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Bunny Bones
Calcium - hypercalcemia or hypocalcemia
| Question | Answer |
|---|---|
| Is calcium a Cation or Anion, mainly intracellular or Extracellular? | Cation, both |
| 99% | Amount of the body’s calcium found in bones |
| What percent of calcium is found in serum and soft tissues? | 1% |
| Name functions of calcium in the body (B, C, C, I, M, H). | bones and teeth are made with calcium and phosphorous, Cell structure and function, Cell membrane permeability, Impulse transmission, Contraction of cardiac, smooth and skeletal MUSCLE, Blood clotting, Release of certain HORMONES |
| Normal range for serum calcium. | 8.5 to 10.5 mg/dL |
| Account for extracellular calcium by percentage. | 41% bound to protein, 9% bound to citrate (or other organic compounds), 50% ionized or free calcium |
| What kind of calcium does the physiologic work in the body? | ionized |
| What is the normal range for adult ionized calcium? | 4.5 to 5.1 mg/dL |
| What is the normal range for child ionized calcium? | 4.4 to 6.0 mg/dL |
| What are the two types of calcium measurements? | Serum Calcium and ionized calcium |
| Which of the two types of calcium measurements would be affected by albumin levels? | serum calcium |
| Why is the serum calcium level affected by the level of albumin? | because nearly half of the calcium is bound to albumin |
| What happens to ionized calcium levels when albumin levels are low? | remain unchanged |
| How do serum calcium levels for children and older adults compare to normal adult levels? | older adults – Lower, Children – higher especially during periods of bone growth |
| RDA for calcium | 800 to 1,200 mg/day |
| Name 7 excellent sources of calcium. | sardines, dairy products, leafy greens, legumes, molasses, nuts, whole grains |
| Where in the GI tract is calcium absorbed? | in the small intestine |
| Which hormone pulls calcium from bones to raise the level of calcium in the blood? | PTH |
| Which hormone keeps calcium locked in bones? | Calcitonin (Sounds like calcium bone in) |
| Where does calcitonin come from? | the thyroid gland |
| What role does vitamin D play in serum calcium levels? | Vitamin D promotes calcium absorption and reabsorption from the GI, Kidneys, and Bones |
| How do we get Vitamin D (2 ways)? | From our diet – especially dairy, and exposure to sun light |
| How does phosphorous affect serum calcium levels? | Phosphorous lowers calcium levels because it inhibits calcium absorption in the intestines. |
| When the kidneys notice calcium levels are low what do they do? | they hold onto calcium and excrete phosphorous |
| What happens to phosphorous levels when calcium levels rise? | They drop |
| What happens to calcium levels when phosphorous levels rise? | They drop |
| What kind of relationship exists between serum calcium and phosphorous levels? | inverse |
| What kind of relationship exists between serum calcium levels and serum PH? | inverse |
| If a patient has alkalosis, what kind of serum calcium level will he have? | Low |
| What is happening to the calcium when a person has alkalosis? | It binds to protein. |
| What happens to serum calcium levels when a patient has Acidosis (low pH)? | they rise |
| Three places calcium goes when it leaves extracellular fluid. | out with urine, out in feces, or into the bones |
| Three ways that calcium gets into the ECF. | reabsorbed from kidneys, reabsorbed from bone, absorbed from the GI tract (small intestine) |
| Three ways that alcoholics are more prone to hypocalcemia. | poor diet, poor absorption, low magnesium levels (much peeing, much vomiting, poor diet lower magnesium levels) |
| Give 3 factors that contribute to hypocalcemia in older folks. | poor dietary intake, poor calcium absorption ( not enough sunlight exposure – vit. D, postmenopause – insufficient estrogen), inactivity (causes loss of calcium from bones) |
| Give 3 broad reasons for the development of hypocalcemia. | not enough in – dietary, what goes in isn’t absorbed properly, or too much is lost. |
| How is it that breast fed infants might suffer hypocalcemia? | If mom isn’t getting enough calcium or Vitamin D |
