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
