strengthening bones and teeth, regulating
muscle functioning (contraction and relaxation), the
transmission of signals in nerve cells
• Resorpsi: pemecahan tulang oleh osteoklas yang
mengakibatkan pelepasan kalsium dan fosfat (mineral
tulang) ke dalam darah
• Osteoblasts are the kind of bone cells responsible for the
bone formation. It is also responsible for the mineralization
of the bone structure.
• Osteoclasts are type of bone cells that removes bone
tissue by removing the mineral matrix of the bone and
dissolving the collagen part of the bone
 HIPOPARATIROIDISME
• Produksi hormon paratiroid yang tidak adekuat

PENYEBAB: Kekurangan sekresi hormon paratiroid (PTH),

akibat:
• kerusakan atau pengangkatan kelenjar paratiroid pada saat
operasi paratiroid atau tiroid
• Radiasi area leher
• Proses autoimun
• Tidak adanya kelenjar paratiroid (secara kongenital)
• Level magnesium yang rendah  normal magnesium
diperlukan untuk sekresi optimal dari paratiroid
• idiopatik
 Manifestasi klinik
• Gejala tetanus spasmodik: tremor, timbul gerakan
tubuh tak terkoordinasi
• Kejang
• Kesemutan, kram pada kaki, kekakuan ekstremitas
• Bronkospasme, spasme laring
• Spasme karpopedal
• Disfagia
• Fotofobia
• Aritmia jantung Perubahan pada EKG
• cemas, iritabilitas, depresi, delirium.
• CARPOPEDAL SPASM: contraction of the muscles of the
hands and feet or especially of the wrists and ankles
Signs and symptoms of neuromuscular irritability:
•Kesemutan/parestesia pada jari kaki, ujung jari dan bibir
•Hyperirritability
•Fatigue
•Anxiety
•Mood swings and/or personality disturbances
•Seizures
•Hoarseness (due to laryngospasm)
•Wheezing and dyspnea (due to bronchospasm)
•Muscle cramps, diaphoresis, and biliary colic
•Hypomagnesemia, hypokalemia, and alkalosis (eg,
hyperventilation), which worsen signs and symptoms of
hypocalcemia
 Pemeriksaan Diagnostik
Erb’s sign
•Dengan stimulasi listrik kurang dari 5 milli-ampere sudah
ada kontraksi dari otot (normal pada 6 milli-ampere)
Chvostek’s sign
•Ketokan ringan pada nervus fasialis menyebabkan
kontraksi dari otot-otot wajah.
Trousseau’s sign
•Jika sirkulasi darah dilengan ditutup dengan manset (lebih
dari tekanan sistolik) maka dalam tiga menit tangan
mengambil posisi spasme carpopedal.
Peroneal sign
•Dengan mengetok bagian lateral fibula akan terjadi
dorsofleksi dan adduksi dari kaki.
Pemeriksaan penunjang
Lab darah didapatkan:
 A low parathyroid hormone level
A low blood-calcium level
Kalsium serum rendah. Tetanus terjadi pada kadar kalsium
yang berkisar 5 - 6 mg/dl (1,2 - 1,5 mmol/L) atau lebih
rendah lagi
A high blood-phosphorus level  Kadar fosfat dalam
serum meningkat
 A low blood-magnesium level
Terjadi penurunan kadar hormon paratiroid, penurunan
kalsium serum (hipokalsemia) dan peningkatan fosfat serum.

Rontgen:
•Densitas dari tulang bisa bertambah
•EKG: biasanya QT-interval lebih panjang.
Penatalaksanaan
• Meningkatkan tingkat kalsium serum
• Pemberian kalsium glukonat intravena
• Obat penenang seperti pentobarbital mungkin diberikan
• Pengaturan lingkungan yang bebas dari kebisingan,
cahaya terang, atau gerakan tiba-tiba.
• Pemberian parathormon parenteral
• Gejala kesulitan pernafasan  trakeostomi atau ventilasi
mekanis, bronchodilating obat
• Diet tinggi kalsium dan rendah fosfor
• Pemberian vitamin D untuk meningkatkan absorbsi Kalsium
di usus
 Treatments and drugs
• Oral calcium carbonate tablets. Oral calcium supplements
can increase calcium levels. However, at high doses,
calcium supplements can cause gastrointestinal side effects,
such as constipation, in some people.
• Vitamin D. High doses of vitamin D, generally in the form of
calcitriol, can help body absorb calcium and eliminate
phosphorus.
Dietary
• Rich in calcium. This includes dairy products, green leafy
vegetables, broccoli, kale, and fortified orange juice and
breakfast cereals.
• Low in phosphorus-rich items  avoiding carbonated soft
drinks, which contain phosphorus in the form of phosphoric
acid, and limiting eggs and meats.
Diagnosa keperawatan
• Ineffective airway clearance related to laryngospasm
• Activity intolerance related to fatigue/weakness,
• Decreased cardiac output related to cardiac dysrhythmias
• Risk for injury related to tetany, muscle weakness
Intervensi
• Evaluasi keadekuatan jalan nafas
• Kaji adanya penurunan kalsium
• Perhatikan adanya tanda Chvostek's and trosseaus yang
positif
• Berikan bantalan pada side rail tempat tidur karena pasien
bisa mengalami kejang
• Komunikasi dengan pasien karena pasien dapat mengalami
gangguan memori
• Sediakan lingkungan yang tidak menstimulasi kejang
 HIPERPARATIROIDISME

