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ELECTROLYTE IMBALANCES
Electrolyte imbalances can occur in healthy people as a result of changes in fluid intake
and output.
These imbalances are usually mild and are easily corrected.
Severe electrolyte imbalances are life threatening.
People at greater risk for severe imbalances are older clients, clients with chronic renal or
endocrine disorders, clients who are mentally impaired, and clients who are taking drugs
that alter fluid and electrolyte levels,
Ill people are at some risk for electrolyte imbalances.
Sodium is the most abundant electrolyte in the ECF. It ranges from 135 to 145 mEq/L
(135 to 145 mmol/L).
Functions:
Regulates the fluid volume of ECF.
Maintain plasma volumes and regulates size of the vascular space.
Controls body H2O distribution by maintaining the osmotic equilibrium between ICF and
ECF because it does not easily cross the cell wall membrane and because of its
abundance and high concentration in the body.
Aid in conduction of nerve impulses
Control muscle contractility especially cardiac muscle
Maintenance of neuromuscular irritability and acid-base balance
The two most common sodium imbalances are Sodium Deficit and Sodium Excess.
Hyponatremia refers to a serum sodium level below 135 mEq/L (135 mmol/L).
Normal values: 135 to 145 mEq/L (mmol/L).
Pathophysiology
1. First mechanism is a change in cell excitability as the sodium level in the blood
and other ECF decreases, the difference in sodium levels between the ECF and the
cellular fluid also decreases.
Less sodium is present to move across the excitable membrane resulting in
slower membrane depolarization.
2. The second mechanism is the movement of water from the ECF space into the
cells cells swells and their functions are impaired.
Common Causes of Hyponatremia:
Hyponatremia can result from the loss of total body sodium, the movement of sodium
from the blood to other fluid spaces, or the dilution of serum from excessive water in
the plasma.
Clinical Manifestations:
Cerebral Manifestations:
= Changes in cerebral function are the most obvious problems of hyponatremia these
changes may be seen as either depressed activity or excessive activity (and sometimes
both).
Behavioral or personality changes – result from cerebral edema and increased
intracranial pressure such as irritability and agitation.
Headache coma death.
Closely observe and document client’s behavior and level of
consciousness.
Neuromuscular Manifestations:
= Assess the client’s neuromuscular status for any changes from baseline.
Generalized skeletal muscle weakness – occurs bilaterally and is worse in the legs
and arms.
Diminished muscle tone and deep tendon reflexes.
Gastrointestinal Manifestations:
= The smooth muscle of the GI system responds to decreased serum sodium levels with
increased motility causing:
Nausea
Diarrhea
Abdominal cramping
Hyperactive bowel sounds – listen to bowel sounds (with rushes and gurgles over
the splenic flexure and in the lower left quadrant.
Bowel movements are frequent and watery.
Peristaltic movements may be palpated and may be visible on the
abdominal surface.
Cardiovascular Manifestations:
= Hyponatremia has a little effect on cardiac muscle contractility but cardiac output is
changed with hyponatremia.
= When hyponatremia occurs with changes in blood volumes, these fluid changes alter
cardiac function.
Normovolemic
Rapid pulse rate
Normal blood pressure.
Hypovolemic (decreased plasma volume or fluid deficit)
Rapid pulse rate
Pulse quality thready and weak
Decreased diastolic pressure. Severe hypotension when moving from lying
to sitting position to a standing position.
Central venous pressure normal or low
Flat neck veins in supine position
Hypervolemic (increased plasma volume or fluid excess)
Cardiac changes include a full-pulse, rapid, bounding pulse with normal or
high blood pressure.
Central venous pressure is normal or high – depending on how well the
left ventricle handles the extra fluid.
Respiratory Manifestations:
Late manifestations related to skeletal muscle weakness:
Shallow, ineffective respiratory movements
Hypervolemia
Pulmonary edema
Rapid, shallow respiration
Moist crackles
Renal Manifestations:
Increased urine output
Decreased urine specific gravity
Integumentary:
Dry skin
Pale, dry mucous membrane
Assessment includes the history and physical examination including a focused neurologic
examination; evaluation of signs and symptoms as well as laboratory results;
identification of IV fluids, and review of all medications the patient is taking.
