FLUIDS AND ELECTROLYTES HYPOCALCEMIA DESCRIPTION A serum calcium

FLUIDS AND ELECTROLYTES

HYPOCALCEMIA • DESCRIPTION – A serum calcium level below 8. 6 mg/d. L – The normal serum calcium level is 8. 6 to 10. 0 mg/d. L

HYPOCALCEMIA • CAUSES – Inhibition of calcium absorption from the GI tract • Inadequate oral intake of calcium • Lactose intolerance • Malabsorption syndromes such as celiac or Crohn’s disease • Inadequate intake of vitamin D • End-stage renal disease

HYPOCALCEMIA • CAUSES – Increased calcium excretion • Renal failure, polyuric phase • Diarrhea • Steatorrhea • Wound drainage, especially GI

HYPOCALCEMIA • CAUSES – Conditions that decrease the ionized fraction of calcium • Hyperproteinemia • Alkalosis • Medications such as calcium chelators or binders • Acute pancreatitis • Hyperphosphatemia • Immobility • Removal or destruction of the parathyroid glands

HYPOCALCEMIA • ASSESSMENT – Cardiovascular • Decreased myocardial contractility and heart rate • Hypotension • Diminished peripheral pulses • ECG changes: Prolonged ST interval, prolonged QT interval – Respiratory • Not directly affected; however, respiratory failure or arrest can result from decreased respiratory movement because of muscle tetany or seizures

HYPOCALCEMIA • ASSESSMENT – Neuromuscular • Irritable skeletal muscles: twitches, cramps, tetany, seizures • Painful muscle spasms in the calf or foot during periods of inactivity • Paresthesias followed by numbness that may affect the lips, nose, and ears in addition to the limbs • Positive Trousseau’s and Chvostek’s signs • Hyperactive deep tendon reflexes • Anxiety, irritability, psychosis

HYPOCALCEMIA • ASSESSMENT – GI • Increased gastric motility, hyperactive bowel sounds • Abdominal cramping, diarrhea

HYPOCALCEMIA • IMPLEMENTATION – Monitor cardiovascular, respiratory, neuromuscular, and GI status; place client on a cardiac monitor – Administer oral calcium supplements or intravenous (IV) calcium – When administering IV calcium, warm injection to body temperature before administration; administer slowly; monitor for ECG changes; observe for infiltration; and monitor for hypercalcemia and hypomagnesemia

HYPOCALCEMIA • IMPLEMENTATION – Administer medications that increase calcium absorption – Aluminum hydroxide reduces serum phosphorus levels, causing the countereffect of increasing calcium levels – Vitamin D aids in the absorption of calcium from the intestinal tract – Administer medications that reduce nerve and skeletal muscle excitability

HYPOCALCEMIA • IMPLEMENTATION – Provide a quiet environment to reduce environmental stimuli – Initiate seizure precautions – Keep 10% calcium gluconate available for treatment of acute calcium deficit – Move client carefully and monitor for signs of a fracture – Instruct client to take oral calcium supplements 1 to 2 hours after meals or at bedtime to maximize intestinal absorption – Instruct client to consume foods high in calcium

HYPERCALCEMIA • DESCRIPTION – A serum calcium level that exceeds 10 mg/d. L

HYPERCALCEMIA • CAUSES – Increased calcium absorption • Excessive oral intake of calcium • Excessive oral intake of vitamin D – Decreased calcium excretion • Renal failure • Use of thiazide diuretics

HYPERCALCEMIA • CAUSES – Increased bone resorption of calcium • Hyperparathyroidism • Hyperthyroidism • Malignancy • Immobility • Use of glucocorticoids – Hemoconcentration • Dehydration • Use of lithium • Adrenal insufficiency

HYPERCALCEMIA • ASSESSMENT – Cardiovascular • Increased heart rate in early phase; bradycardia and cardiac arrest in late phases • Increased blood pressure • Bounding, full peripheral pulses • ECG changes: Shortened ST segment, widened T wave • Clot formation in vessels or organs in which blood flow is slow or blocked

HYPERCALCEMIA • ASSESSMENT – Respiratory • Ineffective respiratory movement as a result of profound skeletal muscle weakness – Neuromuscular • Profound muscle weakness • Diminished or absent deep tendon reflexes • Disorientation, lethargy, coma

