 Hi, welcome to Nursing School Explained and this video on calcium imbalances. So for quick reference, normal calcium levels in the serum are typically 8.5 to 10.5, but as I usually point out, always check the reference values for the lab that you're working with to make sure that you know what is considered normal and abnormal for your particular lab and your patient. So as a quick reminder, calcium in the body is mostly abundant in the bones, 99% of the calcium we have is stored in bones as well as in teeth. But calcium is also responsible for muscle contraction. And whenever we talk about muscles, we have to think about cardiac as well as skeletal and smooth muscle so they all can be affected by imbalances. Calcium also plays a role in nerve impulses and blood clotting and needs vitamin D for absorption. So vitamin D helps the body to absorb the calcium. And patients are particularly at risk for imbalances of their calcium levels after thyroidectomy. And the reason for that is that behind the thyroid gland in the anterior throat, we have four little glands called the parathyroid glands. And what the parathyroid glands do is they regulate how our body processes the calcium in our bodies. So this parathyroid gland in response to low serum calcium levels will release parathyroid hormone PTH, which will then increase the calcium in the serum. And calcium and phosphate have an inverse relationship. So whenever calcium goes up, phosphorus levels go down. So when the parathyroid gland gets stimulated, calcium levels go up and phosphate levels go down. And so those are always that inverse relationship. And then in addition, another tidbit here is that magnesium always moves in the same direction as calcium. So calcium and phosphorus are usually opposite where magnesium and calcium work move together in the same direction. Vice versa, when there's too much calcium in the bloodstream, the parathyroid gland will decrease the release of the parathyroid hormone. Calcium levels go down, inversely, phosphorus levels will go up and magnesium levels will go down again. And so because the parathyroid gland, those four little glands behind the thyroid, when the thyroid is removed, a lot of times the parathyroid glands go with it. And so then we can't regulate the calcium levels and that's how imbalances occur. So particularly we have to be aware of risk point balances after thyroidectomy. And this always comes up on exam questions and it may also come up on your NCLEX exam. So pay particular attention here. So causes for hypo and hypercalcemia. So hypo, we said the parathyroid gland regulates it. So if there's low parathyroid hormone, we're going to have low calcium levels. But it can also occur because of low intake of calcium, vitamin D that's needed for absorption or magnesium. And then there can be decreased absorption. So any kind of GI disorders that alter the way we are able to absorb the calcium. So think about somebody with ulcerative colitis, irritable bowel, some sort of short bowel syndrome, maybe after a electomy or colectomy, any kind of surgery that alters our intestinal structure. And then decreased albumin levels because most of the calcium is stored in bones, but also the calcium that is floating around in the serum, that small percentage, most of it is bound to albumin. So if we don't have that albumin available in our bloodstream, we're not going to have anything to bind that calcium and therefore it will have hypo-calcemia. And then because of that inverse relationship between calcium and phosphorus, when there is increase in phosphorus level because of renal failure or a condition called rhabdomyolysis, calcium levels will go down because we have talked about this inverse relationship. Now on the contrary side here, hyper-calcemia, so increase in calcium levels in the bloodstream, would be again an increase in parathyroid hormone and that's the most common cause actually and that is because of primary hyper-parathyroidism. So that means that the gland itself is malfunctioning for whatever reason and just produces too much of that parathyroid hormone, which then leads to hyper-calcemia and we'll talk about the treatment and solution here in a little bit. And then malignancy, so any kind of cancer that has spread to the bone because we know that calcium is mostly bound to bone and malignancy, so like stage 3, 4 cancers that have spread to the bone destroy the bone. Therefore when the bone gets destroyed, the calcium is released from the bone and leaks into the bloodstream and then what we measure is the serum calcium levels and that will be elevated. So sometimes that can be an early indication that there is some metastatic cancer going on. And then also increased levels of calcium occur because of an increased intake in calcium by the medial magnesium because we said they always go together and think about patients who take a lot of anti-acids, a lot of them are like calcium carbonate, so we have to be very carefully reviewing the patient's medication to see not only what prescription medications but also what supplements they're taking. And then another big reason for hypercalcemia is immobility because we need this weight bearing exercise to store, to make the bones regenerate but if the patient is immobile we're not going to have this weight bearing