HYPOCALCEMIA ( Definition, Causes and S&SX, Nursing Management, dx and

intervention) - Mulok

RU
Lets Talk about Hypocalcemia
When we say Hypocalcemia Hypo means Low and Calc is the prefex for Calcium
and Emia means blood so when we put that together the meaning is “ Low Calcium in
the Blood “ or low levels of calcium in the blood. Calcium is an electrolyte that plays
a vital role in many bodily functions, including muscle contraction, nerve
transmission, and bone formation.

Various factors, including nutritional deficiencies, medications, and underlying

medical conditions, can all lead to low calcium levels. As a nurse, it is essential to be
familiar with the signs, symptoms, and treatment options for hypocalcemia to provide
adequate and timely care to patients.

WHY IS CALCIUM IMPORTANT IN THE BODY?

Is anyone can explain why calcium is important in our body?
Calcium is an essential electrolyte that plays a critical role in maintaining the structure
and function of our bones and teeth. It is also necessary for proper nerve function,
muscle contraction (including the heart), blood clotting, and enzyme activity. In
addition, calcium regulates the release of hormones and other chemicals in the body.

A normal human bone

BONES AND TEETH
Calcium provides the structural support for strong and healthy bones and teeth.

A depiction of a neuron
NERVE TRANSMISSION
Calcium helps regulate the transmission of nerve impulses, which is critical for
communication between the brain and other body parts.

An image of a muscle
MUSCLE CONTRACTION
Calcium helps with muscle contraction and relaxation, including the muscles involved
in breathing and the heart beating.

a desaturated heart and yellow cardiac conductive tissue showing the SA node, AV
node, and ventricles
CARDIAC CONDUCTION
Calcium ions are necessary for the contraction of the heart muscles, but they also play
a critical role in the generation and transmission of electrical impulses that coordinate
the heart’s rhythm. These electrical impulses regulate the heart rate and ensure that
the heart muscles contract in a coordinated manner. Without sufficient calcium, the
heart may experience arrhythmias or other electrical disturbances.

A bundle of red blood cells that are clotted together

BLOOD CLOTTING
Calcium is necessary to form blood clots, which help stop bleeding after an injury.
An enzyme and two substrates
ENZYME ACTIVITY
Calcium activates and regulates a wide range of enzymes, which are essential for the
body to function as it’s supposed to!

HOW IS CALCIUM REGULATED IN THE BODY?

Calcium levels in the body are tightly regulated through a complex system involving
hormones and their effects on the bones, intestines, and kidneys.

The regulation of calcium involves several hormones, including:

A generic hormone depiction

PARATHYROID HORMONE (PTH)
The parathyroid glands releases parathyroid hormone (PTH) in response to low
calcium levels in the blood. It stimulates the release of calcium from bones and
increases the reabsorption of calcium by the kidneys.

A yellow sun with vitamin D in the middle

VITAMIN D
Vitamin D has similar effects to PTH, including increasing calcium absorption in the
intestines and decreasing kidney excretion. It can also mobilize calcium from bones,
but to a lesser extent than PTH.

A generic hormone depiction

CALCITONIN
The C-cells of the thyroid gland release calcitonin in response to high calcium levels
in the blood. It inhibits calcium release from bones and promotes calcium excretion
by the kidneys. This essentially has the opposite effect of PTH.

When calcium levels fall too low, PTH is released, which causes calcium to be
released from bones and increases the reabsorption of calcium by the kidneys. In
addition, PTH stimulates the production of vitamin D, which helps increase calcium
absorption from the intestines. These actions work together to increase calcium levels
in the blood.

When calcium levels are too high, calcitonin is released, inhibiting the release of
calcium from bones and promoting the kidneys’ excretion of calcium. This helps
reduce calcium levels in the blood.

Overall, regulating calcium in the body is a complex process involving multiple

hormones and organs. Disrupting this process can lead to hypocalcemia or
hypercalcemia, which can have serious consequences.

NORMAL CALCIUM LEVELS & HYPOCALCEMIA

Normal calcium levels can range from 8.5 – 10.5 mg/dL.

CALCIUM LEVELS
Normal Levels: 8.5 – 10.5 mg/dL
Hypocalcemia: < 8.5 mg/dL
Critical Hypocalcemia: < 4.4 mg/dL
WHAT ARE IONIZED CALCIUM LEVELS?
When a patient has low calcium, you may have heard that an ionized calcium level is
specifically checked.

Ionized calcium is ordered because it represents the blood’s physiologically active

form of calcium.

Total calcium (checked on a BMP or CMP), includes both ionized and protein-bound
calcium. Total calcium levels can be influenced by pH and albumin levels.

Ionized calcium is considered a more accurate reflection of the body’s calcium status.

IONIZED CALCIUM LEVELS

Normal Levels: 4.4 – 5.4 mg/dL
Hypocalcemia: < 4.4 mg/dL
Critical Hypocalcemia: < 3 mg/dL
ALBUMIN AND CALCIUM
Albumin is a protein in the blood that binds to calcium and other ions, reducing the
amount of ionized calcium available for cellular processes.