HYPERCALCEMIA • ASSESSMENT – Renal • Increased urinary output leading to dehydration • Formation of renal calculi – GI • Decreased motility and hypoactive bowel sounds • Anorexia, nausea, abdominal distention, constipation

HYPERCALCEMIA • IMPLEMENTATION – Monitor cardiovascular, respiratory, neuromuscular, renal, and GI status; place client on a cardiac monitor – IV infusions of solutions containing calcium are discontinued as well as oral medications containing calcium or vitamin D – Thiazide diuretics are discontinued and are replaced with diuretics that enhance the excretion of calcium

HYPERCALCEMIA • IMPLEMENTATION – Administer an IV infusion of normal saline as prescribed to help restore serum calcium levels – Administer medications as prescribed that inhibit calcium resorption from the bone, such as phosphorus, calcitonin (Calcimar), biphosphonates (etidronate), and prostaglandin synthesis inhibitors (aspirin, nonsteroidal anti-inflammatory drugs)

HYPERCALCEMIA • IMPLEMENTATION – Prepare the client with severe hypercalcemia for dialysis or blood ultrafiltration if medications fail to reduce the serum calcium level – Move client carefully and monitor for signs of a fracture – Monitor flank or abdominal pain and strain urine to check for the presence of urinary stones – Instruct client at risk for hypercalcemia regarding the sources of calcium

HYPOMAGNESEMIA • DESCRIPTION – A serum magnesium level below 1. 6 mg/d. L – The normal serum magnesium level is 1. 6 to 2. 6 mg/d. L

HYPOMAGNESEMIA • CAUSES – Insufficient magnesium intake • Malnutrition and starvation • Diarrhea • Steatorrhea • Celiac disease • Crohn’s disease

HYPOMAGNESEMIA • CAUSES – Increased magnesium secretion • Medications such as diuretics, aminoglycoside antibiotics, cisplatin, amphotericin B, cyclosporine • Citrate (blood products) • Ethanol ingestion

HYPOMAGNESEMIA • CAUSES – Intracellular movement of magnesium • Hyperglycemia • Insulin administration • Sepsis • Alkalosis

HYPOMAGNESEMIA • ASSESSMENT – Cardiovascular • ECG changes: Tall T waves, depressed ST segments • Dysrhythmias • Hypertension – Respiratory • Shallow respirations

HYPOMAGNESEMIA • ASSESSMENT – GI • Decreased motility • Decreased bowel sounds • Anorexia, nausea, abdominal distention

HYPOMAGNESEMIA • ASSESSMENT – Neuromuscular • Fasciculations, twitches, paresthesias • Positive Trousseau’s and Chvostek’s signs • Hyperreflexia • Tetany, seizures – Central nervous system • Irritability • Confusion, psychosis

HYPOMAGNESEMIA • IMPLEMENTATION – Monitor cardiovascular, GI, respiratory, neuromuscular, and central nervous system status; place client on a cardiac monitor – Because hypocalcemia frequently accompanies hypomagnesemia, interventions also aim to restore normal serum calcium levels – Medications that contribute to hypomagnesemia are discontinued – Initiate seizure precautions – Instruct client regarding increasing the intake of foods that contain magnesium

HYPOMAGNESEMIA • IMPLEMENTATION – Magnesium sulfate (Mg. SO 4) by the IV route is administered in severe cases (intramuscular injections cause pain and tissue damage) – Monitor serum magnesium levels every 12 to 24 hours when the client is receiving magnesium by IV – Monitor for reduced deep tendon reflexes suggesting hypermagnesemia during administration of magnesium – Oral preparations of magnesium may cause diarrhea and increase magnesium loss

HYPERMAGNESEMIA • DESCRIPTION – A serum magnesium level that exceeds 2. 6 mg/d. L

HYPERMAGNESEMIA • CAUSES – Increased magnesium intake • Magnesium-containing antacids and laxatives • IV magnesium replacement – Decreased renal excretion of magnesium resulting from renal insufficiency

HYPERMAGNESEMIA • ASSESSMENT – Cardiovascular • Bradycardia • Peripheral vasodilation • Hypotension • Dysrhythmias • ECG changes: Prolonged PR interval, widened QRS complexes

