Primary Nursing Diagnosis

Risk for injury related to bone demoralization and confusion

OUTCOMES. Fluid balance; Electrolyte/acid-base balance; Risk control; Safety behavior: Fall prevention; Knowledge: Personal safety; Safety status: Fall occurrence and physical injury; Symptom control behavior; Knowledge: Medications; Mobility level; Neurological status: Consciousness

INTERVENTIONS. Electrolyte management: Hypercalcemia; Medication management; Medication administration; Fall prevention; Environmental management: Safety; Fluid/electrolyte monitoring; Fluid/electrolyte management; Neurological monitoring; Exercise promotion

Ü PLANNING AND IMPLEMENTATION Collaborative

The goals of treatment are to reduce the serum calcium level and to identify and correct the underlying cause. Conservative measures include administering fluids to restore volume and enhance renal excretion of calcium; prescribing a low-calcium diet; eliminating calcium-containing medications (calcium supplements, calcium-containing antacids) or medications that impair calcium excretion (thiazide diuretics, lithium); and, when possible, keeping active.

In severe cases of hypercalcemia, administer large volumes of normal saline (0.9% NaCl) at a rate of 300 to 500 mL per hour until the extracellular volume is restored (usually 3 to 4 L in the first 24 hours), at which time the rate is slowed and the infusion is maintained to promote renal

436 Hypercalcemia calcium excretion. The physician may prescribe furosemide with the saline infusion, which helps prevent fluid volume overload. Monitor for signs of congestive heart failure in patients who are receiving 0.9% NaCl solution diuresis therapy. If hypercalcemia is the result of a malignancy, then surgery, chemotherapy, or radiation may be used.

Pharmacologic Highlights

Medication or Drug Class

Dosage

Description

Rationale

Furosemide (Lasix)

20-40 mg IV bid-qid

Loop diuretic

Used with saline diuresis when clinical evidence of heart failure occurs

Pamidronate

60 mg in 500 mL of 0.9% saline infused as single dose over 4 hr; for severe hypercalcemia (>13.5 mg/dL) dose may be increased to 90 mg in 1000 mL 0.9% saline over 24 hr

Hypocalcemic; biphosphonate

Reduces calcium levels by decreasing phosphate release from bone and increasing calcium excretion by kidneys; response begins in 2 days with peak response in 7 days

Calcitonin Mithramycin

25 |jg/kg in 500 mL D5W

Calcium regulator

Bone resorption inhibitor

Inhibits bone resorption and increase renal calcium excretion; lowers calcium 1-3 mg/dL within several hours, but hypocalcemic effect wanes after several days

Inhibits the action of parathyroid hormone (PTH) on the osteoclasts, resulting in decreased bone demineralization and serum calcium levels; second-line agent in malignant hypercalcemia

Other Drugs: Zoledronate (Zometa) Inhibits bone resorption and Is used for hypercalcemia of malignancy. Bulk laxatives and stool softeners; loop rather than thiazide diuretics; glucocorticoids such as prednisone (inhibit serum calcium by inhibiting cytokine release, inhibiting intestinal calcium absorption, and increasing urinary calcium excretion).

Independent

Encourage sufficient fluid intake. Encourage ambulation as soon as possible and as frequently as allowed, being sure to handle the patient carefully to prevent fractures. Reposition bedridden patients frequently, and encourage range-of-motion exercises to promote circulation and prevent urinary stasis, as well as calcium loss from bone. Choose fluids containing sodium, unless con-traindicated. Discourage a high intake of calcium-rich foods and fluids, and provide adequate bulk in the diet to help prevent constipation. If confusion or other mental symptoms occur, institute safety precautions as necessary. Orient the patient frequently, and design a safe environment to prevent falls.

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