2.3 HYPOCALCEMIA and HYPERCALCEMIA

Fluids and Electrolytes
Calcium
 Calcium is involved in bone formation/
reabsorption, neural transmission/muscle
contraction, regulation of enzyme systems,
and is a coenzyme in blood coagulation.
 Normal serum levels are 4.5–5.3 mEq/L,
8.5–10.5 mg/dL (total) or 2.1–2.6 mEg/L (ionized).
 The ionized calcium is physiologically active
and clinically important, especially in critically
ill patients.
 The total serum calcium is directly related to the
serum albumin, follows it, and must be considered if only total serum readings are available.
 Some factors that alter the percentage of ionized calcium are changes in pH (affects how much
calcium is bound to protein) or increased serum levels of fatty acids, lactate, and bicarbonate.
 Ca – cation, most abundant in entire body
 99% in bone, teeth
 Very little in plasma
 0.8g/dL Ca for every 1 g/dL albumin increase or decrease
 affected by PTH, Calcitonin, albumin, Vitamin D (calcitriol)
 1000-1200mg/day for adults; 1500 for elderly, pregnant, lactating
 Normal serum value = 4.5-5.5 mEq/L
 8.5-10.5 mg/dL – total
Functions
• skeletal & cardiac contraction
• skeletal & dental growth/density
• clotting (CF IV) – important in converting prothrombin to thrombin
• Sources: milk, yogurt, cheese, sardines, broccoli, tofu, green leafy vegetables
IMBALANCES IN CALCIUM
1. HYPOCALCEMIA (Calcium Deficit)
Cause
• Inadequate calcium intake
• Excess loss of calcium- kidney dse,draining intestinal fistula
• Decreased absorption from GIT
– Insufficient vit.D
– Insufficient PTH
PREDISPOSING/CONTRIBUTING FACTORS
Primary or surgical hypoparathyroidism; transient hypocalcemia following
thyroidectomy; hyperphosphatemia, hypomagnesemia
Far Eastern University

Institute of Nursing
Massive subcutaneous tissue infections, acute pancreatitis, burns, peritonitis,
malignancies
Excessive GI losses: Draining fistula, diarrhea, fat malabsorption syndromes,
chronic laxative use (particularly phosphate-containing laxatives/enemas)
Extreme stress situations with mobilization and excretion of calcium
Diuretic and terminal phase of renal failure
Inadequate dietary intake, lack of milk/vitamin D, excessive protein diet
Alcoholism: Primary effect of ethanol, plus intestinal malabsorption,
hypomagnesemia, hypoalbuminemia, and pancreatitis
Use of anticonvulsants, antibiotics, corticosteroids; loop diuretics, drugs that lower
serum magnesium (e.g., cisplatin, gentamycin)
Infusion of citrated blood, calcium-free infusions; rapid infusion of Plasmanate
Malignant neoplasms with bone metastases
Alkalotic states
Decreased ultraviolet exposure
Patient Assessment .
CIRCULATION
May exhibit: Hypotension
Pulses weak/decreased, irregular (weak cardiac contraction/premature
dysrhythmias)
Decreased cardiac contractility
Arrhythmia
ECG: prolonged QT interval, lengthened ST segment
ELIMINATION
May report: Diarrhea, abdominal pain, hyperactive bowel sounds
May exhibit: Abdominal distension (paralytic ileus)
FOOD/FLUID
May report: Nausea/vomiting
May exhibit: Difficulty swallowing, Laryngeal spasms/stridor
HYGIENE
May exhibit: Coarse, dry skin; alopecia (chronic)
NEUROSENSORY
May report: Circumoral paresthesia, numbness and tingling of fingers and toes; muscle cramps
May exhibit: Anxiety, confusion, irritability, alteration in mood, impaired memory, depression,
hallucinations, psychoses
Muscle spasms (carpopedal and laryngeal), increased deep-tendon reflexes; tetany,
tonic/clonic seizure activity, positive Trousseau’s and Chvostek’s signs
• Trousseau’s sign (inflate BP cuff 20mm above systole for 3 min = carpopedal spasm)
• Chvostek’s sign (tap facial nerve anterior to the ear = ipsilateral muscle twitching)

