HYPERCALCEMIA

PRESENTED BY: (Roll no 37 to 40)

Suchita Neupane
Sulochana Lamichhane
Swikriti Aryal
Yamuna Aryal
General Objectives:
 At the end of this session, all the participants will be
able to explain about hypercalcemia (calcium
excess).
Specific Objectives:
 At the end of this session, all the participants will be able to:
 Introduce calcium
 Introduce Parathyroid hormone
 Introduce Hypercalcemia
 List its causes
 Explain its signs and symptoms
 List its diagnostic procedures
 Explain Treatment measures
 Its complications
 Nursing care in hospital and home
CALCIUM
 Calcium is a mineral that is necessary for life. In addition to building bones and keeping
them healthy, calcium enables our blood to clot, our muscles to contract, and our
heart to beat. About 99% of the calcium in our bodies is in our bones and teeth.

 Balance of calcium is controlled by parathyroid hormone, calcitonin and vitamin D.

 The functions of calcium includes:

a. Transmission of nerve impulses and myocardial/ muscle contractions.
b. Activation of Blood clotting factors
c. Formation of teeth and bones and keeping them strong and healthy.
d. Regulation of heart beat.
e. Oocyte activation.
PARATHYROID HORMONE
 Parathyroid hormone (PTH), also called parathormone or parathyrin, is a hormone secreted

by the parathyroid glands that regulates the serum calcium concentration through its effects

on bone, kidney, and intestine.

 When the calcium level in blood decreases, the parathyroid glands produce more parathyroid

hormone. It does the following:

• Stimulates bones to release calcium into blood

• Causes the kidneys to excrete less calcium in urine

• Stimulates the digestive tract to absorb more calcium

• Causes the kidneys to activate vitamin D, which enables the digestive tract to absorb

more calcium
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 When the calcium level in blood increases, the parathyroid glands produce less

hormone.

 Calcitonin is produced by cells of the thyroid gland. It lowers the calcium level in

blood by slowing the breakdown of bone, but only slightly.
HYPERCALCEMIA
 Hypercalcemia is a condition in which the calcium level in the blood is above
normal. Too much calcium in blood can weaken our bones, create kidney stones,
and interfere with how our heart and brain work.

 Hypercalcemia is usually a result of overactive parathyroid glands. These four tiny

glands are situated in the neck, near the thyroid gland. Other causes of
hypercalcemia include cancer, certain other medical disorders, some medications,
and taking too much of calcium and vitamin D supplements.
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Normal level of calcium in blood= 8.6 to 10.3 mg/dl

Mild hypercalcemia= 10.5 to 11.9 mg/dl

Moderate hypercalcemia= 12-13.9 mg/dl

Severe hypercalcemia= 14-16 mg/dl

CAUSES:
The causes of hypercalcemia includes the following:

 Overactive parathyroid glands (hyperparathyroidism): This most common cause of

hypercalcemia can stem from a small, noncancerous (benign) tumor or
enlargement of one or more of the four parathyroid glands.(2/3rd of the cases)

 Cancer: Lung cancer and breast cancer, as well as some blood cancers, can increase
the risk of hypercalcemia. Spread of cancer (metastasis) to our bones also increases
the risk.

 Hereditary factors: A rare genetic disorder known as familial hypocalciuric

hypercalcemia causes an increase of calcium in our blood because of faulty calcium
receptors in our body. This condition doesn't cause symptoms or complications of
hypercalcemia.
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 Other diseases: Certain diseases, such as tuberculosis and sarcoidosis, can raise
blood levels of vitamin D, which stimulates our digestive tract to absorb more
calcium.

 Immobility: People who have a condition that causes them to spend a lot of time
sitting or lying down can develop hypercalcemia. Over time, bones that don't bear
weight release calcium into the blood.

 Severe dehydration: A common cause of mild or transient hypercalcemia is

dehydration. Having less fluid in our blood causes a rise in calcium concentrations.
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 Medications: Certain drugs — such as lithium (used to treat bipolar disorder ) ,
thiazides might increase the release of parathyroid hormone.