• Berlebihnya produksi hormon paratiroid

• Etiologi: adenoma, hiperplasia
 Hiperparatiroid primer
• Etiologi: adenoma, hiperplasia
• Terjadi peningkatan kadar hormon paratiroid serum,
peningkatan kalsium serum (hiperkalsemia) dan penurunan
fosfat serum.
• Hiperkalsemia  anoreksia, nausea, muntah, konstipasi,
berat badan menurun, lekas lelah, otot-otot lemah,
perubahan mental.
• Sebagai akibat kalsifikasi viseral, kalsifikasi pada ginjal
berupa kalkuli (batu ginjal), nefrokalsinosis.
• Peningkatan resorpsi tulang nyeri tulang dan deformitas,
fraktur patologis
 Hiperparatiroidisme sekunder
• Produksi hormon paratiroid yang berlebihan karena rangsangan
produksi yang tidak normal
• Terjadi hiperplasia kompensatorik untuk mengoreksi penurunan
kadar kalsium serum.
• Berkaitan dengan gagal ginjal akut, kekurangan vitamin D,
gangguan penyerapan Kalsium
• Gagal ginjal  menurun fungsi ginjal dalam ekskresi fosfat
retensi fosfat  menekan kadar kalsium  memicu sekresi PTH
• Gagal ginjal  gangguan perubahan vitamin D menjadi 1,25
dihidroksi  gangguan penyerapan kalsium kalsium serum
rendah  memicu sekresi PTH  PTH menarik kalsium dari
tulang
 Tanda dan gejala
• Cepat lelah (Letargi);
• Penurunaan tonus otot sehingga otot menjadi lemah;
• Konstipasi, yang disebabkan oleh gangguan reabsorsi
kalsium di usus dan penurunan peristaltik usus;
• Resorpsi kalsium dari tulang meningkat sehingga terjadi
hiperkalsemia dalam darah;
• Hiperkalsemia menyebabkan poliuri dan polidipsi,
neprolithiasis ginjal, pankreatitis, ulkus peptikum
• Resorbsi kalsium tulang meningkat sehingga tulang mudah
fraktur di berbagai tempat
• Nyeri pinggang karena batu ginjal;
• Henti jantung karena krisis hiperkalsemia
Signs and symptoms of hyperparathyroidism
• Fragile bones that easily fracture (osteoporosis)
• Kidney stones
• Excessive urination
• Abdominal pain
• Tiring easily or weakness
• Depression or forgetfulness
• Bone and joint pain
• Frequent complaints of illness with no apparent cause
• Nausea, vomiting or loss of appetite
Pemeriksaan diagnostik
Hasil Laboratorium:
•Kalsium serum meninggi
•Fosfat serum rendah
•Fosfatase alkali meninggi
•Kalsium dalam urin bertambah
Foto Rontgen: tulang menjadi tipis, ada
dekalsifikasi
Penatalaksanaan Medis
Operasi pengangkatan paratiroid yang mengalami pembesaran (adenoma)
Surgery is the most common treatment for primary hyperparathyroidism and
provides a cure in about 95 percent of all cases.
Medikamentosa
•menghalangi destruksi kalsium dan fosfor tubuh
•Calcimimetics. A calcimimetic is a drug that mimics calcium circulating in
the blood. The drug may trick the parathyroid glands into releasing less
parathyroid hormone. This drug is sold as cinacalcet (Sensipar).
•Hormone replacement therapy. For women who have gone through
menopause and have signs of osteoporosis, hormone replacement therapy
may help bones retain calcium.
•Bisphosphonates. Bisphosphonates also prevent the loss of calcium from
bones and may lessen osteoporosis caused by hyperparathyroidism. Some
side effects associated with bisphosphonates include low blood pressure,
fever and vomiting.
•pemberian diuretik furosemid
Diagnosa keperawatan
• Fatigue berhubungan dengan kelemahan otot
• Ketidakseimbangan nutrisi kurang dari kebutuhan tubuh
berhubungan dengan intake tidak adekuat
• Resiko cedera: fraktur patologis berhubungan dengan
dekalsifikasi tulang
 Nursing intervention
• Monitor level serum potassium, calcium, phosphate, and magnesium
sebelum treatment.
• Lakukan tindakan pencegahan untuk meminimalkan resiko jatuh
• Jadwalkan aktivitas yang memungkinkan pasien dengan kelemahan otot
dapat beristirahat sebaik mungkin
• Sediakan tindakan yang membuat nyaman untuk meredakan nyeri
tulang
• Berikan antasid dengan tepat untuk mencegah ulkus peptikum
• Auskultasi suara paru untuk mengetahui adanya edema pulmo
• Cek peningkatan level kalsium serum jika pasien mendapatkan glikosida
jantung
• Kaji tingkat nyeri dan monitor keefektifan analgesik dan tindakan yang
membuat nyaman
 QUESTIONS
1) A client diagnosed with primary hyperparathyroidism demonstrates that
she understands the teaching plan when the client makes which of the
following statements?