exercise, therefore again calcium gets released from the bones because they can't store it and then it can leak into the bloodstream leading to hypercalcemia. Now over here we have signs and symptoms, so as always here's my little tidbit for you, signs and symptoms for calcium imbalances always think muscles, bones and stones. And again muscles we have to think about cardiac, skeletal as well as smooth muscle. So when we have low calcium levels it can either lead to brady or tachycardia but it'll most likely lead to hypotension. It can also lead to a prolonged QT interval on the EKG as well as irregular heart rate and that all pertains to the cardiac muscle. Then for neuromuscular skeletal muscles, hypocalcemia can lead to numbness and tingling specifically in the fingers and circummoral, so around the mouth. And then the patient might have a positive swastika or true pso sign and watch my separate videos about those if you're not familiar with these terms. Hypocalcemia can also lead to muscle cramping and all the way to tetany where the neuromuscular junction is just constantly contracting and then the patient has this kind of a rigid muscle that's considered tetany. And hypocalcemia, so low levels of calcium also will make the deep tendon reflexes increased. And then in terms of smooth muscle, hypocalcemia can make the bowel sounds hyperactive. On the other side over here for hypercalcemia, so increased level of calcium, we can have hypertension. It can also increase clotting times because we said over here that calcium is partially responsible also for blood clotting. It can also lead to osteoporosis because when the calcium is released from the bones and then is measured in the bloodstream as hypocalcemia, the bones lack that calcium and it can lead to osteoporosis all the way to fractures because the bone structure is now has been altered. For hypocalcemia also the deep tendon reflexes will be decreased as well as bowel sounds will be decreased and it can lead to kidney stones. Most kidney stones consist of calcium oxalate and so if there's too much calcium in the bloodstream they kind of get stuck in the renal tubules and can form these crystals of calcium oxalate leading to kidney stones. So if there's somebody who all of a sudden develops kidney stones and they don't have a history, think about hypocalcemia or something to do with vitamin D or magnesium intake and review their supplement intake, very, very important. And then for treatment, so what do we do? If the calcium level is low we recommend an increase in the diet of calcium as well as vitamin D because without vitamin D we can't absorb the calcium. In severe cases we might need to administer IV calcium gluconate and as always with electrolyte administration make sure you have the patient on a cardiac monitor and that you observe and check very diligently with your pharmacy about the maximum rate of infusion. And then we might also want to give the patient bifosphonates or calcitonin. So bifosphonates are the medications that are usually prescribed for patients with osteoporosis because we want to move that calcium from the bloodstream into the bone and so when we do that it helps to bind it and the bifosphonates will help drive that calcium into the bone. And then calcitonin is basically the antagonist to the vitamin D which is called calciferol and it helps us also get more of the calcium into the bloodstream. On the other side if we have hypercalcemia, so increased levels, the parathyroid gland might need to be removed so parathyroidectomy because we said over here the number one reason is primary hyperparathyroidism. So if that is the case then the gland has to be removed in order to regulate the calcium as well as phosphorus levels. We also want to recommend a decrease in intake of calcium and vitamin D just like we recommend the increase over here and if it's the hypercalcemia is really bad and the patient has bad symptoms such as pertain to the heart or maybe muscle cramps, tetany and it affects their reflexes we might have to put them on dialysis temporarily to filter out their blood and get rid of that calcium with the help of the dialysis machine. In terms of nursing considerations, so because we know it can affect vital signs as well as heart we want to make sure we check vital signs frequently. We check those neuromuscular checks to check for numbness and tingling, schvastectrocell cramps and check their reflexes and we want to put them on a cardiac monitor. We want to keep a close eye on their labs all of those that are related calcium, vitamin D, magnesium as well as the albumin as I discussed over there and then we want to for hypercalcemia we want to recommend weight bearing exercises if the patient of course is able to tolerate it to drive that calcium from the bloodstream into the bone and then very important again closely monitor patients for signs and symptoms after a thyroidectomy because like I discussed before that parathyroid gland might have been removed or portions of it might have been removed causing the imbalance in calcium. Thank you so much for watching this video on hypo and hypercalcemia. Please also check out the other videos in the electrolyte imbalances playlist where I go over all the other major electrolytes. Thanks for watching Nursing School Explained, see you soon.