Confusion

• Depressed reflexes,

• Muscular weakness,

• Fractures (occur when calcium leaves the bone due to cancer, osteoporosis, and other disorders),

• Hypertension,

• Cardiac arrhythmias,

Treatment is based on the calcium level. The calcium level may need to be lowered quickly because severe hypercalcemia can be life threatening. Treat the underlying cause if known.

• If kidney function is adequate:

o Administer isotonic saline IV to hydrate the patient. o Make sure the patient drinks 3000 to 4000 ml of fluid to excrete the calcium in urine.

o Administer furosemide (Lasix) or ethcrynic acid (Edecrin) loop diuretics after adequate fluid intake is established.

• Administer synthetic calcitonin to lower serum calcium concentration

• Administer plicamycin (Mithracin) to increase absorption of calcium in bone.

• Provide a low-calcium diet.

• Make sure the patient performs weight-bearing activities.

• Take safety measure to protect the patient who experiences neuromuscular effects.

Hemodialysis is the most effective method to lower calcium levels in severe cases when kidney function is not normal.

Hypocalcemia

Hypocalcemia occurs when the serum calcium level is lower than 8.5 mg/dL indicating there is a lower than normal concentration of calcium. This usually produces a high serum phosphorus level. Too little calcium intake causes calcium to leave the bone to maintain a normal calcium level. Fractures (broken bones) may occur if a calcium deficit persists because of calcium loss from the bones (demineralization).

Hypocalcemia is caused by:

• Hypoparathyroidism.

• Thyroid or neck surgery where the parathyroid gland is removed or injured.

• Hypomagnesium caused by alcoholism.

• Ingestion of phosphates.

• Inadequate intake of dietary calcium and/or Vitamin D.

Patients who experience hypocalcemia may have the following symptoms:

• Hallucinations.

• Numbness and tingling in the face, around the mouth, and in the hands and feet.

• Muscle spasms in the face, around the mouth, and in the hands and feet.

• Hyperreflexia.

• Ventricular tachycardia.

Patients with hypocalcemia can be treated as follows:

• Calcium preparations can be given PO in tablet, capsule, or powder form or IV. If given IV, then mix with 5% dextrose in water. Do not mix with a saline solution because sodium encourages the loss of calcium.

• Administer parenteral calcium. Caution: tissue infiltration leads to necrosis and sloughing. Calcium increases the action of digoxin and can result in cardiac arrest. Don't add calcium to bicarbonate or phosphorus because precipitates form.

• Administer the following medication intravenously if ordered: o Calcium chloride IV 10 mL

o Calcium gluceptate 5 mL o Calcium gluconate 10 mL

• Administer the following medication PO if ordered:

o Calcium carbonate (Os-cal, Tums, Caltrate, Megacal) 650-1500 mg tablets o Calcium gluconate (Kalcinate) 500-1000 mg tablets o Calcium lactate 325-650 mg tablets o Calcium citrate 950 mg tablet

• Take safety precautions because the patient is at risk for tetany and seizures.

• Tell the patient to refrain from alcohol and caffeine because they inhibit calcium absorption.

• Increase dietary calcium to 1500 mg/day by eating green leafy vegetables and fresh oysters and milk products.

• Administer vitamin D.

• Have the patient undergo regular exercises to decrease bone loss.

Patient education should include information about dietary sources of calcium, the need to maintain physical activity to avoid bone loss, avoid overuse of antacids, and chronic use of laxatives. Patients should be taught to use fruits and fiber for improving bowel elimination. Take oral supplements with meals or after meals to increase absorption.

Magnesium

Magnesium is a sister cation to potassium and is higher in intracellular fluid (ICF). If there is a loss of potassium there is also a loss of magnesium. Magnesium is the coenzyme that metabolizes carbohydrates and proteins and is involved in metabolizing nucleic acids within the cell. Magnesium also has a key role in neuromuscular excitability. The patient acquires magnesium by ingesting magnesium-rich food, where it is absorbed in the GI tract and then excreted in urine.

There is a close relationship between magnesium, potassium, and calcium. PTH (see calcium), which regulates calcium, also influences the magnesium balance. Typically, you'll assess serum magnesium, calcium, and potassium together. The normal serum magnesium level is between 1.5 mEq/L and 2.5 mEq/L.

Hypermagnesemia

Hypermagnesemia is a condition experienced by a patient whose serum magnesium level is greater than 2.5 mEq/L. The major cause of hypermagnesia is an excessive intake of magnesium salts in laxatives such as magnesium sulfate, milk of magnesia, and magnesium citrate. Antacids such as Maalox, Mylanta, and DiGel can also cause hypermagnesemia. Patients who take lithium (antipsychotic medication) are also at risk for hypermagnesemia. The signs and symptoms of hypermagnesemia are:

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