Risk for Injury r/t tetany, muscle spasms, and seizures.
Goal: Patient will have minimal occurrences of injury.
-Assess neuromuscular strength, tone, and reflexes and observe for Trousseau’s and Chvostek’s signs. Rationale: Patients with hypoparathyroidism have hypocalcemia, which increases neuromuscular irritability resulting in muscle spasms.
-Monitor postoperative patients who have undergone thyroidectomy, parathyroidectomy, or radial neck dissection closely. Rationale: Early detection of hypocalcemia signs are important to anticipate signs of tetany, seizures, and respiratory difficulties.
-Keep calcium gluconate and necessary equipment at beside for emergency IV administration as indicated. Rationale: Calcium gluconate provides rapid treatment in acute hypocalcemic patients however, is used with caution in patients taking digoxin, due to toxicity risk, and patients with a cardiac disorders subject to dysrhythmias.
-Maintain a quiet environment free of drafts, bright lights, and sudden movements. Rationale: Patients with hypoparathyroidism have increased neuromuscular irritability.
-Encourage relaxation and stress-reducing techniques, such as deep-breathing and guided imagery. Rationale: Stress and hyperventilation can potentiate hypocalcemic tetany.
Evaluation: Patient displayed no occurrences of injury.