Fluids and Electrolytes 2

Mary J. Aigner RN, MSN, FNPC

Hypercalcemia
Common Causes
Hyperparathyroidism
Malignant neoplasm

Less common causes

Medications
 (eg. thiaside diuretics, lithium, estrogens, antiestrogens)

Granulomatous diseases
 (eg. TB, sarcoid, histoplasmosis, coccidioidomycocsis)

Renal insufficiency

Immobilized patients w/rapid bone turnover

 (eg. Paget’s disease, growing children, bone metastases)

Hyperthyroidism

From your textbook (Lewis):

re causes
2/3’s hyper-PTH
1/3 malignancy
(breast,lung, multiple myeloma esp.)
Also Vitamin D overdose
Rarely from increased Ca intake
eg. antacids w/Ca, excessive admin. during cardiac arrest

Symptoms of hypercalcemia
Neurologic
Fatigue
< MS*
Memory loss (recent)
Coma if severe
GI
Constipation*
Anorexia
N/V
Polyuria*
Polydipsia*
Nocturia
Dry mouth
Weakness

The value of lab tests

Confirm Ca is elevated (serum Ca)
Compare to albumin level
Each l gm/dl drop < 4 g/dl should show > Ca by 0.8 mg/dl

If Ca is elevated – search for cause

Parathyroid hormone level checked
If normal, other tests will be done
(eg. CXR, TSH, UA, PSA, ENT exam, Mammogram, serum protein electrophoresis)
What About Nursing Diagnoses?
Hypercalcemia

Risk for injury r/t

Neuromuscular Δ
sensorium Δ

Potentialcomplications
arrhythmias

Our favorite:
Nursing Interventions for > Ca
Increase client exercise/movement
Encourage PO intake (dilute urine)
Teach re foods/fluids – limit >Ca
Encourage > fiber (prevent constipation)
Protect client if confused
Monitor for pathologic fx if >C longterm
Encourage PO intake acid-ash fluids
Eg. prune or cranberry juice
Counteracts Ca salt deposits in the urine
Hyperparathyroidism
80% primary cases due to hyperactive PTH adenoma
15% have PTH hyperplasia
Key Symptoms
Weakness, fatigue

Musculoskeletal

Bone pain
Arthalgia
Neuro

Confusion

Depression

GI

N/V

Constipation

Ulcers

GU

Renal colic

polyuria

Practice Questions – Calcium/PTH

True or False: If a client has a low albumin level, he could have a false low Ca+ level)

Ca+ is the most abundant mineral found in the body (40%, 2% of weight); where is
most of it found (2 places)?
Name the 2 key symptoms of hypercalcemia (similar to another disease).

 Name one acid-ash fluid that is good for hypercalcemia.

Hypocalcemia - Causes
Low albumin most common cause
Why? Ca bound to protein (45%) in circulation
< PTH activity can cause < Ca
Vitamin D deficiency
Ca sequestration in critically ill pt.
Eg. soft tissue deposition, increase bone deposition, or chelation
Sepsis
Medications
Eg. drugs used to treat > Ca, or antineoplastic agents
Key Symptoms of hypocalcemia
Paresthesias
Muscle cramps, carpopedal spasm
Tetany, laryngospasm
Lethargy, confusion, psychosis
Seizures
Symptoms of CHF, hypotension, and bradycardia

Two Signs: Do you know them?

Chvostek’s Sign
Contraction of the facial muscle in response to tapping the facial nerve against the bone
anterior to the ear
Trousseau’s Sign
Carpal spasm occurring after occlusion of the brachial artery with a blood pressure cuff
for 3 minutes.
Other Data on Hypocalcemia
Key Tests
Albumin
Phosphorus
PTH
Vitamin D
ECG (EKG)
Creatinine
Magnesium
Important Warnings re IV therapy:

Phosphorus and bicarbonate are not compatible w/Ca

Ifon digitalis – monitor closely as IV Ca potentiates digitalis toxicity

Nursing Diagnoses: hypocalcemia
Risk for injury r/t
Tetany
Seizures

Potential complications
Fracture
Respiratory arrest

What about < Ca interventions?

CLOSELY monitor resp/CV status
Protect confused client
Administer PO/parenteral Ca as ordered
If IV – closely monitor status and ECG

Teach client at > risk for osteoporosis

Diets rich in Ca
Recommended: 1000-1500 mg Ca/day
Ca supplements
Regular exercise important
Estrogen replacement therapy???? if postmenop.
What foods are high in Ca?