HYPERMAGNESEMIA • ASSESSMENT – Respiratory • Respiratory insufficiency when the skeletal muscles of respiration are involved – Neuromuscular • Diminished or absent deep tendon reflexes • Skeletal muscle weakness – Central nervous system • Drowsiness and lethargy that progress to coma

HYPERMAGNESEMIA • IMPLEMENTATION – Monitor cardiovascular, respiratory, neuromuscular, and central nervous system status; place client on cardiac monitor – Oral and parenteral magnesium-containing medications are discontinued – Administer magnesium-free IV fluids as prescribed to reduce serum magnesium levels

HYPERMAGNESEMIA • IMPLEMENTATION – Administer high-ceiling (loop) diuretics as prescribed to increase renal excretion – Administer calcium when cardiac manifestations are severe to reverse the cardiac effects of hypermagnesemia – Instruct client regarding restricting dietary intake of magnesium-containing foods – Instruct client regarding avoiding the use of laxatives and antacids containing magnesium

HYPOPHOSPHATEMIA • DESCRIPTION – A serum phosphorus level below 2. 7 mg/d. L – A decrease in the serum phosphorus level is accompanied by an increase in the serum calcium level – The normal serum phosphorus level is 2. 7 to 4. 5 mg/d. L

HYPOPHOSPHATEMIA • CAUSES – Insufficient phosphorus intake • Malnutrition and starvation – Increased phosphorus excretion • Hyperparathyroidism • Renal failure • Malignancy • Use of aluminum hydroxide-based or magnesium-based antacids

HYPOPHOSPHATEMIA • CAUSES – Intracellular shift • Hyperglycemia • Hyperalimentation or total parenteral nutrition • Respiratory alkalosis

HYPOPHOSPHATEMIA • ASSESSMENT – Cardiovascular • Decreased contractility and cardiac output • Slowed peripheral pulses • Reversible cardiomyopathy – Respiratory • Shallow respirations

HYPOPHOSPHATEMIA • ASSESSMENT – Neuromuscular • Weakness • Rhabdomyolysis • Decreased deep tendon reflexes • Decreased bone density that can cause fractures and alterations in bone shape

HYPOPHOSPHATEMIA • ASSESSMENT – Central nervous system • Irritability • Confusion • Seizures – Hematological • Decreased platelet aggregation and increased bleeding • Immunosuppression

HYPOPHOSPHATEMIA • IMPLEMENTATION – Monitor cardiovascular, respiratory, neuromuscular, central nervous system, and hematologic status – Medications that contribute to hypophosphatemia are discontinued – Administer oral phosphorus along with a vitamin D supplement – IV phosphorus is administered only when serum phosphorus levels fall below 1 mg/d. L and when the client has serious clinical manifestations

HYPOPHOSPHATEMIA • IMPLEMENTATION – Assess renal system before administering phosphorus – Move client carefully and monitor for signs of a fracture – Instruct client regarding the use of antacids – Instruct client to increase intake of phosphorus -containing foods while decreasing the intake of calcium-containing foods

HYPERPHOSPHATEMIA • DESCRIPTION – A serum phosphorus level that exceeds 4. 5 mg/d. L – Elevated serum phosphorus levels are tolerated well by most body systems – An increase in the serum phosphorus level is accompanied by a decrease in the serum calcium level – The problems that occur in hyperphosphatemia center on the hypocalcemia that results when serum phosphorus levels increase

HYPERPHOSPHATEMIA • CAUSES – Decreased renal excretion resulting from renal insufficiency – Tumor lysis syndrome – Increased intake of phosphorus including dietary intake or overuse of phosphatecontaining laxatives or enemas – Hypoparathyroidism • ASSESSMENT – Refer to assessment of hypocalcemia

HYPERPHOSPHATEMIA • IMPLEMENTATION – Interventions entail the management of hypocalcemia – Administer phosphate-binding medications that increase fecal excretion of phosphorus by binding phosphorus from food in the GI tract – Instruct client to avoid phosphate-containing medications including laxatives and enemas – Instruct client how to take phosphate-binding medications emphasizing that they should be taken with meals or immediately after meals – Instruct client to decrease the intake of food high is phosphorus