• (A) “I must eat a diet low in potassium.”

• (B) “I must limit my daily fluid intake.”
• (C) “I must take diuretics the rest of my life.”
• (D) “I know I must have surgery to remove my parathyroid gland.”
2) The priority nursing diagnosis for a client with hypoparathyroidism
would be which of the following?
• (A) Knowledge deficit
• (B) Risk for fluid volume excess
• (C) Risk for injury
• (D) Anxiety related to lack of knowledge
3) In providing care for a client being admitted for hyperparathyroidism,
the nurse anticipates implementing which of the following aactions?

• (A) Maintaining strict fluid restriction

• (B) Administering intravenous calcium gluconate
• (C) Administering large amounts of intravenous saline
• (D) Monitoring for tetany
 CASE STUDY
Case 1
•A female patient, 41 years old, was hospitalized in the Oncology Clinic in February 2003 with
suspicion on multiple bone metastases, and a tumor in the pelvis (CT verified). A detailed anamnesis
showed that the patient had four spontaneous fractures (foot, clavicle, upper arm, forearm) four years
before. She had not been examined in the sense of determining the etiology of the fractures. She
complained about gastric problems for many years accompanied by minor loss of weight. She also
reported poor appetite, nausea and vomiting every day during the last several months, constipation
(up to 10 days), regular urination. Menstrual cycles were irregular.
•A few months after coming to hospital, she felt pains in the lumbar part of the spine and in pelvis with
pains spreading to both legs. Difficulties in walking, numbness, and dull pain were becoming more
intense, and soon she was confined to bed. Then, she was transferred to the Neurology Clinic.
•Because of suspected bone metastases (CT of skeleton) she was transferred to the Oncology Clinic.
Extremities were painful on palpation and movement, fractures were conservatively treated by plaster
fixation. Based on the detailed anamnestic data, objective findings and analysis performed before the
patient was hospitalized at the Oncology Clinic,a working diagnosis of primary hyperparathyroidism
was made and further examination was conducted in that direction. ECHO of abdomen and kidneys: in
both kidneys a few small stones, other findings were regular.
•The patient was transferred to the Institute of Endocrinology in where she was operated on April 17,
2003. OP: Parathyreoidectomia. In the postoperative period, the patient felt much better. She had
good appetite, she was gaining weight, stools were regular. Menstrual cycle was normalized two
months after operation. With the application of symptomatic therapy, laboratory analysis were within
the limits of referred values. A year after the operation, the patient walks without help, she has gained
15kg, and does not complain of any discomfort.
Case 2
•A 30 year old male, was presented to the emergency facility in an
unconscious condition. He was intubated on the way to the hospital as
he had suffered from two episodes of ventricular tachycardia. He had
previous history of recurrent seizures for 6 years inspite of multiple
anticonvulsants including phenytoin sodium, sodium valproate, and
levetiracetam. The seizure frequency increased in the last year and he
would have 5-6 episodes/ month. A MRI brain scan and EEG at the
onset were both normal, as was the general examination but he had
history of bilateral cataracts. Investigations revealed a normal
hemoglobin and glucose level with normal electrolytes. He had a serum
calcium level of 3.3 mg% with a serum parathyroid hormone level of
1pg/ml, serum 25(OH) vitamin D levels of 6.6ng/ml and
hypomagnesemia. Head scan showed bilateral basal ganglia, and deep
white matter calcification. Patient was diagnosed with primary
hypoparathyroidism.
 Case 3
•On October 3, 2006, a 27-year-old Hispanic woman presented with a 2-
year history of trouble with memory, violent mood swings, thoughts of death,
trouble concentrating, and suicidal ideation. Her family history was negative
for mental illness and positive for kidney stones in paternal relatives. The
patient was married, had a young child, and was a full-time student at a
local community college. She did not use tobacco products, alcohol, or
drugs. The patient was initially treated with citalopram 20 mg (1 tablet by
mouth daily) and lorazepam 0.5 mg (by mouth every 8 hours as needed) for
anxiety.
•On October 10, 2006, there was little change in the patient's symptoms.
Citalopram was increased to 40 mg by mouth daily. Fourteen days later the
patient complained of dry mouth and decreased energy and libido.
Lorazepam was discontinued and bupropion was added at a dose of 150
mg by mouth every 24 hours. At the next appointment, on December 21,
2006, the patient admitted to not taking the bupropion. After refusing
previous referrals to a psychiatrist, the patient accepted at this time;
however, she did not go. She also missed her next clinic appointment, which
had been scheduled for December 29, 2006.
•On February 3, 2008, the patient presented at an emergency room with
right abdominal pain. An abdominal computed tomography scan showed
multiple left intrarenal calculi, right hydronephrosis, and a 5-mm calculus
in the uretovesicular junction. Laboratory evaluation revealed a calcium
level of 12.5 mg/dL (normal range, 8.5–10.2 mg/dL). The patient was told
she had kidney stones. She was prescribed hydrocodone 5 mg and
acetaminophen 500 mg and was advised of the need for hydration and to
make an appointment with her primary care physician.

