Hypercalcemia

Predisposing Factors Precipitating Factors

Gender (Postmenopausal women) Malignancies

Age (50-60 years old) Hyperparathyroidism
Prolonged immobilization Intake of thiazide diuretics
Family History Vitamin A & D intoxication
Digoxin toxicity
Overuse of calcium supplements

Excessive PTH secretion

Increased release of calcium Increased intestinal and renal

from bones absorption of calcium

 Serum calcium level

Elevated calcium levels in the blood >10.2 mg/dL
Muscle weakness and reduced
DTR
stream  (+) Sulkowitch urine test

Myoneural junction activity is Kidney Stones form
Thirst
suppressed Polyuria
Renal Insufficiency

Neuromuscular excitability is reduced

Increased sodium excretion and
depletion of body water
Decreased tone in smooth and striated
muscle
Metabolic Alkalosis

Impaired Muscle Increased myocardial

Reduced Glomerular filtration rate
Strength contractility & irritability

Decreased Respiratory Irregular Shortening of QT interval

Muscular Capacity Heartbeats/Arrythmias and ST segment

Respiratory Muscle Cardiac arrest IV admin of 0.9% Sodium Chloride

Fatigue Administer fluids
IV Phosphate
Calcitonin Mobilize patient
Dyspnea Restrict calcium intake
Furosemide (Lasix)
Rapid Shallow Breathing Cancer patients:
Cancer patients:
Corticosteroids Surgery
Biphosphonates Chemotherapy
Mithramycin Radiation therapy
Inorganic phosphate salts

Nursing Management Legend

 Instruct to increase fluid intake Disease
 Encourage to ambulate Risk Factors
 Instruct to include adequate fiber in diet Signs and Symptoms
 Implement safety precautions Treatment
 Assess for s/s of digitalis toxicity Diagnostic Tests
 Monitor cardiac rate and rhythm Medications
 Elevate head of bed Disease Process
Definition

Hypercalcemia is a condition in which the calcium level in your blood is above normal
(Serum calcium value greater than 10.2 mg/dL). Too much calcium in your blood can weaken
your bones, create kidney stones, and interfere with how your heart and brain work. Usualy it is
caused by overactive parathyroid glands. It may also be due to cancer, specific drugs and
overconsumption of calcium and vitamin D supplements.

Pathophysiology

The most common causes of hypercalcemia is due to hyperparathyroidism and cancers.

Therefore there is an increased risk of postmenopausal women as studies have shown that they
are more likely to develop hyperparathyroidism. The excessive PTH secretion attributed to
hyperparathyroidism or due to malignant tumors increases the release of calcium from bones
and also increases the intestinal and renal absorption of calcium. This leads to elevated calcium
levels in the blood stream which then affects several organ systems.

Due to the increased calcium levels in the circulatory system, kidney stones form
blocking the flow of urine and may cause bleeding and infection. Over time this can cause renal
insufficiency leading to a reduced glomerular filtration rate, because of this the body
experiences an increased sodium excretion and depletion of water. Although very rare, a
reduced GFR can lead to a decreased reabsorption of bicarbonate causing Metabolic Alkalosis.

Myoneural junction activity is surpressed due to the elevated calcium levels resulting to a
reduced neuromuscular excitability causing a decreased tone in smooth and striated muscle.
This causes muscle weakness and a diminished deep tendon reflex. Impaired muscle strength
also results in a decreased respiratory muscular capacity which entails a condition called
respiratory muscle fatigue. Not only is the musculoskeletal and respiratory system affected but
also the cardiovascular system as well. Due to the decreased tone in smooth muscle the heart
experiences increased myocardial contractility and irritability which generates irregular
heartbeats wherein it can ultimately lead to a cardiac arrest.

Clinical Manifestations

The symptoms of hypercalcemia vary according to the serum calcium level.

Hypercalcemia is considered mild if the total serum calcium level is between 10.5 and 12 mg
per dL (2.63 and 3 mmol per L). However, mild hypercalcemia usually does not show any signs
or symptoms. On the other hand, hypercalcemia is considered severe if the total serum calcium
level is approximately 16 mg/dL and higher, this where severe symptoms usually tend to
appear. Mild symptoms include nausea, confusion, thirst, diarrhea, muscle weakness, etc.
However, these can progress into reduced deep tendon reflexes, polyuria, dyspnea, heart
attack and coma. Hypercalcemic crisis happens when there is a sudden rise in the serum
calcium level to 17 mg/dL or higher. During this crisis, the person experiences severe thirst and
excessive urination due to an affected renal system.

Diagnostic Studies

Due to hypercalcemia only exhibiting symptoms when it reaches severe levels, you
might not know you have one until blood tests showing increased levels of blood calcium. Blood
tests can also reveal levels of parathyroid hormones which indicates when one has
hyperparathyroidism, the leading cause of hypercalcemia. Another diagnostic test is the
Sulkowitch urine test which can reveal the levels of calcium in urine. The kidneys have a
calcium threshold, when the serum calcium levels reaches above a certain levels it will spill into
the urine. A high calcium level is indicated by a milky-water solution after dropping the
Sulkowitch reagent into urine.
Medical Management

Measures include administering fluids, diluting serum calcium and promoting calcium
excretion in the kidneys. The client will also be undergoing restricted dietary calcium intake. IV
administration of 0.9% NaCl inhibits tubular reabsorption of calcium thus temporarily diluting the
serum calcium levels and increasing urinary calcium excretion. Furosemide (Lasix) often is used
in conjunction with a saline solution as it causes diuresis and increases calcium excretion.
Another medication that lowers the serum calcium level is Calcitonin and is used for patients
with heart diseases or renal failure as they cannot tolerate large sodium loads. This drug is
administered intramuscularly and a skin allergy for Salmon must be performed before
administering as they commonly use Calcitonin that is derived from Salmon.

The treatment for cancer patients is directed at controlling the condition. This is done by
surgery, chemotherapy or radiation therapy. Corticosteroids can be used in order to reduce
bone turnover and tubular reabsorption for patients with sarcoidosis, myelomas, lymphomas
and leukemias. Biphosphonates can be used to inhibit osteoclast activity,, Mithramycin, a
cytotoxic antibiotic inhibits stops bone resorption resulting to a lowered serum calcium level.
Inorganic phosphate salts can also be administered however extreme caution is used if it is
administered intravenously as it causes severe complications.

Nursing Diagnoses

1. Ineffective Breathing Pattern r/t musculoskeletal impairment aeb rapid shallow breathing
2. Decreased Cardiac Output r/t Hypercalcemia aeb altered heart rate
3. Risk for Falls r/t impaired physical mobility s/t muscle rigidity

Nursing Interventions

1. Encourage to ambulate to help prevent hypercalcemia.

2. Instruct to include adequate fiber in diet to offset constipation.
3. Assess for s/s of digitalis toxicity as hypercalcemia increases effects of digitalis.
4. Implement safety precautions due to client’s muscle weakness and altered mental status.
5. Elevate client’s head of bed because a sitting position permits maximum lung excursion and
chest expansion.
6. Monitor cardiac rate and rhythm for any abnormalities because ECG changes can occur any
time.
7. Instruct to increase fluid intake to dilute serum calcium and promote calcium excretion in the
kidneys.