Medical Management:
The key to treating hyponatremia is assessment including identifying patients who are at
risk and recognizing that the rapidity of the onset of hyponatremia is of primary
importance.
Mild Hyponatremia:
Restrict fluid intake
Oral Na supplements
Hyponatremia related to hypovolemia:
Isotonic fluid such as NS or LR – to restore both sodium and fluid volume.
High Na foods
Severe Hyponatremia:
Requires treatment to ICU.
Hypertonic saline solution such as 3% or 5% NaCl infusion causes water to shift
out of cells may lead to intravascular overload and brain damage – must be given
in small-volume. Monitor the infusion rate and client’s response.
Fluid volume overload prevented with slow infusion of furosemide – usually
administered simultaneously.
Hyponatremia related to Fluid excess:
Drug therapy
= Osmotic Diuretics such as mannitol (Osmitrol) – promotes excretion of water
rather than sodium.
Assess the client hourly for signs of excessive fluid loss and increased sodium
levels.
= Hyponatremia caused by inadequate secretion of ADH includes agents that
antagonize ADH such as lithium and demeclocycline (Declomycin).
Nursing Interventions:
Hypernatremia is a serum sodium level higher than 145 mEq/L (145 mmol/L). It can be caused
by a gain of sodium in excess of water or by a loss of water in excess of sodium.
In sodium excess, the patient ingests or retains more sodium than water.
Pathophysiology:
As serum sodium level rises increases sodium levels between ECF and ICF causing
an increase in osmolarity levels of the ECF this problem causes water to move from
the cells into the ECF to dilute the hyperosmolar ECF as hypernatremia persists or
worsens, compensatory actions cause severe cellular dehydration.
Clinical Manifestations:
The manifestations of hypernatremia vary with the severity of imbalance and whether a
fluid imbalance is also present. Rapid increase in serum sodium cause more obvious and
severe symptoms.
The manifestations of hypernatremia involve changes in excitable membrane activity,
especially cerebral, neuromuscular, and cardiac functions.
Thirst – is the primary characteristic of hypernatremia. It is a strong defender of serum
sodium level.
Neuromuscular Manifestations:
Skeletal muscles responses vary with the degree of sodium increases.
Mild or early hypernatremia
Spontaneous muscle twitching
Irregular muscle contraction
Severe hypernatremia – as it worsens, the muscles and nerves are less able
to respond to a stimulus.
Skeletal muscle weakness – the muscles become progressively
weaker with rigid paralysis.
Diminished or absent deep tendon reflexes
= Assess neuromuscular status by observing for twitching in
muscle group.
Cardiovascular Manifestations:
Decreased cardiac contractility – Increased serum sodium slows movement of
calcium into the heart cells which decreases contractility.
Diminished cardiac output
Heart rate and blood pressure respond to vascular volume
Assess cardiac status by measuring blood pressure and the rate and quality
of the apical and peripheral pulses.
Pulse rate and blood pressure may be normal, above normal or
below normal depending on the fluid volume and how rapidly the
imbalance occurred.
Hypernatremia with hypovolemia
Pulse rate is increased and peripheral pulses are difficult to palpate
and are easily blocked.
Hypotension and severe orthostatic (postural) hypotension are
present and pulse pressure is reduced.
Hypernatremia with hypervolemia
Slow to normal bounding pulses
Peripheral pulses are full and difficult to block.
Distended neck veins even in upright position.
Increased diastolic blood pressure
Respiratory Manifestations:
Problems associated with pulmonary edema when hypernatremia is accompanied
by hypervolemia.
Renal Manifestations:
Decreased urine output
Increased urine specific gravity
Integumentary Manifestations:
Dry, flaky skin
Presence or absence of edema related to accompanying fluid volume changes
Increased serum sodium level exceeds 145 mEq/L (145 mmol/L) and serum osmolality
exceeds 300 mOsm/kg (300 mmol/L)
Increased urine specific gravity and urine osmolality – the kidneys attempt to conserve
water (provided the water loss is from a route other than the kidneys).