| Why might a vampire suffer hypocalcemia? | not enough exposure to sunlight so not enough vitamin D |
| Give some reasons for calcium malabsorption. | diarrhea, laxative abuse, Malabsorption syndrome, Lack of dietary Vitamin D or sun, Anticonvulsants -Phenobarbital and phenytoin (Dilatin), high phosphorous level, low gastric acidity (Calcium salts don’t dissolve.) |
| What is the effect of pancreatic insufficiency on calcium? | can lead to hypocalcemia due to malabsorption of calcium resulting in excess loss in feces. |
| What is the effect of acute pancreatitis on calcium levesl? | Can cause hypocalcemia maybe because of PTH or maybe because fatty acids and calcium combine in the pancreas. (We don’t really know how, just that it does.) |
| Since PTH takes calcium to the blood, anything that messes up PTH will lower serum calcium. What are some things that can mess up PTH? | Thyroid or parathyroid surgery; removal of parathyroid tumor; injury, disease, or disorder of the parathyroid gland (like hypoparathyroidism) |
| How do calcitoinin and mithramycin cause hypocalcemia? | They decrease reabsorption of calcium from bone. |
| What is disodium EDTA used for and how can it cause hypocalcemia? | Used for lead poisoning. Can combine with calcium and carry it out of the body when excreted. |
| Anything that lowers magnesium will also lower calcium. Why? | magnesium is necessary for the production of PTH which is responsible for maintaining blood calcium level. PTH is the taxi that carries calcium to the blood. |
| Why would drugs like Cisplastin and Gentamicin cause lowered calcium? | because they lower magnesium, thus PTH, thus serum calcium. |
| What is the most common cause of hypocalcemia? | hypoalbuminemia |
| A common result of cirrhosis, nephrosis, malnutrition, burns, chronic illness, or sepsis. | hypoalbuminemia |
| Why does extra phosphorous lower calcium levels? | extra phosphorous combines with calcium to form salts that are deposited in tissues. |
| Why might an infant get hypocalcemic tetany from cow’s milk? | Cow’s milk has plenty of phosphorous which binds with calcium lowering serum calcium. |
| What pH causes calcium to bind with protein decreasing ionized calcium levels? | alkalosis – high pH |
| Which of these ions are cations and which are anions? Magnesium, Sodium, Chloride, Potassium, Phosphate, Bicarbonate | Cations = sodium, potassium, calcium, and magnesium; Anions = bicarbonate, Chloride, phosphate |
| Why might an infant get hypocalcemic tetany from cow’s milk? | Cow’s milk has plenty of phosphorous which binds with calcium lowering serum calcium. |
| What pH causes calcium to bind with protein decreasing ionized calcium levels? | alkalosis – high pH |
| Why would a patient receiving a large blood transfusion be at risk for hypocalcemia? | Citrate is added to donated blood to prevent clotting. Calcium binds to citrate. Bound calcium cannot do physiologic work. |
| How do severe burns and infections lower calcium levels? | Burned or diseased tissues trap calcium ions from serum. |
| If our patient comes in anxious, confused, and irritable we should suspect what kind of electrolyte imbalance? | hypocalcemia |
| What kind of drugs are furosemide and ethacrynic acid? How do they affect calcium levels? | Forosemide (Lasix) and ethacrynic acid (Edecrin) are loop diuretics that cause increased excretion of water and electrolytes including calcium. |
| What organ if damaged cannot activate vitamin D? | the kidneys |
| Renal failure affects the kidneys ability to activate vitamin D. What affect would that have on calcium? | It would inhibit calcium absorption |
| Name drugs associated with hypocalcemia (A;A-pp; C;C; MLDs; E; LD; M; P). | Aluminum containing Antacids; Anticonvulsants phenytoin/Phenobarbital; Calcitonin; Corticosteriods; Drugs that lower magnesium; editate disodium; Loop diuretics; mithramycin; phosphates |
| What lab values are used to diagnose hypocalcemia? | serum calcium < 8.5 mg/dL; ionized calcium < 4.5 mg/dL; low albumin level; characteristic ECG |
| What is the focus of treatment of hypocalcemia? | restore calcium levels and fix the cause |
| What I. V. Solutions are used to treat acute hypocalcemia? | Calcium gluconate or Calcium chloride |
