Coma

Hyponatremia is treated by:

• Treating the underlying cause.

• Administering hypertonic saline solution IV such as Dextrose 5% in saline to restore the serum sodium level.

• Replacing fluid loss with commercially available electrolytic fluids.

The nurse should monitor:

• Fluid intake and output,

• Serum sodium levels,

• Dietary sodium intake,

• Breath sounds and signs of respiratory distress.

The nurse should educate the patient to:

• Not drink excessive amounts of pure water on a hot day or after extreme exercise. Fluid replacement should be an electrolyte solution such as Gatorade or other commercial preparations that include sodium.

• Monitor for signs and symptoms of hyponatremia if the patient is taking a potent diuretic such as furosemide (Lasix) or a thiazide diuretic such as hydrochlorothiazide (HydroDiuril) .

• Report any signs of respiratory distress to healthcare provider.

Calcium

Calcium is found in equal proportion in intracellular fluid and extracellular fluid. It is combined with phosphate in bone and with protein (albumin) in the serum. A patient receives calcium from ingesting calcium-containing food. Calcium plays a critical role in transmission of nerve impulses, blood clotting, muscle contraction, and the formation of teeth and bone. There is also growing evidence that calcium can help with weight loss.

There are three forms of calcium in serum that can fluctuate among forms depending on changes to the serum pH and/or serum protein (albumin) levels.

1. Free ionized form, which is the biologically active form. Half of the patient's total calcium is in the free ionized form.

2. Protein bound, which binds primarily with albumin.

3. Complex form, which is where calcium is combined with phosphate, citrate, or carbonate.

The normal serum calcium ranges between 8.5 mg/dL to 10.5 mg/dL. This reflects the calcium level for all three forms of calcium. However, ionized calcium (iC) levels are sometimes reported separately (4-5 mg/dL).

There is a balance between calcium and phosphorus. As serum calcium increases, serum phosphorus decreases. Conversely, as serum calcium decreases, serum phosphorus increases. The level of calcium is regulated by the parathyroid hormone (PTH), calcitonin, and vitamin D.

Low serum calcium causes an increase in the production of PTH. PTH moves calcium out of bone and into the serum. It increases the absorption of calcium from the GI tract. PTH also increases reabsorption of calcium in the kidneys.

Calcitonin is produced by the thyroid gland. Production is increased when there is a high serum calcium level. Calcitonin reverses the action of PTH by increasing the absorption of calcium by bone, decreases calcium absorption in the GI tract, and causes an increase in urine to excrete calcium.

Table 10-2. Medications that increase and decrease serum calcium.

Decreases Serum Calcium

Increases Serum Calcium

Magnesium sulfate

Calcium salts

Propylthiouracil (propacil)

Vitamin D

Colchicines

IV lipids

Pliamythin

Kayexalate androgens

Neomycin Acetazolamide

Diuretics (Thiazides, Chlorthalidone, Hygroten)

Aspirin

Anticonvulsants

Glutethimide

Estrogens

Aminoglycosides (gentamicin, amikacin, tobramycin)

Phosphate preparations: oral, enema, and IV (sodium phosphate, potassium phosphate)

Corticosteroids (cortisone, prednisone)

Loop diuretics (furosemide [Lasix])

Dairy products are the major source of dietary calcium. Eggs, green leafy vegetables, broccoli, legumes, nuts, and whole grains provide smaller amounts. Only about 10% to 30% of the calcium in foods is actually absorbed in the body. Calcium is absorbed in the small intestine. Absorption is influenced by the amount of vitamin D available and the levels of calcium already present in the body.

Hypercalcemia

Hypercalcemia is a condition when the serum calcium level is higher than 10.5 mg/dL indicating there is a higher than normal concentration of calcium. This usually produces a low serum phosphorus level. Hypercalcemia can be caused by:

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