 Zollinger- Ellison Syndrome: It is a rare condition in which one or more tumors form
in pancreas or the upper part of small intestine (duodenum). These tumors, called
gastrinomas, secrete large amounts of the hormone gastrin, which causes stomach
to produce too much acid.

 Supplements: Taking excessive amounts of calcium or vitamin D supplements over

time can raise calcium levels in blood above normal.
SIGNS AND SYMPTOMS:
Signs and symptoms of hypercalcemia range from nonexistent to severe. We might not
have signs or symptoms if our hypercalcemia is mild. More-severe cases produce signs
and symptoms related to the parts of our body affected by the high calcium levels in our
blood. It includes:

 Kidneys: Excess calcium makes our kidneys work harder to filter it. This can cause
excessive thirst and frequent urination. Also, it adds to formation of renal stones.

 Digestive system: Hypercalcemia can cause stomach upset, nausea, vomiting and
constipation.
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 Bones and muscles: In most cases, the excess calcium in our blood is leached from our
bones, which weakens them. This can cause bone pain and muscle weakness.

 Brain: Hypercalcemia can interfere with how our brain works, resulting in confusion,
lethargy and fatigue. It can also cause depression.

 Heart: Rarely, severe hypercalcemia can interfere with our heart function, causing
palpitations and fainting, indications of cardiac arrhythmia, and other heart problems.

When to see a doctor

 Contact doctor if you develop signs and symptoms that might indicate hypercalcemia,

such as being extremely thirsty, urinating frequently and having abdominal pain.
DIAGNOSTIC PROCEDURES:
 History taking

i. Health history

ii. Medication history

iii. Family history

 Physical Examination

 Because hypercalcemia can cause few, if any, signs or symptoms, we might not know
one has the disorder until routine blood tests reveal a high level of blood calcium.
Blood tests can also show whether our parathyroid hormone level is high, indicating
that we have hyperparathyroidism.
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 Serum BUN and Serum creatinine level is checked in patients with renal disease.

 After diagnosing hypercalcemia, a doctor may perform further tests, such as:

• an ECG to record of the electrical activity of the heart.

• a chest X-ray to check for lung cancer or infections.

• a mammogram to check for breast cancer.

• a CT or MRI to examine the body’s structure and organs.

• dual energy X-ray absorptiometry, commonly known as a DEXA scan, to measure

bone density.
TREATMENT MEASURES:
 Treatment depends upon cause.

 If hypercalcemia is mild, doctor might choose to watch and wait, monitoring our bones
and kidneys over time to be sure they remain healthy.

 For more severe hypercalcemia, doctor might recommend medications or treatment of

the underlying disease, including surgery. The medications used are listed as follows:

• Calcitonin: This hormone from salmon controls calcium levels in the blood. Mild nausea
might be a side effect.

# Salmon Calcitonin (4 IU/kg) administerd IM or Sub-cut every 12 hours.

• Calcimimetics: This type of drug can help control overactive parathyroid glands. Cinacalcet
(Sensipar) has been approved for managing hypercalcemia.
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• Bisphosphonates: Intravenous osteoporosis drugs, which can quickly lower calcium
levels, are often used to treat hypercalcemia due to cancer. Risks associated with
this treatment include breakdown (osteonecrosis) of the jaw and certain types of
thigh fractures.

# The choice of drug is Zoledronic Acid (ZA): 4mg IV over atleast 15 minutes.

• Denosumab: This drug is often used to treat people with cancer-caused

hypercalcemia who don't respond well to bisphosphonates.

• Prednisone:  If your hypercalcemia is caused by high levels of vitamin D, short-term

use of steroid pills such as prednisone are usually helpful. 20 to 40mg of Prednisone
will reduce serum calcium concentration within 2 to 5 days by decreasing calcitriol
production.
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• IV fluids and diuretics. 

 Extremely high calcium levels can be a medical emergency. You might need
hospitalization for treatment with IV fluids and diuretics to promptly lower the
calcium level to prevent heart rhythm problems or damage to the nervous system.

 It is a reasonable regimen used when there is absence of edema and other co-
morbid conditions.

 An initial rate of 200 to 300 ml/hr given to maintain urine output of 100 to 150
ml/hr with intensive furosemide administration ( 80 to 100mg in every 1-2 hrs).

