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 fibersbecome more and more excitable and may dischargespontaneously, causing muscles to twitch and to gointo spasms or even tetany. Spasms of the musclesof the larynx interfere with respiration and may leadto death. During hypocalcemia, the bone is stimulatedto release calcium, which makes the boneosteoporotic and subject to fracture. Hypocalcemiaincreases capillary permeability; causesneuromuscular excitability of skeletal, smooth, andcardiac muscles; and decreases blood coagulation,which results in bleeding. Severe hypocalcemiacauses neuromuscular excitability that result intetany. If it is untreated, convulsions and death canoccur. Acute hypocalcemia may cause cardiacinsufficiency 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.
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 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.
Pathophysiology Because calcium levels are increased,there is a lesser gradient between the cell andthe serum. There is also an increased amountof calcium in the cell. Therefore, the thresholdbecomes more difficult to achieve and the cellmembrane becomes refractoryto depolarization. As a result, cardiac andsmooth muscle activity is decreased. Calciumin the bloodstream impairs renal function and itprecipitates as a salt, forming renal stones.Some cancer tumors destroy the bone,whereas others such as lung and breastcancers cause an ectopic PTH production.Hypophosphatemia is a complication ofexcessive PTH production that promotescalcium retention. A shortened QT segmentand depressed T waves may be seen on ECG.
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