| Calcium gluconate is preferred to Calcium chloride except under what circumstances? | Calcium chloride is for cardiac arrest. |
| Hypocalcemia does not always respond to calcium therapy alone. What else may be ordered? | Magnesium replacement |
| What is the treatment for chronic hypocalcemia? | Vitamin D and Calcium supplements |
| What should be included in a diet to treat hypocalcemia? | Vitamin D, Calcium, and protein |
| What treatment helps if a patient’s phosphorous levels are too high for calcium absorption? | aluminum hydroxide antacids may be given to bind with the excess phosphorous |
| Why would we want to know if our patient has ever had neck surgery? | because hypoparathyroidism can develop immediately or several years after neck surgery |
| What are the neurologic symptoms of hypocalcemia (a, c, i) ? | Anxiety, Confusion, Irritability |
| What are the neuromuscular symptoms of hypocalcemia ( P of ftfm; tct;LB;T, T&C) ? | Parethesia of the fingers, toes, face, especially around the mouth; Twitching, muscle Cramps, Tremors; Laryngospasm, Bronchospasm; Tetany; Trousseau’s and Chvostek’s sign |
| What is the best solution for diluting I.V. calcium in? | dextrose 5% in water |
| Why not use a solution with bicarbonate for calcium I.V.? | because it forms precipitate |
| Why not use a saline solutions for Calcium I. V. ? | Because sodium chloride increases renal calcium loss |
| The Doctor orders I.V. calcium for your patient. What do you need to clarify? | Calcium gluconate or Calcium chloride |
| Fainting, Syncope, and cardiac arrhythmias can result if I.V. calcium is administered this way. | Too rapidly – Initially calcium may be given by as a slow I.V. bolus, then followed by a slow I.V. drip by infusion pump (if calcium levels are still too low). |
| Our patient receiving I.V. calcium for hypocalcemia starts feeling nauseous, doesn’t want to eat, really doesn’t feel like doing anything at all, and is acting a little dingy. What should we suspect? | hypercalcemia – signs are anorexia, nausea, vomiting, lethargy, and confusion. |
| If our patient is hypercalcemic we need to start monitoring for what? | cardiac arrhythmias, especially if the patient is taking digoxin. |
| Why is it important to periodically check the I.V. site when our patient is receiving calcium? | Calcium can cause tissue sloughing and necrosis. |
| What needs to be on hand for a patient who is recovering from parathyroid or thyroid surgery and why? | Calcium gluconate should be on hand so that we can respond quickly in case the patients calcium levels drop. |
| When teaching our patient about hypocalcemia what topics should we cover? | What is it, causes it, fixes it, signs and symptoms; High calcium diet/foods; Laxatives are bad; exercise is good; medications vs calcium; report pain during I.V.; osteoporosis, estrogen, and calcium |
| If our patient has overt signs of hypocalcemia, how do we prepare to act in case of laryngospasm? | Keep a tracheotomy tray and a resuscitation bag at the bedside. |
| In addition to vital signs what do we need to monitor or hypocalcemic patient for? | respiratory rate, depth, and rhythm; watch for stridor, dyspnea, or crowing; use a cardiac monitor and watch for changes in rate or rhythm; |
| When should oral calcium supplements be given? | 1 to 1 ½ hours after meals |
| How can we prevent stomach upset from oral calcium supplements? | Offer them with milk. |
| What lab results will we monitor for our patient with hypocalcemia? | serum and ionized calcium levels; albumin levels; magnesium levels |
| If our patient is receiving blood transfusion how often should we check ionized calcium levels? | every 4 units of blood |
| Name 9 things that should be included in documentation for our hypocalcemic patient. | assessments, vital signs including heart rhythm; I&O; Seizure activity; Safety measures; Interventions and responses; patency and appearance of I.V. site; lab results; Dr. notifications; patient teaching |
| Name the 5 types of cancer that put patients at the most risk for hypercalcemia. | Squamous cell carcinoma of the lung; myeloma; Hodgkin’s lymphoma; renal cell carcinoma; breast cancer |
