Calcium Imbalances

Hypocalcemia

• Is a total serum level of less than 8.5 mg/dl

• It can result for decreased total body calcium stores or low levels of extracellular calcium with normal amounts of Calcium stored in bones.

PathophysiologyA lack of PTH results in inactivity of osteoclasts and aconsequent fall in serum calcium levels. Nerve fibers become more and more excitable and may discharge spontaneously, causing muscles to twitch and to go into spasms or even tetany. Spasms of the muscles of the larynx interfere with respiration and may lead to death. During hypocalcemia, the bone is stimulated to release calcium, which makes the bone osteoporotic and subject to fracture. Hypocalcemia increases capillary permeability; causes neuromuscular excitability of skeletal, smooth, and cardiac muscles; and decreases blood coagulation, which results in bleeding. Severe hypocalcemia causes neuromuscular excitability that result in tetany. If it is untreated, convulsions and death can occur. Acute hypocalcemia may cause cardiac insufficiency and cardiac dysrhythmias.

Risk Factors:

• People who have had parathyroidectomy

• Older adults (especially women)

• People with lactose intolerance

• Alcoholic people

Causes:

• Parathyroidectomy• Acute Pancreatitis• Inadequate dietary intake• Lack of sun exposure• Lack of weight bearing exercise• Drugs: Loop diuretics, calcitonin• Hypomagnesemia, alcohol

abuse

Manifestations:• 2 signs indicate hypocalcemia:Chvostek’s Sign

-is the contraction of the facial muscle that is produced by tapping the facial nerve in front of the ear.

Trosseau’s Sign-is a carpal spasm that occurs

by inflating a BP cuff on the upper arm to 20mmHg greater than systolic pressure for 2-5 mins.

• Neuromuscular signs:

Tetany and Convulsions – most serious manifestation; tonic muscular spasms.

Paresthesias Muscle spasms Laryngospasms Seizures Anxiety, confusion, psychosis

Collaborative Care:

• Management of hypocalcemia is directed toward restoring normal calcium balance and correcting the underlying cause.

Diagnostic Exams:

• Total serum calcium

• Serum albumin

• Serum magnesium

• Serum phosphate

• Parathyroid hormone

• ECG

Medical Management:

• Oral or intravenous calciumCalcium ChlorideCalcium GluconateCalcium LactateCalcium CitrateCalcium GluceptateCalcium Carbonate

Nursing Management:

• Assess IV site for patency. Don’t administer Calcium if there is a risk for leakage into the tissues.

• May be given by slow IV push (dilute with normal saline for injection prior to administration) or added to copatible parenteral fluids such as Normal Saline, Lactated Ringers, D5W

• Administer into the longest available vein.• Continuously monitor ECG when

administering IV calcium to clients taking digitalis due to increased risk of digitalis toxicity.

• Frequently monitor serum calcium levels and response to therapy.

• Administer oral calcium preparations 1-1.5 hours after meals and at bedtime.

• Give calcium tablets with a full glass of water.

• Diet high in calcium: cottage cheeseCheeseMilkCreamYogurtice creamSpinachTofubroccoli

Nursing Process

• Subjective Data: • Fatigue • Tingling/numbness; fingers and • circumoral • Abdominal cramps • Palpitations • •Dyspnea

Assessment:

• Objective Data:

Muscle spasms: tonic muscles, carpopedal, laryngeal Neuromuscular: grimacing, hyperirritable facial nerves Tetany convulsions Orthopedic: osteoporosis fractures Cardiac: arrhythmias arrest GI: diarrhea

Nursing Diagnosis:

• Risk for injury r/t laryngospasm, cardiac dysrhythmias, convulsions, rapid administration of IV calcium, extravation of the medication into the subcutaneous tissue, increased neuromuscular irritability secondary to hypocalcemia

• Pain

• Diarrhea

• Hypocalcemia

• Altered nutrition, less than body requirements

• requirements

• Sensory-perceptual alteration

• (gustatory)

Planning:

• Patient will be able to verbalize understanding of individual factors that contribute to possibility of injury and take steps to correct situations

• Patient will be free from injury associated with calcium deficit, as evidenced by no falls or near falls and no pathologic fractures.

Interventions:• Monitor peripheral pulses and vital signs, especially the

heart rate every hour to every four hours depending on the client’s condition. To assess baseline data.

• Provide information regarding disease/condition that may result in increased risk of injury. To assist client to reduce or correct individual risk factor.

• Evaluate individual’s response to violence in surroundings

• If the client is receiving intravenous calcium, the nurse needs to monitor the IV site for infiltration or phlebitis every hour

• Symptomatic hypocalcemia should be assessed by testing of the Chvostek’s and Trousseaus’ signs. Calcium chloride is extremely irritating to the subcutaneous tissue.

• The serum calcium level should be closely monitored and changes reported. To check for increased neuromuscular excitability and tetany.

Hypercalcemia

• Is a serum calcium value greater than 10.0 mg/dL

• Usually results from increased absorption of calcium from the bones and intestines.

PathophysiologyBecause calcium levels are increased,

there is a lesser gradient between the cell and the serum. There is also an increased amount of calcium in the cell. Therefore, the threshold becomes more difficult to achieve and the cell membrane becomes refractoryto depolarization. As a result, cardiac and smooth muscle activity is decreased. Calcium in the bloodstream impairs renal function and it precipitates as a salt, forming renal stones. Some cancer tumors destroy the bone, whereas others such as lung and breast cancers cause an ectopic PTH production. Hypophosphatemia is a complication of excessive PTH production that promotes calcium retention. A shortened QT segment and depressed T waves may be seen on ECG.

Causes:

• Hyperparathyroidism

• Cancer

• Prolonged immobilization

• Paget’s disease

• Excess milk or antacid intake

• Renal failure

Manifestations:

• Neuromuscular Muscle weakness Fatigue Decreased deep tendon reflexes

• Behavioral Personality changes Altered mental status Decreased LOC

• Gastrointestinal Abdominal pain Constipation Anorexia, N/V

• Cardiovascular Dysrhythmias Hypertension

• Renal Polyuria thirst

Complications:

• Peptic ulcer

• Pancreatitis

• Kidney stones

• Hypercalcemic crisis

Diagnostic Exams:

• Serum electrolytes

• Serum PTH levels

• ECG

• Sulkowitch’s urine test

Collaborative Care:

• The management of hypercalcemia focuses on correcting the underlying cause and reducing serum calcium levels.

Medical Management:

• Loop Diuretics (Furosemide)

• Calcitonin

• Biphosphonates

• Glucocorticoid drugs

Nursing Process

• Subjective Data: Pain: flank, deep bone, shin splints Muscle weakness, fatigue Anorexia, nausea Headache Thirst polyuria

Assessment:

• Objective Data:

Muscles: relaxed GU: kidney stones GI: increased milk intake, constipation, dehydration Neurological: stupor coma

Nursing Diagnosis:

• Risk for injury r/t changes in mental status, the effect of hypercalcemia on muscle strength, loss of calcium in bones

• Decreased cardiac output • Constipation • Activity intolerance • Altered urinary elimination • Pain

Planning

• Patient will be able to verbalize understanding of individual factors that contribute to possibility of injury and take steps to correct situations

• Patient will be free from injury associated with calcium excess, as evidenced by no falls or near falls and no pathologic fractures.

Interventions

• decrease foods high in calcium; • identify cause of imbalance • give steroids as indicated • diuretics as ordered • isotonic • saline IV • Prevent injury: prevent pathological

fractures (e.g. advanced cancer)• prevent renal calculi by increasing

fluid intake