Patients with nephrogenic or central diabetes insipidus have hypernatremia and produce a
dilute urine with a urine osmolality less than 250 mOsm/kg.
Medical Management:
Drug Therapy
Hypotonic IV infusions, usually 0.225% or 0.45% NaCl are prescribed -
when hypernatremia is caused by fluid loss. It is used to restore fluid
balance
Isotonic NaCl solutions – for hypernatremia caused by fluid and sodium
losses as fluid replacement.
Diuretics such as furosemide (Lasix, Furoside), bumetanide (Bumex), and
ethacrynic acid (Edecrine) – for hypernatremia caused by poor renal
excretion of sodium to promote sodium loss.
Desmopressin acetate (DDAVP) – a synthetic antidiuretic hormone, may
be prescribed to treat diabetes insipidus if it is the cause of hypernatremia.
Assess the client hourly for symptoms of excessive fluid, sodium or
potassium losses.
Diet Therapy
Mild hypernatremia can be prevented or corrected by ensuring adequate water
intake.
Dietary sodium restriction – may be needed to prevent sodium excess when
renal problems are present.
Collaborate with the dietitian to teach the client how to determine the
sodium content of foods, beverages, and drugs.
Stress the importance of adhering to the diet.
Fluid restriction must be followed.
Nursing Management:
Potassium is the major intracellular electrolyte; 98% of the body’s potassium is inside
the cells. The remaining 2% is in the ECF and is important in neuromuscular function.
Potassium influences both skeletal and cardiac muscle activity.
Ex: alterations in its concentration change myocardial irritability and rhythm.
The normal serum potassium concentration ranges from 3.5 to 5.0 mEq/L (mmol/L).
The normal ICF potassium level is about 140 mEq/L (mmol/L).
Potassium control also occurs through the kidney function, because about 80% of
potassium removed from the body occurs via the kidney.
Aldosterone is the only hormone that enhances kidney excretion of potassium.
A. HYPOKALEMIA
Pathophysiology:
Low serum potassium levels increases the difference in the amount of potassium between
the fluid inside the cells (ICF) and the fluid outside the cells (ECF) as a result, the cell
membranes of all excitable tissues such as nerve and muscle are less responsive to normal
stimuli.
When the loss of ECF potassium is gradual cells adjust and cellular potassium
decreases in proportion to the ECF potassium level potassium difference between the
2 fluid spaces remained unchanged symptoms of hypokalemia may not appear until
the potassium loss is extreme.
Rapid reduction of serum potassium levels causes dramatic changes in function.
Hyperkalemia may result either from an actual total body potassium loss or from
movement of potassium from the ECF to the ICF causing a relative decrease in ECF
potassium level.
Clinical Manifestations:
Diagnostic Findings:
ECG changes:
Depressed ST segment
Flattened or inverted T wave
Prominent U wave – extreme hypokalemia
Decrease K level
Elevated pH and bicarbonate level
Decrease serum Mg level
Increase 24H urine level
Medical Management:
Nursing Intervention:
Interventions for hypokalemia aim to prevent potassium loss, increase serum potassium
levels and provide a safe environment.
Drug and nutrition therapies help restore normal serum potassium levels.
The priorities for nursing care of patient with hypokalemia are: ensuring adequate
oxygenation, patient safety for falls prevention, and prevention of injury from
potassium administration and monitoring the patient’s response to therapy.
Monitor patients who are at risk – implement safety measures who have muscle weakness
from hypokalemia.
Eliminating hazards and assisting with ambulation.
Encouraging the patient at risk to eat foods rich in potassium – helps prevent further loss
but supplementation is needed to restore normal potassium levels.
Monitor heart rate and rhythm such as hypotension, broad T wave, U wave, tachycardia
and weak pulse.
Assess respiratory rate, depth and pattern – hourly for severe hypokalemia.
Check oxygen saturation by pulse oximetry to determine breathing effectiveness.
Assess respiratory muscle effectiveness by checking patient’s ability to cough.
Examine face, oral mucosa and nailbeds for pallor or cyanosis.