| The prognosis for hypercalcemia associated with malignancy is poor. What is the average one year survival rate by percentage? | only 10 to 30% |
| Two mechanisms that can cause hypercalcemia and may occur together or separately are an increase in what and a decrease in what? | increase in calcium absorbtion in the GI tract or Decrease of calcium excretion by the kidneys |
| How does hyperthyroidism cause hypercalcemia? | causes more calcium to be reabsorbed from bone |
| Multiple ________ or Prolonged ________ can cause hypercalcemia by increasing calcium release from bone. | fractures; immobilization |
| What are two metabolic conditions that cause an increase in calcium ionization? | acidosis and hypophosphatemia |
| How does Vitamin A overdose cause hypercalcemia? | causes increased reabsorption of calcium from bone |
| What do Lithium and thiazide diuretics have to do with hypercalcemia? | They can decrease calcium excretion by the kidneys. |
| A condition that raises calcium levels when calcium and alkali (baking soda) are combined | Milk-alkali syndrome |
| Name 6 medications/supplements associated with hypercalcemia (A, C, L, T, V, V). | Antacids with calcium, Calcium preparations (oral or I.V.), Lithium, Thiazide Diuretics, Vitamin A, Vitamin D |
| Fatigue, confusion, altered mental status, depression, personality changes, lethargy | Signs of hypercalcemia |
| What happens in the cells of muscle and nervous tissue when there is too much calcium? | The cells get groggy. Excess calcium in the cells causes a decrease in cell excitability. |
| What are the life endangering manifestations of hypercalcemia (A, C, C, P, S)? | Arrhythmias like bradycardia, Cardiac Arrest, Coma, Paralytic Ileus, Stupor |
| What are the effects of hypercalcemia on reflexes and muscles? | hyporeflexia, loss of muscle strength and tone |
| What are the effects of hypercalcemia on the heart muscle and cardiac conduction system? | arrhythmias like bradycardia and possible cardiac arrest |
| What do we need to watch for if our hypercalcemic patient is taking Digoxin? | Digoxin toxicity |
| What are the signs of Digoxin Toxicity?. | Anorexia, Nausea, Vomiting, irregular pulse, yellow vision |
| What are the effects of hypercalcemia on the GI system? | Calcium slows smooth muscle resulting in decreased motility – anorexia, N&V, decreased bowel sounds, Paralytic Ileus, Flank or abdominal pain |
| What are the effects of hypercalcemia on the kidneys? | The kidneys will work overtime trying to eliminate calcium leading to polyuria and subsequent dehydration. There may be kidney stones or calcification. If the kidneys get worn out, Kidney problems will ensue. |
| Name 5 Lab results related to hypercalcemia. | High serum and ionized calcium - > 10.5 and 5.1 mg/dL; Digoxin toxicity; X-ray = pathologic fractures; ECG = shorter QT, Longer PR, Flatter T |
| What are the characteristic ECG changes for hypercalcemia? | shorter QT, Longer PR, Flatter T |
| How is asymptomatic hypercalcemia treated? | Reduce calcium intake – diet, I.V. , Medications; Increase calcium excretion – hydration= pee out calcium; Decrease calcium reabsorption from bones |
| What I.V. solution is used for hydration to increase the excretion of calcium and why? | normal saline because sodium inhibits renal tubular reabsorption of calcium |
| What diuretics are used to promote calcium excretion? | Loop diuretics like furosemide (Lasix) and ethacrynic acid ( Edecrin) |
| Why aren’t thiazide diuretics used to treat hypercalcemia? | because they inhibit calcium excretion |
| Name two situations in which hypercalcemia treatment may include hemodialysis or peritoneal dialysis. | Life threatening hypercalcemia and renal failure |
| How do corticosteroids work to treat hypercalcemia? | They block bone reabsorption and decrease calcium absorption from the bone. |
| Patients who are immobile, have cancer, or parathyroid disorders are at risk and need to be monitored for what? | hypercalcemia |
| Name four drugs that are used to treat hypercalcemia. | Diuretics, Corticosteroids, bisphosphonates, and plicamycin |
Created by:
Perseverandovercome
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