CALCIUM IMBALANCES

The normal total serum calcium level is 8.6 to 10.2 mg/dL (2.2 to 2.6 mmol/L).
Hypocalcemia (Calcium deficit)
Hypocalcemia (serum values lower than 8.6 mg/dL [2.15 mmol/L]) occurs in a variety
of clinical situations. Elderly people and those with disabilities, who spend an
increased amount of time in bed, have an increased risk of hypocalcemia, because
bed rest increases bone resorption.
Factors that cause hypocalcemia:

Hypoparathyroidism
surgical hypoparathyroidism
massive administration of

citrated blood
pancreatitis
renal failure
Hyperphosphatemia
inadequate vitamin D

consumption
magnesium deficiency
medullary thyroid carcinoma

Clinical Manifestations:

Tetany, the most characteristic

manifestation of hypocalcemia
Sensations of tingling may

depression, impaired memory,

occur in the tips of the fingers,

hallucinations.
prolonged QT interval, torsades

de pointes
dyspnea and laryngospasm
Signs and symptoms of chronic

around the mouth, and, less

commonly, in the feet.

Spasms of the muscles of the

extremities and face may occur.

Hyperactive DTRs
Trousseaus sign
Chvosteks sign
Seizures

low serum albumin levels

alkalosis
alcohol abuse
Medications predisposing to
hypocalcemia include
aluminum-containing antacids,
aminoglycosides, caffeine,
cisplatin, corticosteroids,
mithramycin, phosphates,
isoniazid, and loop diuretics.

mental

changes

confusion,

such

delirium,

hypocalcemia

as
and

include

hyperactive bowel sounds, dry

and brittle hair and nails, and

abnormal clotting.
Osteoporosis

Medical Management:

Acute symptomatic hypocalcemia is life-threatening and requires prompt

treatment with IV administration of a calcium Salt.

Parenteral calcium salts include calcium gluconate, calcium chloride, and

calcium gluceptate.
Too-rapid IV administration of calcium can cause cardiac arrest, preceded by

bradycardia.
IV administration of calcium is particularly dangerous in patients receiving
digitalis-derived medications, because calcium ions exert an effect similar to

that of digitalis and can cause digitalis toxicity, with adverse cardiac effects.
Therefore, calcium should be diluted in D5W and administered as a slow IV

bolus or a slow IV infusion using a volumetric infusion pump.

A 0.9% sodium chloride solution should not be used with calcium because it

increases renal calcium loss.

Solutions containing phosphates or bicarbonate should not be used with

calcium because they cause precipitation when calcium is added.

Vitamin D therapy may be instituted to increase calcium absorption from the

GI tract
Increasing the dietary intake of calcium to at least 1000 to 1500 mg/day in the
adult is recommended.

Nursing Management:

Seizure precautions are initiated if hypocalcemia is severe.

Teach the patient with hypocalcemia what foods are rich in calcium.
Advise the patient to consider calcium supplements
Alcohol and caffeine in high doses inhibit calcium absorption, and moderate

cigarette smoking increases urinary calcium excretion.

The patient is also cautioned to avoid the overuse of laxatives and antacids
that contain phosphorus, because their use decreases calcium absorption.

Hypercalcemia (Calcium Excess)

Hypercalcemia (greater than 10.2 mg/dL [2.6 mmol/L]) is a dangerous

imbalance when severe. Hypercalcemia reduces neuromuscular excitability
because it suppresses activity at the myoneural junction. Decreased tone in

smooth and striated muscle may cause symptoms such as muscle weakness,
incoordination, anorexia, and constipation.

Factors that cause hypercalcemia:

Malignancies
hyperparathyroidism
immobilization
Thiazide diuretics

Clinical Manifestations:

Most

common:

nausea,

vomiting,

well as chronic lithium use and

theophylline toxicity

Anorexia,

increases the secretion of acid

and

and pepsin in the stomach

Confusion, impaired memory,

constipation

Dehydration
Abdominal and bone pain
Excessive urination
Severe thirst
Patients
with
chronic
hypercalcemia

may

milk-alkali syndrome
Vitamin A and D intoxication, as

develop

symptoms similar to peptic ulcer

slurred speech, lethargy, acute

psychotic behavior, or coma

may occur
The more severe symptoms
tend to appear when the serum
calcium level is approximately
16 mg/dL (4 mmol/L) or higher.

disease because hypercalcemia

Diagnostics:

Dysrhythmias
shortening of the QT
interval and ST segment.
The double-antibody PTH test may be used to differentiate between primary
hyperparathyroidism and malignancy as a cause of hypercalcemia: PTH
levels are increased in primary or secondary hyperparathyroidism and

suppressed in malignancy.
X-rays may reveal bone changes
The Sulkowitch urine test analyzes the amount of calcium in the urine

Medical Management:

Treating the underlying cause (eg, chemotherapy for a malignancy, partial

parathyroidectomy for hyperparathyroidism) is essential.

Measures include administering fluids to dilute serum calcium and promote its
excretion by the kidneys, mobilizing the patient, and restricting dietary calcium
intake.

IV administration of 0.9% sodium chloride solution

Administering IV phosphate
fluids and medications that contain calcium and dietary sources of calcium

should be halted
Calcitonin- useful for patients with heart disease or renal failure who cannot

tolerate large sodium loads

For patients with cancer, treatment is directed at controlling the condition by

surgery, chemotherapy, or radiation therapy.

Some bisphosphonates (eg, etidronate disodium [Didronel], pamidronate

disodium [Aredia], and ibandronate sodium [Boniva]) inhibit osteoclast activity.

Mithramycin, a cytotoxic antibiotic, inhibits bone resorption and thus lowers
the serum calcium level.

Nursing management:

Interventions such as increasing patient mobility and encouraging fluids can

help prevent hypercalcemia, or at least minimize its severity.

Fluids containing sodium should be administered unless contraindicated,

because sodium assists with calcium excretion.

Patients are encouraged to drink 3 to 4 quarts of fluid daily.
Adequate fiber in the diet is encouraged to offset the tendency for

constipation.
Safety Precautions
assess for signs and symptoms of digitalis toxicity.
cardiac rate and rhythm are monitored for any abnormalities