As a result, total calcium levels may be affected by changes in albumin levels.

Ionized calcium levels are unaffected by changes in albumin levels and are considered
a more accurate reflection of the body’s calcium status. This means if the calcium is
low but the albumin level is also low, ionized calcium should definitely be checked.
There is a correction calculator, but this isn’t always accurate so it’s best to check an
ionized calcium level to verify.

CAUSES OF HYPOCALCEMIA:
There are multiple causes of hypocalcemia, including:

An image of the thyroid and parathyroid glands

HYPOPARATHYROIDISM
Hypoparathyroidism is when the parathyroid glands produce insufficient amounts of
PTH, leading to decreased calcium levels in the blood. This is usually caused by
surgery or radiation.

Vitamin D in a softgel
VITAMIN D DEFICIENCY
As stated above, vitamin D is essential for calcium absorption from the intestines.
This means a lack of vitamin D can lead to hypocalcemia.

The kidneys, with the left one transected so you can see the inside
CHRONIC KIDNEY DISEASE
The kidneys play a critical role in regulating calcium levels in the blood. Chronic
kidney disease can cause decreased vitamin D production, as well as too much
calcium excretion.

Milk overflowing
HYPERPHOSPHATEMIA
High phosphate levels lead to depositing calcium outside the blood, such as in skeletal
muscle or bones.

Milk overflowing
ABNORMAL MAGNESIUM LEVELS
Hypomagnesemia can cause parathyroid hormone resistance or decrease PTH
secretion in severe cases. Severe hypermagnesemia can also induce hypocalcemia.

An image of an inflamed appendix

ACUTE PANCREATITIS
Acute pancreatitis can lead to calcium deposition in the pancreatic tissue, leading to
decreased calcium levels in the blood.

A bottle of medications that are prescription

MEDICATIONS
Certain medications can cause low calcium levels, including:

Bisphosphonates
Colchicine
Chemos (cisplatin)
Immunomodulators
Anticonvulsants (Dilantin, Phenobarbital)
A bag of Type A blood
OTHER CONDITIONS
There are various other causes of low calcium levels, including:

Certain genetic conditions

Sepsis or severe illness
Post-surgical state
Massive blood transfusions (from citrate in the blood)
HYPERVENTILATION
Anxiety and hyperventilation can lead to a decrease CO2 in the blood, which can
result in respiratory alkalosis.

Alkalosis can cause calcium ions to bind more readily to proteins like albumin,
resulting in decreased levels of ionized calcium in the blood. This is often why
patient’s having panic attacks experience numbness, tingling, and even muscle
spasms.

Having the patient breathe into a non-rebreather not hooked up to oxygen (or a good
ole paper bag) can help them retain more CO2 and decrease symptoms.

NURSING ASSESSMENT OF HYPOCALCEMIA

SYMPTOMS
Hypocalcemia can cause many symptoms, with tetany being the most common and
hallmark sign.
Tetany is when there is hyper-irritability of the peripheral neurons and their control
over muscles. This can range from mild symptoms to more severe symptoms. This is
unlikely to occur until calcium levels below 7-7.5 mg/dL.

Symptoms of tetany include:

Lips with blue tingling numbness around it

PERI-ORAL NUMBNESS
Numbness and/or tingling around the mouth and lips.

A muscle with red electric bolts indicating pain

MUSCLE CRAMPS AND SPASMS
Hypocalcemia can cause muscle cramps, carpopedal spasms, and even laryngospasms
which can cause hypoxia and respiratory distress.

A hand with blue electric bolts indicating tingling

PARESTHESIAS
The patient may have numbness or tingling of their hands or their feet.

Other generalized symptoms of hypocalcemia include:

A fatigued muscle with a sad tired expression

MUSCLE WEAKNESS
Low calcium can cause generalized weakness and fatigue.

A silhouette of a head with red and orange markings above the head, indicating
anxiety
MENTAL HEALTH
Hypocalcemia can lead to anxiety, irritability, and even depression.

A blue brain with yellow lightning bolts depicting a seizure

SEIZURES
Severe hypocalcemia can cause focal or generalized seizures.

PHYSICAL ASSESSMENT
When performing a physical exam for a patient suspected of having hypocalcemia,
the nurse should assess for the following:

VITAL SIGNS
HR: May be irregular (indicating an arrhythmia)
BP: May be decreased
A face with the facial nerve present, which is causing Chvostek sign
CHVOSTEK’S SIGN
Chvostek’s sign is positive when tapping the facial nerve in front of the ear causing
twitching of the facial muscles on that side in patients with hypocalcemia.

Sensitivity: 10-64%
Specificity: 69-92%
This means that it is not always present in hypocalcemia, but if it is present, then
hypocalcemia is a good possibility.

An image of carpopedal spasms occurring with a blood pressure cuff inflated on the
upper arm
TROUSSEAU’S SIGN
Trousseau’s sign is positive when spasms of the hand and wrist occur after inflating a
blood pressure cuff above the patient’s systolic BP for 3-5 minutes.

