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

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

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: doesnt 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 anticonvulsantsphenobarbital 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

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 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 10.5 mg/dl Above 5.1 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- 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 10.5 mg/dl Ionized calcium level above 5.1 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; 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

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.