Phosphorus/Phosphate Imbalances
Phosphorus is a primary anion in ICF

Essential for function

Muscles
Red blood cells
Nervous system

Deposited with Ca for

Bone structure
Tooth structure
Phosphorus also …
Involved in

Acid-base buffering system

Mitochondrial energy production of ATP
Cellular uptake and use of glucose
Acts as intermediary in metabolism (carbs, fats, proteins)
Kidney function must be adequate
Kidneys are major route of phosphorus excretion

Small amount P lost in feces

> P tends to cause < Ca in serum

(A reciprocal relationship)
Hyperphosphatemia
Main cause: acute or chronic renal failure

Other:
Chemotherapy
Eg. lymphomas
Excessive PO intake of milk or P containing laxatives
large intake Vit D
Increases GI absorption of P

Hyper-P resultsin metastatic Ca/P deposits

Normally only in bone

Results in Ca deposits in soft tissue

Skin
Joints
Arteries
Kidneys
cornea
What can be done for >P?
Identify/RX cause
Restrict >P foods
Dairy products
Adequate hydration
Correct <Ca status
3+4 enhance renal excretion of P
Special measures used in renal failure
Ca supplements
P binding agents
Diet restrictions
What about low P?
Hypophosphatemia?
Primary Causes:
Malnutrition or Malabsorption syndrome

Other Causes:
Alcohol withdrawal
Phosphate-binding antacids

TPN

Glucose administration

•Recovery from diabetic ketoacidosis

Respiratory alkalosis

Symptoms of < P

Confusion, coma
Rhadomyolysis
Renal tubular wasting of Mg, Ca, HCO3
Arrhythmias, < stroke volume
Muscle weakness, includes resp.
Osteomalacia

Management of < P ???

Oral supplement
Eg. Nutra-Phos
PO foods high in P
Eg. dairy products

Severe <P may need

IV of Na or K phosphate
P levels need monitoring
Sudden hypocalcemia
may occur
(2° Ca-P binding)
Practice Q’s for Phosphorus
True or False: hyperphosphatemia commonly occurs with renal failure.

 Name a Vitamin that in excess can cause hyperphosphatemia.

 True or False: Vegetables and fruit are high in phosphorus.
True or False: there is an inverse relationship between Phosphorus and Ca+ (one rises,
other falls, and vice versa)
Some precautions re Phosphorus
Phosphorus is
incompatible with Ringer’s or lactated Ringer’s solution, D10/0.9%NS, or D5 lactated
Ringer’s solution
Because of the inverse relationship with Ca …
if Ca+ falls too fast, tetany can occur
Never give Phosphorus IM
Dietary Comments re Phosphorus
1 quart cow’s milk daily
Supplies daily requirement of Phosphorus

Provides necessary amt of Vitamin D to enhance absorption

Other foods high in Phosphorus:

Cheese, egg yolk, meat, fish, fowl, nuts

Spinach, rhubarb, bran, whole grains

May decrease phosphorus absorption

Good oral Phosphorus supplements are K-Phosphare, Neutra-Phos K, and Phospha-

Soda
Preparations with Na and K can cause osmotic diarrhea, volume overload, or

hyperkalemia

Magnesium Imbalances
nd
ICF – 2 most common cation
Only 1% found in ECF
50-60% found in bone
Involved in cell metabolism
Cell proteins and nucleic acids
Coenzyme in metabolism of
Carbs amd proteins

Regulated by GI absorption
Excreted by kidneys

Mg related to Ca and K balance

Often mistaken for Ca imbalance
Best to measure Mg, Ca, and K
> Mg Causes
Renal failure, adrenal insufficiency, excess Mg given in ecclampsia
< Mg Causes
Diarrhea, vomiting, chronic alcoholism,
NG suction, prolonged malnutrition (starvation),
Malabsorption syndrome, poor GI absorption
Poorly controlled DM
hyperaldosteronism
< Mg Symptoms/Treatment > Mg
Resembles <Ca
May contribute to start of <Ca
RX:
Mild:
oral supplements,
Foods high in Mg
Severe:
IV or IM Mg
*Too rapid infusion can cause cardiac or resp arrest!

Usu > Mg intake 2° renal failure or insuff.

Mild: lethargy, N/V, drowsiness
Worsening:
Lose DTRs
Somnolence
Resp arrest, then
Cardiac arrest
Where do we get Magnesium?
Present in plant pigment chlorophyll
So – mainly ingested from veggies
Spinach, broccoli, squash, avocado, potato, lima beans

Others: whole grains (esp. wheat germ), rolled oats, nuts, seeds

Some meats: tuna, beef, pork, chicken

Another common source: hard tap water (well water)

Because Mg is so common in food and water … healthy people usually have plenty.

One more imbalance – protein

Plasma volume greatly affected by plasma proteins – esp. albumin
Large molecular size
Stay in vascular space
Contribute to colloidal oncotic pressure

Causes and Symptoms of Hypoproteinemia Hyperproteinemia

Decreased food intake
Starvation

Liver disease

Massive burns

Renal disease
Lose albumin

Majorinfection
Dehydration
Hemoconcentration
Rare

Symptoms and Treatment

< Protein
Edema from < oncotic pressure
Slow healing
Anemia
Fatigue
Muscle loss (body breaks down tissue to get protein)
Ascites (< vascular oncotic pressure)

High carb, high protein diet

Protein supplements

Enteral or parenteral nutrition may be needed

Protein-Calorie Malnutrition (Ch 39)
Primary < PO
Can occur if eats but foods low in protein
Secondary
Malabsorption, Cancer, other defects
Marasmus
<calorie,<protein = loss body fat/muscle
Appear emaciated but serum levels may be ok
Kwashiorkor
<protein with catabolic stress event (eg cancer or surgery)
May appear well but serum levels very low