Calcium:         (+) charged ion or cation found in ICF and ECF 99 % found in bones and teeth 1 % found in serum and

tissues Functions: formation and structure of bones and teeth maintain cell structure and function plays a role in cell permeability and impulse transmission contraction or cardiac, smooth, skeletal muscle plays a role in blood clotting process and in release of certain hormones

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Measured in two ways: 1. Total serum Calcium level: measures the total calcium level in the blood 2. Measured in the ECF  41% bound to protein  9% bound to citrate and other organic ions  half (50%) ionized/free calcium: Normal Range of Ionized Calcium: Adults: 4.5-5.1 mg/dl Children: 4.4-6.0mg/dl Calcium Regulation: 800-1200 mg/day       Dietary intake: Dairy products,bone meals,green leafy vegestables,legumes,molasses,nuts,whole grains excretion: Urine and feces Bones o PTG – PTH o Thyroid Gland – Vitamin D Phosphorus Serum pH

Drugs: o calcitonin/mithramycin Kidneys excretes excessive Ca: o loop diuretics: Furosimide ethacrynic aicd o renal failure: doesn’t activate Vit D o Edelate Disodium (EDTA) for lead poisoning others: o low Mg level o low serum albumin o hyperphospathemia  excess combines with Ca to form salts and deposited in the tissues o phosphate administered IV and rectally o alkalosis o citrate

Signs and symptoms: Neurologic: anxiety, confision and irritability Neuromuscular:     paresthesia of toes, fingers and face twitching,muscle cramps and tremors laryngeal and abdominal spasm nerve excitability o Troussues sign: o Chevosteks sign:

Others:          prone to fracture brittle nails and dry skin and hair diarrhea hyper active DTR diminished response to digoxin decrease cardiac output/arrhythmias prolong ST segment lengthened QT interval o torsades de pointes (ventricular tachycardia) decrease myocardial contractility o angina, bradycardia, hypotension and heart failure.

Hypocalcemia   Cause:  inadequate intake: o alchoholics: o breastfed infants:low Ca and Vit D intake o insufficient exposure to sunlight: Vit D deficiency Malabsorption: Not properly absorbed in the GI tract o severe diarrhea o laxative abuse o chronic malabsorption syndrome o anticonvulsantsphenobarbital and Phenytoin o high phosphorus level pancreatic insufficiency: unknown PTH: below 8.5 mg/dl below 5.mg/dl ionized calcium

Diagnostics reveals     total serum calcium < 8.5 mg/dl ionized calcium level < 4.5 mg/dl-definitive method low albumin level ECG changes

Treatment: Treat the underlying cause Acute HypoCal:   Calcium gluconate/Calcium Chloride magnesium replacement

Chronic Hypocalcemia  Vit D supplement  Oral Calcium supplements Diet: Vitamin D and Protein Nursing intervention

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Neuro muscular muscle weakness hypereflexia decrease muscle tone  hypertention Cardiac:  arrhythmias (bradycardia):cardiac arrest o shortened QT interval o shortenened ST segment GI :  anorexia  decrease bowel sound  constipation  abdominal and flank pain  paralytic ileus Kidney  Polyuria kidney stones/other calcifications:  pathologic fracture Diagnostic results: Serum calcium level above 10.1 mg/dl digoxin toxicity ECG changes o shortened QT interval o shortenened ST segment o flattened T waves] o heart block: Treatment:     Manage underlying cause decrease dietary intake of Calcium hydrate patient loop diuretics: o Furosimide (lasix) o Ethacrynic acid (edecrin)  life threatening situations: o dialysis o peritoneal dialysis  Inhibit bone resorption: o corticosteroids IV and Oral  block bone resorption  Decrease calcium absorption in the GI o Biphosphate: treat hypercalcemia caused by CA o Etridionate Disodium: o Plicamycin (mithramycin):  antineoplastic drug treat hypercalcemia when the cause is CA o Calcitonin: Nursing Intervention.5 mg/dl Ionized calcium level above 5. Assess patient who are at risk:  Assess patients suspected with Hypocalcemia  teach patient about signs and symptoms of hypocalcemia Patients with low Ca:  Recovering from PT and Thyroid surgery  monitor V/S:  keep tracheostomy tray and resuscitation bag at bed side  place cardiac monitor:  check for Chvosteks and Troussues signs  Monitor patient IV calcium for arrhythmias  insert and maintain a patent IV line for Ca therapy  Administer Ca replacement therapy carefully:  oral replacement as ordered o 1-1 ½ after meals with milk  monitor lab result:  Check ionized Ca level every 4 units of BT  encourage older px to take Ca supplement as ordered  seizure precautions  re orient confused patients  provide calm and quiet environment  teach patients about signs and symptoms of hypocalcemia  Document  HYPERCALCEMIA Common metabolic emergency that occurs when:  Above 10.1 mg/dl: ionized calcium Cause:  Hyper para thyroidism  Malignant Cancer: o poor prognosis 1yr survival rate is 10-30 percent Other Cause:  Increase absortion in the GI tract  Decrease secretion in kidneys  Hyphophosphatemia  Acidosis Drugs associated with Hypercalcemia:  Lithium:  Thiazide diuretics:  Vit A over dose:  Milk-alkali syndrome:  excessive Vitamin D Signs and symptoms: Neurologic:        confusion altered mental status personality changes lethargy.       Monitor patients who are at risk Monitor VS : watch for arrhythmias assess neurologic and neuromuscular changes monitor serum electrolyte level of Ca insert and maintain IV access o PNSS 200-500 ml/hr o monitor pulmonary edema crackles and dyspnea  administer proper diuretic:  Encourage px to drink 3-4 L of fluid daily: Unless contraindicated     .5 mg/dl  Above 5.

 strain urine for calculi.watch for digoxin toxicity: o anorexia o nausea o vomiting o arrhythmias  encourage the patient to move:  Handle patient with chronic hypercalcemia:  do PROM-AROM:  safe environment  emotional support  Document. .