Evaluate arterial blood gas values for decreased blood oxygen levels (hypoxemia)
and increased arterial carbon dioxide levels (hypercapnia).
Administer prescribed supplemental potassium (PO, NG, or IV) as prescribed.
Prevent/reduce irritation from potassium(is a severe tissue irritant) supplement –
administer PO or NG potassium supplements during or after meals to minimize GI
irritation, dilute IV potassium adequately, administer IV supplement slowly and apply
topical anesthetics to IV sites.
MIO – because 40mEq of K is lost per 1L of urine output.
Diuresis put the patients at risk for serious K loss – but for patients with
hypokalemia who needs diuretics, potassium-sparing diuretics such as
spironolactone (Aldactone), triumterene (Dyrenium) and amiloride (Midamor) –
they increase urine output without increasing potassium loss.
Monitor serum K level.
Monitor for signs of hypokalemia-related metabolic alkalosis.
Provide teaching.
Stop drugs that cause hypokalemia e.g. diuretics, laxatives.
B. HYPERKALEMIA
The normal range for serum potassium values is narrow but a slight increase above
normal values can affect excitable tissues, especially the heart cardiac arrest.
Pathophysiology:
A high serum potassium level decreases the potassium difference between the ICF and
the ECF this decreased difference increases cell excitability, as a result excitable
tissues respond to less intense stimuli causing altered cardiac function (the heart is
very sensitive to serum potassium increases).
Sudden rises in serum potassium levels between 6 and 7 mEq/L cause severe
problems.
Hyperkalemia may result from an actual increase in total body potassium or from the
movement of potassium from the cells to the blood.
Hyperkalemia are rare in people with normal kidney function but most cases occur in
hospitalized patients and those undergoing medical treatment. Those that are at a greater
risk are the chronically ill patients, debilitated patients and the older adults.
Ask about chronic illnesses particularly renal disease and diabetes mellitus, recent
medical or surgical treatment, and urine output, including frequency and amount of
voiding.
Ask about drug use, particularly potassium-sparing diuretics and ACE inhibitors.
Diet history – intake of potassium-rich foods and use of salt substitutes.
Cardiovascular Changes: the most severe problems from hyperkalemia and are
the most common cause of death.
Bradycardia, hypotension and ECG changes: Tall, peaked T waves,
prolonged PR intervals, flat or absent P waves and wide QRS complexes.
As serum potassium rises heartbeat generated outside the normal
conduction system in the ventricle (ectopic beats) may appear complete
heart block, asystole and ventricular fibrillation may occur life-
threatening complication of severe hyperkalemia.
Neuromuscular Changes:
Skeletal muscle twitching such as tingling and burning sensations
followed by numbness in the hands and feet and around the mouth
(paresthesia) – early stages of hyperkalemia.
As hyperkalemia worsens muscle twitching changes to weakness
followed by flaccid paralysis. The weakness moves up from the hands and
feet and affects the muscles of the arms and legs.
Intestinal Changes:
Increased motility – causing diarrhea and spastic colonic activity.
Bowel sounds are hyperactive, with audible rushes and gurgles.
Bowel movements are frequent and watery.
Diagnostic Findings:
ECG changes: Tall, peaked T waves, prolonged PR intervals, flat or absent P waves and
wide QRS complexes.
Arterial blood gas analysis – may reveal both a metabolic and respiratory acidosis.
Correcting the acidosis helps correct hyperkalemia.
Medical Management:
Drug Therapy is the main medical intervention.
Potassium level between 5.0 to 5.5 mEq/L – restriction of dietary K intake.
If potassium excess is due to metabolic acidosis – correcting the acidosis with
NaHCO3 which promotes K+ uptake into the cells.
Improving urine output usually decreases the elevated serum K+ level. Potassium-
wasting diuretics (furosemide) can be used.
Severe Hyperkalemia:
Intravenous Ca gluconate infusion or Ca chloride to decrease the antagonistic effect of
K+ excess in the myocardium – monitor BP for hypotension which may result from the
rapid IV administration of Ca gluconate.