• Dialysis for the patient who are in ESRD.

COMPLICATIONS:
The complications of Hypercalcemia include:

 Osteoporosis: If our bones continue to release calcium into our blood, we can
develop the bone-thinning disease osteoporosis, which could lead to bone
fractures, spinal column curvature and loss of height.

 Kidney stones: If urine contains too much calcium, crystals might form in our
kidneys. Over time, the crystals can combine to form kidney stones. Passing a stone
can be extremely painful.

 Kidney failure: Severe hypercalcemia can damage our kidneys, limiting their ability
to cleanse the blood and eliminate fluid.
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 Nervous system problems: Severe hypercalcemia can lead to confusion, dementia
and coma, which can be fatal.

 Abnormal heart rhythm (arrhythmia): Hypercalcemia can affect the electrical

impulses that regulate our heartbeat, causing our heart to beat irregularly.
NURSING CARE
Nursing care at hospital:
 Obtain detail medical history of patient.

 Assess the vital signs of the patient.

 Assess the factors that aggravate hypercalcemia. It includes:

a. Medicines used

b. Calcium supplementation

The specific care provided to the patient with hypercalcemia are described as follows:

 Dietary modification: Intake of calcium rich food is limited.

 ( Normally 1000mg/day calcium is required for the proper functioning of body. Good
sources of calcium includes milk, cheese, yogurt, soy products, sardines, canned
salmon, fortified cereal, and dark leafy vegetables ). The amount of calcium to be
taken by patient with hypercalcemia ranges from 100 to 300mg/day
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 Fluid Encouragement (unless contraindicated):

- Intake of more fluid promotes elimination of calcium through urine.

- Staying hydrated may lower blood calcium levels, and it can help to prevent kidney
stones.

 Encouragement of sodium containing fluid (unless contraindicated):

- 0.9% NaCl which contains 154 mmol/l sodium.

- Sodium increases calcium excretion.

 Monitoring serum calcium levels: Continuous monitoring of calcium level helps to

know the effectiveness of the treatment. Also, Sodium and Potassium levels should
strictly be monitored if patient is under diuretics use.
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 Monitoring Cardiac rhythm:

- Hypercalcemia can interfere with the heart function. So, cardiac rhythm should be
monitored to prevent complications.

-Monitor for ECG changes, such as bradycardia, atrioventricular blocks, and

shortening of the QT interval.

 Close monitoring of patient’s fluid status:

-Proper maintenance of patient’s fluid intake and output is necessary.

 Assess the patient for muscle weakness and lethargy. 

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 Supportive Care:

• Preventing and managing side effects of therapy, such as getting too much fluid.

• Protecting from injury caused by confusion.

• Preventing fractures by being gentle.

• Helping with walking and other weight bearing exercises.

• Controlling pain, nausea, vomiting, and constipation.

Nursing care at home:
The patient and the family members play an important role in caring client with
hypercalcemia at home. The following are the measures:

 Dietary modification: Educate patient and family about limiting intake of calcium
rich foods. Sodium rich food is encouraged as it helps in excretion of calcium via
urine.
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 Fluid intake: Patient is advised to drink plenty of water (unless contraindicated) as
it helps in increasing urine output and eventually excretion of calcium through
urine. It also helps in preventing formation of renal stones.

 Quitting smoking and substance abuse: Smoking can increase bone loss. In
addition to improving the health of the bones, quitting will reduce the risk of
cancer and other health problems.

 Regular exercise: Both active and passive exercises is recommended. Exercise

increases absorption of calcium in bones . This eventually helps in lowering
concentration of calcium in blood.
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 Follow guidelines for medications and supplements: Doing so may decrease the
risk of consuming too much vitamin D and developing hypercalcemia. Intake of
calcium supplements is contraindicated. Don’t take any medications without
doctors prescription.

 Monitor serum calcium levels: This helps in evaluating the effectiveness of the
treatment measures used.

 Follow-up appointments with the doctor for chronic disease treatment.

 Consult doctors if severe symptoms are seen such as confusion, cardiac

arrhythmias.