Fluids and Electrolytes 3

Mary J. Aigner RN, MSN, FNPC

 Hypercalcemia
Common Causes
 Hyperparathyroidism
 Malignant neoplasm

Most patients are asymptomatic

until serum Ca is over
11.5 to 13.5 mg/dl
 Less common causes

 Medications
 (eg. thiazide diuretics, lithium, estrogens,
antiestrogens)

 Granulomatous diseases
 (eg. TB, sarcoid, histoplasmosis,
coccidioidomycocsis)

 Renal insufficiency

 Immobilized patients w/rapid bone

turnover
 (eg. Paget’s disease, growing children, bone
metastases)

 Hyperthyroidism
From your textbook (Lewis):
re causes

 2/3’s hyper-PTH
 1/3 malignancy
 (breast, lung, multiple myeloma esp.)
 Also Vitamin D overdose
 Rarely from increased Ca intake
 eg. antacids w/Ca, excessive admin.
during cardiac arrest

Our text also tells us that >Ca blocks effect of Na in

Skeletal muscles = <excitability of muscles & nerves
 Symptoms of hypercalcemia
*Wha
Polyuria* t
 Neurologic  disea
se
Fatigue  Polydipsia* does

this
< MS* Nocturia remin
  d
Memory loss (recent)  you o

Dry mouth f?
 Coma if severe
 Weakness
 GI
 Constipation*
 Anorexia * Key Symptoms
 N/V

Key Signs:
altered mental status and
soft tissue calcifications
 The value of lab tests
 Confirm Ca is elevated (serum Ca)
 Compare to albumin level
 Each l gm/dl drop < 4 g/dl should show >
Ca by 0.8 mg/dl

 If Ca is elevated – search for cause

 Parathyroid hormone level checked
 If normal, other tests will be done
 (eg. CXR, TSH, UA, PSA, ENT exam,
Mammogram, serum protein electrophoresis)
Saunders, 2000
What About Nursing Diagnoses?
 Hypercalcemia

 Risk for injury r/t

 Neuromuscular Δ
 sensorium Δ

 Potential
complications
 arrhythmias
 Our favorite:
Nursing Interventions for > Ca
 Increase client exercise/movement
 Encourage PO intake (dilute urine)
 Teach re foods/fluids – limit >Ca
 Encourage > fiber (prevent constipation)
 Protect client if confused
 Monitor for pathologic fracture if >Ca longterm
 Encourage PO intake acid-ash fluids
 Eg. prune or cranberry juice

 Counteracts Ca salt deposits in the urine

Double Click here

to review symptoms
 Hyperparathyroidism: Remember? This
is primary cause of hypercalcemia!
 Key Symptoms
 80% primary cases
due to hyperactive
 Weakness, fatigue
PTH adenoma  Musculoskeletal
 Bone pain
 15% have PTH  Arthalgia
hyperplasia
 Neuro
 Confusion
 Depression
 GI
An elevated fasting  N/V
iPTH (immuno-  Constipation
Reactive PTH level)  Ulcers
w/>Ca confirms  GU
hyperPTH  Renal colic
 polyuria
 Practice Questions – Calcium/PTH
1. Hyperparathyroidism is
the primary cause of 1. Name the 2 key
hypercalcemia … name symptoms of
two medications that can hypercalcemia
also cause it. (similar to another
disease).
thiazide diuretics, lithium,
estrogens, and antiestrogens Polydipsia and Polyuria

5. Ca+ is the most

abundant mineral found 5. Name one (of two)
in the body (40%, 2% of acid-ash fluids that
weight); where is most are good for
of it found (2 places)? hypercalcemia.

Bones and Teeth Prune or Cranberry Juice

 Hypocalcemia - Causes
 Low albumin most common cause
 Why? Ca bound to protein (45%) in circulation
 < PTH activity can cause < Ca
 Vitamin D deficiency
 Ca sequestration in critically ill pt.
 Eg. soft tissue deposition, increase bone
deposition, or chelation
 Sepsis
 Medications
 Eg. drugs used to treat > Ca, or antineoplastic
agents
Key Symptoms of hypocalcemia
 Paresthesias
 Muscle cramps, carpopedal spasm
 Tetany, laryngospasm
 Lethargy, confusion, psychosis
 Seizures
 Symptoms of CHF, hypotension,
and bradycardia
Emergency RX: IV Ca Gluconate 10%,
10-20 ml infused over 10 minutes
 Two Signs: Do you know them?
Chvostek’s Sign Trousseau’s Sign
 Contraction of the  Carpal spasm
facial muscle in occurring after
response to occlusion of the
tapping the facial brachial artery with
nerve against the a blood pressure cuff
bone anterior to for 3 minutes.
the ear

Both signs (if +) indicate hypocalcemia.