RESPIRATION
May exhibit: Labored shallow breathing; stridor (spasm of laryngeal muscles)
SAFETY
May exhibit: Bleeding with no or minimal trauma
DIAGNOSTIC STUDIES
Serum calcium: Decreased, less than 4.5 mEq/L or 8.5 mg/dL (total), 2.1 mEq/L (ionized)
Urine Sulkowitch test: Shows light or no precipitate.
ECG: Prolonged QT interval (characteristic but not necessarily diagnostic). In severe deficiency, T waves
may flatten or invert, giving appearance of hypokalemia or myocardial ischemia; ventricular
tachycardia may develop.
Related electrolyte imbalances:

Hypomagnesemia, hypokalemia, hyperphosphatemia
MANAGEMENT
1. Calcium gluconate 10% IV
2. Calcium chloride 10% IV
- both usually given by Dr, very slowly; venous irritant; cardiac probs
3. Oral: calcium citrate, lactate, carbonate; Vit D supplements
4. Diet: high calcium
5. WOF: tetany, seizures, laryngospasm, resp & cardiac arrest
seizure precautions
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
1. Display heart rhythm and laboratory results WNL for patient, absence of neuromuscular irritability,
respiratory impairment.
NURSING ACTIONS/INTERVENTIONS
Electrolyte Management: Hypocalcemia
Independent
1. Monitor heart rate/rhythm.
2. Assess respiratory rate, rhythm, effort. Have tracheostomy equipment available.
3. Observe for neuromuscular irritability, e.g., tetany, seizure activity. Assess for presence of
Chvostek’s/Trousseau’s signs.
4. Provide quiet environment and seizure precautions as appropriate.
5. Encourage relaxation/stress reduction techniques, e.g., deep-breathing exercises, guided imagery,
visualization.
6. Check for bleeding from any source (mucous membranes, puncture sites, wounds/incisions, and
so on). Note presence of ecchymosis, petechiae.
7. Review patient’s drug regimen, e.g., use of insulin, mithramycin (Mithracin), parathyroid
injection, digitalis.

8. Discuss use of laxatives/antacids.
9. Review dietary intake of vitamins and fat.
10. Identify sources to increase calcium and vitamin D in diet, e.g., dairy products, beans,
cauliflower, eggs, oranges, pineapples, sardines, shellfish. Restrict intake of phosphorus, e.g.,
barley, bran, whole wheat, rye, liver, nuts, chocolate.
11. Encourage use of calcium-containing antacids if needed (e.g., Titralac, Dicarbosil, Tums).
12. Stress importance of meeting calcium needs.
Collaborative
13. Assist with identification/treatment of underlying cause.
14. Monitor laboratory studies, e.g.: Serum calcium and magnesium; serum albumin, ABGs; PT,
platelets.
15. Administer the following:
 Calcium gluconate/gluceptate/chloride IV;
 Oral preparations, e.g., calcium lactate/carbonate;
 Magnesium sulfate IV/PO if indicated;
 Vitamin D supplement (e.g., calcitriol).
2. HYPERCALCEMIA (Calcium Excess) - usually from bone resorption

Cause
• Hyperparathyroidism (eg. adenoma)
• Metastatic cancer (bone resorption as tumor’s ectopic PTH effect) – eg. Multiple myeloma
• Thiazide diuretics (potentiate PTH effect)
• Immobility
• Milk-alkali syndrome (too much milk or antacids in eggs with peptic ulcer)
PREDISPOSING/CONTRIBUTING FACTORS
Hyperparathyroidism, hyperthyroidism, multiple myeloma/other malignancies (e.g.,
cancer of breast, lung); renal disease, skeletal muscle paralysis, parathyroid
tumor, sarcoidosis, adrenal insufficiency, TB
Excessive/prolonged use of vitamins A and D and calcium-containing antacids;
prolonged use of thiazide diuretics, theophylline, lithium
Multiple fractures, bone tumors, osteoporosis, osteomalacia, prolonged
immobilization causing imbalance between the rate of bone formation and
resorption
Milk-alkali syndrome as a side effect of prolonged milk/antacid self-medication for
gastric pain/ulcer
Hypophosphatasia, hyperproteinemia
Anticancer drugs, e.g., tamoxifen, androgens/estrogens