Sensitivity: 30-94%
Specificity: 29-63%
This means it is likely more commonly present in hypocalcemia than Chvostek’s sign,
but its presence doesn’t necessarily mean it is from hypocalcemia.

There are no other specific physical findings for low calcium, but you should observe
for weakness, irregular heart rhythms, and possibly painful muscles to palpation.

Also check out: “The Cranial Nerve Assessment for Nurses”

NURSING INTERVENTION OF HYPOCALCEMIA

When you get a low calcium level back on the blood work of your patient, as the
nurse you should:

STEP 1: ASSESS THE PATIENT

Ensure they don’t have any symptoms and are stable, including recent vital signs.

STEP 2: CARDIAC MONITOR

Make sure your patient is on the cardiac monitor. Obtain an ECG if it still needs to be
done. Close cardiac monitoring is essential when infusing electrolytes through the IV
as well.

STEP 3: NOTIFY THE PROVIDER

Notify the provider of the calcium levels, your assessment, and their cardiac rhythm
(and if any QT prolongation is present)..

STEP 4: ENSURE IV ACCESS

Make sure there is at least one IV site, but place a second line if the hypocalcemia is
severe.

STEP 5: ADMINISTER TREATMENT

Administer medications that are ordered that will be discuss by my group member
Naga

Nursing Diagnosis for Hypocalcemia with interventions

Risk for Electrolyte Imbalance

Hypocalcemia, which is low level of Calcium in the blood, can occur in patients with
chronic laxative use, diarrhea, renal failure, or as a side effect of certain medications.
This can lead to an electrolytes imbalance as low levels of calcium can disrupt the
balance of other electrolyte in the body such as phosphorus and magnesium. The
resulting electrolyte imbalance van cause symptoms ranging from mild to severe and
can potentially be life-threatening if left untreated.

Risk for electrolye Imbalance related to

 Chronic laxativee abuse
 Diarrhea
 Renal Failure
 Treatment-related side effects of medications such as antibiotics, anticonvulsants,
conrticostiroids, diuretics

Nursing Interventions
Nursing Assessment and Rationales
1. Monitor respiratory rate, effort, and rhythm. Place tracheostomy set at the bedside.
Hypocalcemia may result in laryngeal stridor leading to respiratory arrest.

2. Monitor heart rate and rhythm.

The heart muscle may contract irregularly with calcium and magnesium deficit.

3. Assess for areas of possible bleeding. Observe for petechiae and ecchymosis.
Severe hypocalcemia is associated with depressed circulatory function and alterations
in coagulation.

4. Assess neuromuscular strength, tone, movement, and reflexes; observe for

Trousseau’s and Chvostek’s sign.
Hypocalcemia directly increases peripheral neuromuscular irritability resulting in
muscle spasms.

5. Monitor laboratory studies.

Evaluates therapy needs and effectiveness.

6. Review the client’s medication regimen such as digoxin, insulin use, mithramycin
(Mithracin), and parathyroid injection.
These drugs can decrease magnesium levels, affecting calcium levels. The effect of
digoxin is enhanced by calcium, and, in clients receiving calcium, digoxin
intoxication may develop.

Nursing Interventions and Rationales

1. Discuss the use of antacids and laxatives.
Those containing phosphate may negatively affect the metabolism of calcium.

2. Maintain a safe, quiet environment and seizure precautions.

Reduces CNS stimulation and protects the client from injury.

3. Stress the importance of meeting calcium needs.

Adverse effects of long-term deficiency include cataracts, eczema, osteoporosis, and
tooth decay.

4. Encourage relaxation and stress-reduction measures such as deep-breathing

exercises, guided imagery, and visualizations.
Hypocalcemic tetany can be potentiated by stress and hyperventilation.

5. Encourage the use of calcium-containing antacids if needed, such as Dicarbosil,

Titralac, and Tums.
Possible sources for an oral replacement to help maintain calcium levels, especially in
clients at risk for osteoporosis.

6. Encourage the client to eat foods high in calcium such as dark leafy greens, cheese,
low-fat milk, yogurt, eggs, oranges, green beans, and sardines. Avoid intake of
phosphorus-rich foods such as bran, chocolates, nuts, whole wheat, and barley.
Vitamin D aids in the absorption of calcium from the intestinal tract. Phosphorus
competes with calcium for intestinal absorption.

7. Review dietary intake of vitamins and fat.

Vitamin D and fat insufficiency impair calcium absorption.

8. Administer medication as indicated:

8.1. Calcium gluconate, gluceptate, or chloride intravenously (IV)

Provides rapid treatment in acute calcium deficit, especially in the presence of tetany
or convulsions.
8.2. Calcium carbonate/lactate PO
Oral preparations are useful in correcting subacute deficiencies.
8.3. Vitamin D supplement
May be used in combination with calcium therapy to enhance calcium absorption
once concomitant phosphate deficiency is corrected.
8.4. Magnesium sulfate IV or PO
Hypomagnesemia is a precipitating factor in calcium deficit.
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