CALCIUM (Ca) - Most active form is called calcitriol.

Minimum daily requirement 800 mg/day
 Higher among adolescents and young adults
because they are still growing.
 Pregnant, lactating women, post-menopausal
women and adults older than age 65, have low
calcium levels.
 Increases calcium absorption from intestine and
acids PTH in mobilizing bone calcium.
 Enhances calcium and phosphorus availability
for new bone formation.

Distribution of calcium in the body

 99% of calcium found in bones and teeth.
(Calcium makes bones and teeth durable)
 1% of calcium in Extra Cellular Fluid
o Normal serum calcium (total serum
calcium) level 4.5-5.5 mEq/L (9-11
mg/dl)
 53% of calcium in ECF is bound to protein,
mainly albumin. (It cannot cause capillary
membranes to leave the vascular system.)
 Ionized calcium (iCa) accounts for 47% serum
This illustration of maintaining calcium balance
calcium. (Calcium dissolved in plasma is
considered physiologically active because it
Extracellular calcium levels are normally kept
crosses cell membranes)
constant by several interrelated processes that move
o Normal value of iCa: 2.2-2.5 mEq/L
calcium ions into and out of ECF. Calcium enters the
(4.5-5.0mg/dl)
extracellular space through resorption of calcium ions
from bone through the absorption of dietary calcium in
Calcium deposited in bones in teeth
the GI tract and through reabsorption of calcium from
 Maintenance of skeletal elements.
the kidneys. Calcium leaves ECF as it is excreted in stool
and urine, and deposited in bone tissues.
Ionized calcium
 Regulation of neuromuscular activity
HYPOCALCEMIA (Calcium Deficit)
 Regulates cell membrane permeability.
- Characterized by serum calcium less than 4.5
 Regulates transmission of nerve impulse.
mEq/L.
 Regulates muscle contraction and relaxation.
 Influences enzyme activity. (Activates enzymes)
Medical Definition
 Other roles: functions in blood coagulation by
 HYPO: Low
converting prothrombin to thrombin; a
 CALC: Calcium
necessary part of material that holds cell
together.  EMIA: In the blood
o Calcium less than 9.0 mg/dl
Normal Regulation of Calcium Levels
 Bone resorption CALCIUM
 Renal absorption
Regulated by 3 main hormones:
 Intestinal absorption.
1. Parathyroid hormone
Parathyroid hormone (PTH)
- Increases calcium concentration in the blood.
- When serum calcium level is low in the blood.
2. Calcitonin hormone
 Promotes transfer of Ca from bone to plasma.
- Decreases blood calcium.
 Promotes absorption of Ca from small intestine.
- Puts a ton of calcium into the bones.
 Enhances renal absorption of Ca.
 Secreted in response to low serum Ca levels.
3. Calcitriol
- Controls blood calcium by stopping or inhibiting
Calcitonin (thyrocalcitonin)
the release of calcitonin.
- Hormone produced by thyroid gland.
- Reverses the ton of calcium in the bone so
calcium gets released into the blood stream.
 Promotes transfer of calcium from plasma to
bone.
Best friend = Magnesium
 Secreted in response to high serum calcium
levels.  Calcium helps build job functions for
magnesium often when magnesium is low.
Vitamin D
- Ingested in food or synthesized in the body. Worst Enemy = Phosphate
  When phosphate is low, calcium is high and vice
versa.
The function of Calcium is to keep the 3 B’s strong:
1. Bones
2. Blood – The clotting factors will be strong.
3. Beats – Heartbeats
Pathophysiology & Etiology
 Dietary Factors
- Sources of calcium.
- Inadequate intake of food rich in calcium.
o Inadequate calcium in food
o Lack of vitamin D
o Inadequate protein in diet
 GI Factors
- May interfere with the absorption of calcium
from the gut.
o Decreased absorption due to
pancreatitis
o Crohn’s disease
 chronic inflammatory bowel
disease (IBD) of unknown origin
which usually affects the ilium
and colon.
o Resection of small bowel
o Chronic diarrhea
 Hormonal Factors
- Regulate calcium levels
o PTH deficiency (usually the main cause
often secondary to sepsis, burns, and
surgery like parathyroidectomy,
thyroidectomy, radical neck dissection.)
o Vitamin D deficiency (may be r/t renal
failure)
 Other electrolyte imbalances
o Magnesium deficiency
 less than 1 mg/dl
 When magnesium goes down
so does calcium.
o Increased serum phosphorus
 often due to renal failure
 As serum phosphorus increase,
serum calcium decreases.
o Alkalosis
 resulting in increased protein
bound calcium with less than
ionized calcium available even
when total serum calcium is
normal.
o Increased serum albumin
 may result in increase in bound
calcium. Thus, serum calcium
decreases.
o Rapid dilution of plasma with calcium
free solution.
 Drugs predisposing to hypocalcemia
o Magnesium sulfate, Propylthiouracil
(PTU - for hypothyroidism), Colchicine
(Antigout), Plicamycin, Neomycin,
excessive sodium citrate.
 These agents inhibit
parathyroid hormone secretion
and decrease serum calcium
level.
o Acetazolamide (for acute altitude
sickness), Aspirin (Anticoagulant),
Anticonvulsants, Estrogens,
Aminoglycosides, Gentamycin, Amikacin
 These agents can alter the
vitamin D metabolism that is
needed for calcium absorption.
o Phosphate preparations (Sodium
phosphate, Potassium phosphate)
 Can increase the serum
phosphorus level and decrease
the serum calcium level.
o Corticosteroids
 May also decrease calcium
mobilization and inhibit the
absorption of calcium.
o Loop diuretics (furosemide, Lasix)
 Reduce calcium absorption
from the renal tubules.
 Other Causes
o Alcoholism
o Medullary thyroid carcinoma
 Alter the functions of thyroid
and parathyroid glands.
o Rapid infusion of banked blood during
transfusion
 Because of increased number of
sodium citrate.
Causes
L – ow Parathyroidism
o PTH increased blood calcium
History of Thyroidectomy (check the
calcium levels)
o Pancreatitis
O – ral meds
o PTH increased blood calcium
o Laxatives, Loop Diuretics (furosemide)
o Corticosteroids
o Antiseizure meds (Dilantin (Generic =
Phenytoin), Phenobarbital)
o Phosphate enemas
o Citrate
W – ound drainage
o GI Wounds
o Higher risk for low calcium
C – hronic diseases
o Celiac & Crohn’s disease
o Chronic kidney issues (excessive
excretion of calcium)
o Diuretics & Corticosteroids
A – ntibiotics
L – ow Vitamin D & Low Magnesium
I – ncreased Phosphate levels in the blood