Other Data on Hypocalcemia
 Key Tests Important Warnings re IV
 Albumin therapy:
 Phosphorus
 PTH 3. Phosphorus and
 Vitamin D bicarbonate are not
 ECG (EKG) compatible w/Ca
 Creatinine
 Magnesium
5. If on digitalis –
monitor closely as IV
Ca potentiates digitalis
toxicity
Saunders, 2000
 Nursing Diagnoses: hypocalcemia

 Risk for injury r/t

 Tetany
 Seizures

 Potential
complications
 Fracture
 Respiratory arrest
What about < Ca
interventions?
 CLOSELY monitor resp/CV status
 Protect confused client
 Administer PO/parenteral Ca as ordered
 If IV – closely monitor status and ECG

 Teach client at > risk for osteoporosis

 Diets rich in Ca
 Recommended: 1000-1500 mg Ca/day
 Ca supplements
 Regular exercise important
 Estrogen replacement therapy???? if postmenop.
 True or False: Answer these questions
Tachycardia and
hypertension are
both symptoms If
s e :
of
r Fal low
hypocalcemia. e o s a
Tru nt ha el, he
lie ev e
a c min l a fals
u
alb h ave evel)
u ld + l
c o C a
lo w
True
Chvo or Fa
lse: True o
stek r
whe
nac
’s Si
gn is It is im False:
occu a rpal to mo portant
rs af spas nitor b
of th t er oc m respir oth
e br clus atory
cardia an
with a c hial ion c statu d
a blo arte hypoc s
od p ry alcem in
cuff r essu ia.
for 3 re
minu
tes.
Phosphorus/Phosphate Imbalances
 Phosphorus is a
primary anion in ICF

 Essential for function

 Muscles
 Red blood cells
 Nervous system

 Deposited with Ca for

 Bone structure
 Tooth structure
Phosphorus also …
 Involved in

 Acid-base buffering
system
 Mitochondrial energy
production of ATP
 Cellular uptake and use
of glucose
 Acts as intermediary in
metabolism (carbs, fats,
proteins)
Kidney function must be adequate
 Kidneys are major route of
phosphorus excretion

 Small amount P lost in feces

 > P tends to cause < Ca in serum

 (A reciprocal relationship)
 Hyperphosphatemia
 Main cause: acute or  Hyper-P results in
chronic renal failure metastatic Ca/P
deposits
 Normally only in bone
 Other:
 Chemotherapy
 Eg. lymphomas  Results in Ca deposits
 Excessive PO intake of in soft tissue
milk or P containing  Skin
laxatives  Joints
 large intake Vit D  Arteries
 Increases GI  Kidneys
absorption of P  cornea
 What can be done for >P?
1. Identify/RX cause
2. Restrict >P foods
 Dairy products
3. Adequate hydration
4. Correct <Ca status
 3+4 enhance renal
excretion of P
 Special measures
used in renal failure
Nsg Dx?
 Ca supplements
 P binding agents Nsg Rx?
 Diet restrictions
 What about low P?
Hypophosphatemia?
 Primary Causes: Symptoms of < P
 Malnutrition or
Malabsorption
syndrome  Confusion, coma
 Rhadomyolysis
 Other Causes:  Renal tubular wasting of
 Alcohol withdrawal Mg, Ca, HCO3
 Phosphate-binding  Arrhythmias, < stroke
antacids volume
 TPN  Muscle weakness,
 Glucose administration includes resp.
• Recovery from diabetic  Osteomalacia
ketoacidosis
 Respiratory alkalosis
 Management of < P ???
 Oral supplement
 Eg. Nutra-Phos
 PO foods high in P
 Eg. dairy products