IV infusion of insulin and glucose or NaHCO3 to promote K+ uptake into the cells – help
decrease serum potassium levels (usually 100 ml of 10% to 20% glucose with 10 to 20
units of regular insulin). This is a hypertonic solution.
Observe patient manifestations of hypokalemia and hypoglycaemia during this
therapy.
Loop diuretics – increase excretion of water by inhibiting Na, K, Cl reabsorption in the
ascending loop of henle and distal renal tubule
Beta – 2 agonist, such as albuterol – is highly effective in decreasing potassium.
Kayexelate (polysterane sulfonate) may be given orally or rectally – This treatment
stimulates the exchange of a K ion for a Na ion that promotes the intestinal sodium
absorption. The K ion is then excreted in the stool. Sorbitol may be combined with
kayexelate to prevent constipation.
Peritoneal Dialysis or Hemodialysis – if potassium levels are dangerously high.
Nursing Interventions:
Interventions for hyperkalemia are aimed at rapidly reducing the serum potassium level,
preventing recurrences and ensuring patient safety during the electrolyte imbalance.
The priorities for nursing care of patient with hyperkalemia are:
Close monitoring to prevent cardiac complications – allows for the early
recognition of dysrhythmias and other manifestations of hyperkalemia on cardiac
muscle.
Assess vital signs, monitor cardiovascular status.
Anticipate cardiac monitoring and a 12 lead ECG.
Refer if the patient’s heart rate falls below 60 beats per minute or if
the T waves become spiked.
Patient safety for falls prevention - Implement safety measures.
Monitoring the patient’s response to therapy
Monitor serum potassium levels
Assess motor and sensory function
Monitor neurologic status
Be prepared to give calcium gluconate by slow IV infusion in
acute cases of hyperkalemia – monitor BP for hypotension which
may result from rapid IV administration of Ca gluconate.
Prepare the patient for the possibility of dialysis – those with
chronic renal failure.
Great care should be taken to administer and monitor potassium
solutions closely.
Health teaching – is the key to the prevention of hyperkalemia and early detection
of complication.
Patient at risk for hyperkalemia includes diet (avoid foods high in
potassium and use of salt substitutes), drugs (Administer insulin
and glucose and sodium bicarbonate as or ordered) and recognition
of the manifestations of hyperkalemia.
2.3 CALCIUM IMBALANCES
Calcium (Ca+) is a mineral with functions closely related to those of phosphorous and
magnesium.
Calcium is an ion having 2 positive charges (divalent cation) that exist in the body in a
bound form and an ionized (unbound or free) form.
Bound calcium is usually attached to serum proteins, especially albumin.
Ionized calcium is present in the blood and other ECF as free calcium which is
in active form and must be kept within a narrow range in the ECF.
More than 99% of the body’s calcium is located in the skeletal system; it is a major
component of bones and teeth.
About 1% of skeletal calcium is rapidly exchangeable with blood calcium and the rest is
more stable and only slowly exchanged.
Functions:
Calcium enters the body by dietary intake and absorption through the intestinal tract.
Dairy products are common foods high in calcium and absorption of dietary calcium
requires the active form of vitamin D.
PTH and Calcitonin – controls the serum calcium level.
As ionized calcium decreases the parathyroid glands secrete PTH increases
calcium absorption from the GI tract, increases calcium reabsorption in the renal
tubule and releases calcium from the bones.
When calcium increases excessively the thyroid gland secretes calcitonin
which inhibits calcium reabsorption from the bone and decreases the serum
calcium concentration and increasing kidney excretion of calcium in the urine.
The body functions best when calcium levels are maintained between 9.0 and 10.5
mg/dl or between 2.25 and 2.75 mmol/L.
Hypocalcemia is a total serum calcium level below 9.0 mg/dl or 2.25 mmol/L.
A patient may have a total body calcium deficit (as in osteoporosis) but has a normal
serum calcium level. Elderly people and those with disabilities, who spend an amount of
time in bed, have an increased risk of hypocalcemia because bed rest increased bone
resorption.
Pathophysiology:
Calcium is stored in the bone, with only a small amount of total calcium present in the
ECF has a major effect on its function.