Initial Laboratory Values

•On February 8, 2008, tests to measure PTH and calcium levels were
ordered. The PTH was 200 pg/mL (normal range, 10–65 pg/mL) and her
calcium level was 11.7 mg/dL. The combination of persistent elevated
serum calcium and PTH met the requirement for a diagnosis of PHPT (
primary hyperparathyroidism). A referral to an endocrinologist was
made.
•On the first visit to endocrinology on June 10, 2008 the PTH
was 248.5 pg/mL, alkaline phosphate was 138 U/L, and calcium
was 12.9 mg/dL. The patient met the National Institute of
Health's criteria for parathyroidectomy by being younger than
50 and having neuropsychiatric symptoms as well as
nephrolithiasis.
•A Sestamibi scan showed a parathyroid adenoma of the right
superior parathyroid gland. The right superior parathyroid gland
was removed on July 7, 2008. Intraoperative PTH monitoring
was done (baseline PTH level was 341.1 pg/mL. Ten minutes
after the adenoma was removed, the PTH level was 54.8 pg/mL.
Twenty minutes later the PTH level was 27.5 pg/mL. The
pathology report diagnosis was hypercellular parathyroid.
Approximately 1 month after surgery the patient's moods and
concentration were much improved.
• Laboratory Values After Parathyroidectomy
• On September 11, 2008, the laboratory values were as follows: calcium level, 9.3
mg/dL; phosphate level, 3.2 mg/dL; PTH level, 81.8 pg/mL. The endocrinologist
ordered a test to measure the patient's 25 hydroxy vitamin D level because of an
elevated PTH level with a normal calcium level. It was low at 24 mg/mL. The
endocrinologist postulated that the elevated PTH level was caused by vitamin
D deficiency. The patient was prescribed 50,000 units of ergocalciferol by mouth
every week for 12 weeks, then every other week.
• On June 23, 2009, the patient had a follow-up appointment with her
endocrinologist. She admitted to initially being noncompliant with the prescribed
vitamin D supplementation. At this visit her calcium level was 9 mg/mL, her PTH
level was 75 pg/mL, and her 25 hydroxy vitamin D level was 18 ng/mL. She was
treated with 12 more weeks of ergocalciferol 50,000 units, then 12 weeks of the
same medication every other week.
• The most recent laboratory findings came from a tests drawn on January 8, 2010.
Her calcium level was 10 mg/dL, her PTH level was 67 pg/mL, and her 25
hydroxy vitamin D level was 23 ng/mL. The patient continues to supplement with
50,000 units ergocalciferol every other week and has her calcium, PTH, and
vitamin D levels monitored every 6 months.