Signs and Symptoms
 Vary widely from client to client based on
severity, duration, and rapidity of onset.
 When hypokalemia is present, symptoms are
potentiated.
Neuromuscular signs
o Tetany, including neural excitability
o Tingling and muscle spasms of mouth, hands,
and feet, and larynx in severe hypocalcemia.
o Trousseau’s sign
o Chvostek’s sign
Classic Physical Examination Findings
o Chvostek’s sign
 Twitching of facial muscles in
response to tapping over the
facial nerve area.
 This test is neither sensitive or
specific.
 Absent in about 30% of patients
with hypocalcemia.
 Present in 10% of patients with
normal levels of calcium.
o Trousseau’s sign
 Development of carpopedal
spasm that results from
ischemia. One way to induce
the ischemia is the application
of a blood pressure cuff that
gets inflated over the arm and
gradual flexion of the fingers
and thumb, and the wrist, and
some degree of pronation
occurs.
 This test is more sensitive and
specific.
 Present in 94% of the patients
with hypocalcemia.
 Only occurs in about 1% of
patients with normal calcium.
CNS Changes
o Irritability
o Anxiety
o Delusions
o Hallucinations
o Memory impairment
o Depression
o Convulsions
Cardiovascular Changes
o Gross changes: weak contractions, potential for
CHF
o ECG abnormalities: S-T segment lengthened, Q-
T interval prolonged
Changes in Laboratory Test Values
o Serum calcium is decreased
o Ionized calcium decreased
o Blood-clotting time is increased
Chronic Hypocalcemia
-exist for more than six (6) months.
 Osteoporosis (loss of bone mass)
o Due to prolonged low calcium intake.
o Serum calcium levels are normal, but
total body calcium is decreased.
o Increased incidence of skeletal
fractures.
Treatment & Management
 Emergency measures: administration of
parenteral calcium salts such as:
o Calcium gluconate
o Calcium chloride
o Calcium gluceptate diluted with 5%
dextrose in water.
 Mild or chronic hypocalcemia:
o Foods high in calcium
o Oral calcium supplements
o Vitamin D supplements
o Increased protein in diet
Nursing Process/Nursing Assessment
 Obtain client history relative to potential causes
of hypocalcemia.
 Obtain client history relative to drugs
predisposing to hypocalcemia.
 Assess for signs of hypocalcemia.
 Obtain baseline values for serum calcium,
ionized calcium, serum albumin, and acid-base
status.
 Obtain baseline ECG, noting abnormalities in S-T
segment and Q-T interval.
 Take safety precautions if client is confused or
hallucinating.
 Prepare to adopt seizure precautions if
hypocalcemia is severe.
Nursing Diagnoses
 Altered nutrition related to inadequate intake
of calcium, vitamin D, or protein
 Altered nutrition relative to inadequate calcium
absorption
 High risk for injury, bleeding, related to
interference with coagulation secondary to
calcium loss.
Nursing Interventions
 Monitor laboratory test results, with emphasis
on serum and ionized calcium.
 Monitor ECG for changes in pattern.
 When calcium is given parentally, monitor for
irritation of subcutaneous tissue and tissue
sloughing.
 Teaching client to eat high-calcium foods;
educate client concerning prevention of
osteoporosis.
 Educate client concerning proper, moderate
use of laxatives and antacids.
 Monitor for signs of cardiac arrythmia in clients
receiving digitalis and calcium supplements
(either oral or I.V.)
 Monitor for hypocalcemia in clients receiving
massive transfusions of citrated blood.