Low calcium levels increases sodium movement across excitable membranes
allowing depolarization to occur more easily and at inappropriate times.
Acute hypocalcemia results in the rapid onset of life-threatening manifestations, even
when the serum calcium level is not very low.
Chronic hypocalcemia occurs slowly overtime excitable membrane manifestations
may not be severe because the body has adjusted to the gradual reduction of serum
calcium levels.
Common Causes of Hypocalcemia:
Clinical Manifestations;
Diet history is important to assess for the risk of hypocalcemia. Ask the patient about his
or her intake of dietary products and whether a calcium supplement is taken regularly.
Report of frequent painful muscle spasm (“charley horses”) in the calf or foot during rest
or sleep – one indicator of hypocalcemia.
Other information that may indicates possible hypocalcemia: History of recent
orthopaedic surgery or bone healing; endocrine disturbances and treatment; history of
thyroid surgery, therapeutic irradiation of the upper chest and neck area, or a recent
anterior neck injury.
Most manifestations of acute hypocalcemia are caused by overstimulation of the nerves
and muscles.
Neuromuscular Changes:
Tetany – is the most characteristic manifestations of hypocalcemia and
hypomagnesemia which refers to the entire symptoms complex induced by
increased neural excitability.
Paresthesia occurs at first with sensations of tingling that affects the lips, nose
and ears and numbness.
If hypocalcemia continues or worsen actual muscle twitching or painful
cramps and spasms occur.
Assess hypocalcemia by testing for Trousseau’s and Chvostek’s sign.
Cardiovascular Changes:
Heart rate may be slower or slightly faster than normal with a weak, thready
pulse.
Severe hypocalcemia severe hypotension and ECG changes of prolonged ST
interval and a prolonged QT interval.
Intestinal Changes:
Increased peristaltic activity hyperactive bowel sounds.
Painful abdominal cramping and diarrhea
Skeletal Changes:
Most common with chronic hypocalcemia.
Calcium is moved from the bone storage sites causing a loss of bone density
(Osteoporosis).
The bones are thinner, more brittle and fragile breaks easily with even slight
trauma.
Vertebrae become more compact and may bend forward leading to an overall
loss of height.
Ask about changes in height and any unexplained bone pain.
Observe for spinal curvatures and any unusual bumps or protrusions in
bone areas that may indicate old fractures.
Diagnostic Findings:
Medical Management:
Nursing Management:
Hypercalcemia is a total serum calcium level above 10.5 mg/dl or 2.75 mmol/L. which
is a dangerous imbalance when severe; in fact hypercalcemic crisis has a mortality rate as
high as 50% if not treated promptly.
Pathophysiology:
Hypercalcemia is either cause by the greater amount of serum calcium that the normal
calcium-controlling mechanism (parathyroid gland) cannot cope or that one control
mechanism is not functioning properly.
Hypercalcemia causes excitable tissues to be less sensitive to normal stimuli, thus
requiring a stronger stimulus to response.
The excitable tissues mostly affected by hypercalcemia are: the heart, muscles, nerves,
and intestinal smooth muscles.
Calcium is needed by many of the enzymes involved in blood clotting.
Hypercalcemia causes faster clotting times and excessive clotting from
hypercalcemia occurs more easily in vessels with slow blood flow.
Clinical Manifestations:
The manifestations of hypercalcemia are related to severity and how quickly the
imbalances occur.
The patient with mild but rapidly occurring calcium excess usually has more severe
problems than the patient whose imbalance is severe but has developed slowly.
Neuromuscular Changes:
Severe muscle weakness and decreased deep tendon reflexes with paresthesia.
Bone pain may also be present.
Patient may have an altered level of consciousness that can range from confusion,
impaired memory, slurred speech, and lethargy to coma.
Mild psychotic behaviour or problems can occur also.
Renal Changes:
Excessive urination – due to disturbed renal tubular function produced by
hypercalcemia.
Severe thirst may occur with polyuria secondary to high calcium load.
Chronic hypercalcemia they may develop symptoms similar to peptic ulcer disease
because hypercalcemia increases the secretion of hydrochloric acid and pepsin in the
stomach.