 Severe <P may need

 IV of Na or K
phosphate
 P levels need
monitoring
 Sudden hypocalcemia

may occur
(2° Ca-P binding)
Some precautions re Phosphorus
 Phosphorus is
 incompatible with Ringer’s or lactated
Ringer’s solution, D10/0.9%NS, or D5
lactated Ringer’s solution
 Because of the inverse relationship
with Ca …
 if Ca+ falls too fast, tetany can occur
 Never give Phosphorus IM
 Dietary Comments re Phosphorus
 1 quart cow’s milk daily
 Supplies daily requirement of Phosphorus
 Provides necessary amt of Vitamin D to enhance
absorption
 Other foods high in Phosphorus:
 Cheese, egg yolk, meat, fish, fowl, nuts
 Spinach, rhubarb, bran, whole grains
 May decrease phosphorus absorption

 Good oral Phosphorus supplements are K-Phosphare,

Neutra-Phos K, and Phospha-Soda
 Preparations with Na and K can cause osmotic
diarrhea, volume overload, or hyperkalemia
 Practice Q’s for Phosphorus
1. True or False:
1. True or False:
Vegetables and fruit
hyperphosphatemia
are high in phosphorus.
commonly occurs with
renal failure.
False
True

5. True or False: there is

an inverse relationship
5. Name a Vitamin that in
between Phosphorus
excess can cause
and Ca+ (one rises,
hyperphosphatemia.
other falls, and vice
versa)
Vitamin D
True
 Magnesium Imbalances
 ICF – 2nd most common cation
 Only 1% found in ECF
 50-60% found in bone
 Involved in cell metabolism
 Cell proteins and nucleic acids
 Coenzyme in metabolism of BO
Carbs and proteins
NE


 Regulated by GI absorption
 Excreted by kidneys
 Mg related to Ca and K balance
 Often mistaken for Ca imbalance
 Best to measure Mg, Ca, and K
 > Mg Causes
 Renal failure, adrenal insufficiency, excess Mg
given in ecclampsia
 < Mg Causes
 Diarrhea, vomiting, chronic alcoholism,
 NG suction, prolonged malnutrition (starvation),
 Malabsorption syndrome, poor GI absorption
 Poorly controlled DM
 hyperaldosteronism
< Mg Symptoms/Treatment > Mg
 Resembles <Ca  Usu > Mg intake 2°
 May contribute to renal failure or insuff.
start of <Ca  Mild: lethargy, N/V,
RX: drowsiness
 Mild:  Worsening:
 oral supplements,  Lose DTRs
 Foods high in Mg  Somnolence
 Resp arrest, then
 Severe:
 Cardiac arrest
 IV or IM Mg
 *Too rapid infusion
can cause cardiac or >Mg
resp arrest! Best RX is prevention!
IV of Ca gluconate/Cl
Increase urine output/dialysis
 Where do we get Magnesium?
 Present in plant pigment chlorophyll
 So – mainly ingested from veggies
 Spinach, broccoli, squash, avocado, potato, lima

beans
 Others: whole grains (esp. wheat germ), rolled

oats, nuts, seeds

 Some meats: tuna, beef, pork, chicken

 Another common source: hard tap water

(well water)
 Because Mg is so common in food and water
… healthy people usually have plenty.
One more imbalance – protein
 Plasma volume greatly affected by
plasma proteins – esp. albumin
 Large molecular size
 Stay in vascular space
 Contribute to colloidal oncotic pressure
 Causes and Symptoms of
Hypoproteinemia Hyperproteinemia
 Decreased food  Dehydration
intake
 Hemoconcentration
 Starvation
 Rare
 Liver disease

 Massive burns
What about Atkin’s
Diet?
 Renal disease Could it lead to
 Lose albumin hyperproteinemia?
 Major infection
Symptoms and Treatment
< Protein  High carb, high
 Edema from < protein diet
oncotic pressure
 Slow healing  Protein
 Anemia supplements
 Fatigue
 Muscle loss (body  Enteral or
breaks down tissue parenteral
to get protein) nutrition may be
 Ascites (< vascular needed
oncotic pressure)
 FYI:
Protein-Calorie Malnutrition (Ch 39)
 Primary < PO
 Can occur if eats but foods are low in protein
 Secondary
 Malabsorption, Cancer, other defects Edema can mask
emaciation
 Marasmus
 <calorie,<protein = loss body fat/muscle
 Appear emaciated but serum levels may be ok
 Kwashiorkor
 <protein with catabolic stress event (eg cancer
or surgery)
 May appear well but serum levels very low
 A few questions about
Magnesium and Protein

Hyperproteinemia is rare What is the best

but what two conditions treatment for
can cause it? hypermagnesemia?

What diet is
recommended for
clients with
hypoproteinemia?
Before the next class,
read about Acid-Base Balance