1. Calcium
Imbalances

2. 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.

3. Pathophysiology
A lack of PTH results in inactivity of osteoclasts and a
consequent fall in serum calcium levels. Nerve fibers
become more and more excitable and may discharge
spontaneously, causing muscles to twitch and to go
into spasms or even tetany. Spasms of the muscles
of the larynx interfere with respiration and may lead
to death. During hypocalcemia, the bone is stimulated
to release calcium, which makes the bone
osteoporotic and subject to fracture. Hypocalcemia
increases capillary permeability; causes
neuromuscular excitability of skeletal, smooth, and
cardiac muscles; and decreases blood coagulation,
which results in bleeding. Severe hypocalcemia
causes neuromuscular excitability that result in
tetany. If it is untreated, convulsions and death can
occur. Acute hypocalcemia may cause cardiac
insufficiency and cardiac dysrhythmias.

5. Risk Factors:
• People who have had
parathyroidectomy
• Older adults (especially women)
• People with lactose intolerance
• Alcoholic people

6. Causes:
• Parathyroidectomy
• Acute Pancreatitis
• Inadequate dietary intake
• Lack of sun exposure
• Lack of weight bearing exercise
• Drugs: Loop diuretics, calcitonin
• Hypomagnesemia, alcohol
abuse

7. 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.

11. • Neuromuscular signs:
 Tetany and Convulsions – most
serious manifestation; tonic
muscular spasms.
 Paresthesias
 Muscle spasms
 Laryngospasms
 Seizures
 Anxiety, confusion, psychosis

12. Collaborative Care:
• Management of
hypocalcemia is directed
toward restoring normal
calcium balance and
correcting the underlying
cause.

13. Diagnostic Exams:
• Total serum calcium
• Serum albumin
• Serum magnesium
• Serum phosphate
• Parathyroid hormone
• ECG

14. Medical Management:
• Oral or intravenous calcium
Calcium Chloride
Calcium Gluconate
Calcium Lactate
Calcium Citrate
Calcium Gluceptate
Calcium Carbonate

15. 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

16. • 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.

17. • Diet high in calcium:
cottage cheese
Cheese
Milk
Cream
Yogurt
ice cream
Spinach
Tofu
broccoli

18. Nursing Process
Assessment:
• Subjective Data:
• Fatigue
• Tingling/numbness; fingers and
• circumoral
• Abdominal cramps
• Palpitations
• •Dyspnea

19. • Objective Data:
 Muscle spasms: tonic muscles,
 carpopedal, laryngeal
 Neuromuscular: grimacing,
 hyperirritable facial nerves
 Tetany convulsions
 Orthopedic: osteoporosis fractures
 Cardiac: arrhythmias arrest
 GI: diarrhea

20. 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

21. • Pain
• Diarrhea
• Hypocalcemia
• Altered nutrition, less than body
requirements
• requirements
• Sensory-perceptual alteration
• (gustatory)

22. 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.

23. 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.

25. Hypercalcemia
• Is a serum calcium value greater
than 10.0 mg/dL
• Usually results from increased
absorption of calcium from the
bones and intestines.

26. Pathophysiology
Because calcium levels are increased,
there is a lesser gradient between the cell and
the serum. There is also an increased amount
of calcium in the cell. Therefore, the threshold
becomes more difficult to achieve and the cell
membrane becomes refractory
to depolarization. As a result, cardiac and
smooth muscle activity is decreased. Calcium
in the bloodstream impairs renal function and it
precipitates as a salt, forming renal stones.
Some cancer tumors destroy the bone,
whereas others such as lung and breast
cancers cause an ectopic PTH production.
Hypophosphatemia is a complication of
excessive PTH production that promotes
calcium retention. A shortened QT segment
and depressed T waves may be seen on ECG.

27. Causes:
• Hyperparathyroidism
• Cancer
• Prolonged immobilization
• Paget’s disease
• Excess milk or antacid intake
• Renal failure

28. Manifestations:
• Neuromuscular
 Muscle weakness
 Fatigue
 Decreased deep tendon reflexes
• Behavioral
 Personality changes
 Altered mental status
 Decreased LOC

29. • Gastrointestinal
 Abdominal pain
 Constipation
 Anorexia, N/V
• Cardiovascular
 Dysrhythmias
 Hypertension
• Renal
 Polyuria
 thirst

30. Complications:
• Peptic ulcer
• Pancreatitis
• Kidney stones
• Hypercalcemic crisis

31. Diagnostic Exams:
• Serum electrolytes
• Serum PTH levels
• ECG
• Sulkowitch’s urine test

32. Collaborative Care:
• The management of
hypercalcemia focuses on
correcting the underlying cause
and reducing serum calcium
levels.

33. Medical Management:
• Loop Diuretics (Furosemide)
• Calcitonin
• Biphosphonates
• Glucocorticoid drugs

34. Nursing Process
Assessment:
• Subjective Data:
 Pain: flank, deep bone, shin
 splints
 Muscle weakness, fatigue
 Anorexia, nausea
 Headache
 Thirst polyuria

35. • Objective Data:
Muscles: relaxed
GU: kidney stones
GI: increased milk intake,
constipation, dehydration
Neurological: stupor coma

36. 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

37. 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.

38. 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