The more severe symptoms tend to appear when serum calcium level is approximately
16 mg/dL (4 mmol/L) or higher. However, some patients become profoundly disturbed
with serum calcium levels of only 12 mg/dL (3 mmol/L).
These symptoms can be resolved once serum calcium levels return to normal
after treatment.
Hypercalcemic Crisis – refers to an acute rise in the serum calcium levels to 17 mg/dL
(4.3 mmol/L) or higher.
Severe thirst and polyuria are often present.
Muscle weakness, intractable nausea, abdominal cramps, constipation, or
diarrhea, peptic ulcer symptoms, bone pain, lethargy, coma, and confusions
This condition is very dangerous and may result to cardiac arrest.
Pharmacologic Therapy:
IV administration of 0.9% sodium chloride solution – temporarily dilutes the
serum calcium and increases urinary calcium excretion.
Administering IV phosphate – can cause a reciprocal drop in serum calcium.
Furosemide (Lasix) – often used in conjunction with administration of saline
solution by causing diuresis and it increases calcium excretion.
Often overlooked, fluids and medications that contain calcium and dietary
sources of calcium should be stopped. (D/C IV with calcium ex: PLR).
Calcitonin – can be used to lower the serum calcium level and is particularly
useful for patients with heart disease or renal failure who cannot tolerate large
sodium loads.
Although several forms are available, calcitonin derived from salmon is
commonly used. ( Skin testing for allergy to salmon calcitonin is
necessary before the hormone is administered) systemic allergic
reactions are possible because this hormone is protein; resistance to the
medication may develop later because of antibody formation.
Calcitonin is administered by intramuscular (IM) injection rather than
subcutaneously – because patients with hypercalcemia have poor
perfusion of subcutaneous tissue.
For patient with cancer – treatment is directed at controlling the condition by:
Surgery
Chemotherapy
Radiation therapy
Corticosteroids – may be used to decreased bone turnover and tubular
reabsorption (ex: patients with myelomas, lymphomas and leukemias).
Mithramycin – a cytotoxic antibiotic inhibits bone resorption thus lowers serum
calcium levels.
Inorganic phosphate salts (Phospho-Soda, Neutra-Phos) can be administered
orally or by NGT.
Dialysis – for life-threatening hypercalcemia.
Nursing Management:
Interventions for hypercalcemia aim to reduce serum calcium levels through drug therapy
and dialysis.
It is important to monitor hypercalcemia in at-risk patients.
Rehydration and cardiac monitoring are also important.
Increasing patient mobility and increasing fluids – can help prevent
hypercalcemia or at least minimize its severity.
Hospitalized patients at risk for hypercalcemia should be encouraged to ambulate
as soon as possible.
Outpatients – are instructed about the importance of frequent ambulation.
Oral fluids
The nurse should consider the patient’s likes and dislikes.
Fluids containing sodium should be administered unless contraindicated –
because sodium assists with calcium excretion.
Encouraged patient to drink at least 3 to 4 quarts of fluid daily.
Adequate fiber in the diet – to offset the tendency for constipation.
Safety precautions are implemented as necessary, when mental symptoms are
present.
The patient and family are informed that these mental changes are
reversible with treatment.
Drug therapy
Preventing increases in calcium, as well as drugs to lower calcium levels.
IV solutions containing calcium (ex: Ringer’s Lactate) are stopped.
Oral drugs containing calcium or vitamin D (ex: calcium-based antacids)
are discontinued.
IV normal saline (0.9% sodium chloride) – as fluid volume replacement which
can help restore normal serum calcium levels because sodium increases kidney
excretion of calcium.
Thiazide diuretics are discontinued and replaced with diuretics that enhance the
excretion of calcium such as furosemide, (Lasix, Furoside).
Calcium chelators (calcium-binders) such as plicamycin (Mithracin) and
penicillamine (Cuprimine, Pedramine) – helps lower serum calcium levels.
Drugs to prevent hypercalcemia include agents that inhibit resorption from bones
such as phosphorous, calcitonin (Calcimar), biphosphonates (etidronate) and
prostaglandin synthesis inhibitors (aspirin, NSAIDs).