Patient Assessment
ACTIVITY/REST
May report: General malaise, fatigue/weakness
Lethargy, coma
May exhibit: Incoordination, ataxia
CIRCULATION
May exhibit: Hypertension
Irregular pulse, dysrhythmias, bradycardia, arrythmia
ECG: shortened QT interval, decreased ST segment
ELIMINATION
May report: Constipation, decreased bowel sounds
May exhibit: Polyuria, nocturia
Kidney stones/calculi
FOOD/FLUID
May report: Anorexia, nausea/vomiting
Thirst
ABDOMINAL PAIN
May exhibit: Poor skin turgor, dry mucous membranes
NEUROSENSORY
May report: Headache
May exhibit: Hypotonicity/muscular relaxation, Hyporeflexia, flaccid paralysis, depressed/absent
deep-tendon reflexes
Drowsiness, apathy, paranoia, personality changes, decreased attention span,
memory loss, depression, inappropriate/bizarre behaviors, psychosis, confusion,
stupor/coma
Slurred speech
PAIN/DISCOMFORT
May report: Epigastric, deep flank pain, or bone/joint pain
Bone fractures from resorption
DIAGNOSTIC STUDIES
Serum calcium: Increased, greater than 2.6 mEq/L (ionized) or 10.5 mg/dL (total).
BUN: Increased (calculi can damage kidney).
Serum phosphorus: Decreased levels may be noted.
Urine Sulkowitch test: Shows heavy precipitate.
Urine calcium: Increased.
Urine osmolality: Decreased.
Urine specific gravity: Decreased.
X-ray: May reveal evidence of bone cavitation, pathological fracture, osteoporosis, urinary calculi.

ECG changes: Shortened QT interval, inverted T waves. In severe deficit, QRS may widen, PR interval
lengthen, and ventricular prematurities develop.
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Display heart rhythm, muscle strength, cognitive status, and laboratory results WNL for patient.
MANAGEMENT
1. If parathyroid tumor = surgery
2. Diet: low Ca, stop taking Ca Carbonate antacids, increase fluids
3. Hydrate (usually NaCl or Saline diuretics)
4. Loop diuretics(LASIX)
5. Corticosteroids—dec.plasma Ca
6. Inorganic PO4 [Inc.PO4—Dec.Ca.]
7. Biphosphonates, like etidronate (Calcitonin) & alendronate (Fosamax)
8. Plicamycin (Mithracin) – inhibits bone resorption
9. Calcitonin – IM or intranasal
10. Dialysis (severe case)
11. WOF: digitalis toxicity
12. Prevent fractures, handle gently
NURSING ACTIONS/INTERVENTIONS
Electrolyte Management: Hypercalcemia
Independent
1. Monitor cardiac rate/rhythm. Be aware that cardiac arrest can occur in hypercalcemic crisis.
2. Assess level of consciousness and neuromuscular status, e.g., muscle movement, strength, tone.
3. Monitor I&O; calculate fluid balance.
4. Encourage fluid intake of 3–4 L/day, including sodium-containing fluids, (within cardiac
tolerance) and use of acid-ash juices, e.g., cranberry and prune if kidney stones present or
suspected.
5. Strain urine if flank pain occurs.
6. Auscultate bowel sounds.
7. Maintain bulk in diet.
8. Encourage frequent repositioning and ROM and/or muscle-setting exercises with caution.
Promote ambulation if patient is able.
9. Provide safety measures, e.g., gentle handling when moving/transferring patient.
10. Review drug regimen, noting use of calcium-elevating drugs, e.g., heparin, tetracyclines,
methicillin, phenytoin.
11. Identify/restrict sources of calcium intake, e.g., dairy products, eggs, and spinach; calcium-
containing antacids (Titralac, Dicarbosil, Tums).
Collaborative
1. Assist with identification/treatment of underlying cause.
2. Monitor laboratory studies, e.g., calcium, magnesium, phosphate.

3. Administer isotonic saline and sodium sulfate IV/
orally.
4. Prepare for/assist with hemodialysis.
5. Administer medications as indicated:
 Diuretics, e.g., furosemide (Lasix);
 Sodium bicarbonate;
 Phosphate;
 Glucocorticoid therapy;
 Mithramycin (Mithracin);
 Disodium edetate (EDTA);
 Calcitonin;
 Neutra-Phos, Fleet Phospho-Soda.


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2.3 HYPOCALCEMIA and HYPERCALCEMIA

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Fluids and Electrolytes

Far Eastern University

Far Eastern University

Related electrolyte imbalances:

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Far Eastern University

2. HYPERCALCEMIA (Calcium Excess) - usually from bone resorption

Far Eastern University

Far Eastern University

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Far Eastern University

Far Eastern University

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