How to: Priority Nursing Interventions (Hypocalcemia)

Daytonite, BSN, RN · Feb 28, 2009

the sequencing of interventions for "risk for" diagnoses include the following:

strategies to prevent the problem from happening in the first place
monitoring for the specific signs and symptoms of this problem
reporting any symptoms that do occur to the doctor or other concerned professional
if symptoms of the problem ever occur, you have an actual problem on your hands and you have to re-evaluate the care plan and change the nursing diagnosis

for actual nursing problems, the sequence of interventions is always: assessment, nursing care, teaching, management.

priority nursing diagnosis

risk for unstable blood calcium related to throidectomy secondary to thyroid cancer

#1_intervention

review lab ca+ levels as soon as received from lab for ↓ blood ca+ as ordered by the md.

#3_intervention

immediate and ongoing (with every entrance into pts room) observation for signs and symptoms of hypocalcemia are indicated (i.e., tetany symptoms: muscular twitching and tremors, spasms of the larynx, paresthesia [tingling in and numbness of fingers], facial spasms, and spasmodic contractions).

#4_intervention

if no hypocalcemic signs appear, implement immediate q day or prn for positive chvostek's/trousseau's signs e.g., spasms of the cheek and the corner of the lip, carpal spasms. continue until lab result show ca+ levels 8.5 - 10.0 mg/dl. - what? read what you have written. i don't understand what you are saying here. is this the same as intervention #3 just stated differently?

#2_intervention

if ↓ blood ca+ is indicated administer calcium carbonate 500 mg 2 tabs t.i.d. per m.d. - if you have to do this then you no longer have a risk for unstable blood calcium, do you? this intervention, rationally, doesn't belong here because you are now treating the problem that you are trying to prevent. what it should say is "if blood ca+ is low, notify the md immediately." at that point it becomes a new nursing problem.

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#5_intervention

once pt ca+ has stabilized teach him to

avoid overuse of antacids

, avoid chronic laxative use,

consume foods ↑in ca+/protein

, avoid hyperventilation/crossing his legs, and how he can observe for tetany symptoms - this diagnosis, your own diagnosis, is not about the patient being stabilized! this diagnosis is all about watching for unstability. this intervention is nice but it is inappropriate for this diagnosis. i explain why further down.

#6_intervention

confirm that pt understands instruction by having him explain in his own words all you have taught him. - as written, this sounds like a goal statement - why are you teaching the patient anything? this diagnosis is about preventing a problem from happening. after a thyroidectomy all you can do is wait and watch. what can you teach a patient about that? i was one of those patients. if you tell me you are watching to see if my doctor accidentally made a mistake and cut out something he shouldn't have (a parathyroid gland) you will make me a basket case! i'll be snapping my finger against my cheeks every 5 minutes to see if the corner if my mouth starts to spasm. and, i'll be thinking "why did i let this guy cut on me?" nurses don't do that and keep their jobs for very long. their employers see unhappy patients and lawsuits coming down the pike and that nurse gets canned pretty fast. trust me, you don't want to do that to the poor patient. it was bad enough that they kept a tracheotomy tray at my bedside for an emergency (did you include that in your care plan?). keep this diagnosis between you and the rest of the healthcare staff. the staff (you) just wait and watch for any signs or symptoms to appear and then act on them if they do show up. see below.

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now, i know about this subject. i've had 2 thyroidectomies and i've had a patient where the doctor did accidentally remove one of her parathyroids and she developed carpopedal tetany and hypocalcemia, so i saw first hand what can happen. i also know a fair amount about calcium and calcium replacement. i'm not being mean here, but did you look up any information about this surgery or the labs involved? the reason i ask is because calcium isn't the only electrolyte involved with what the parathyroids do. granted, it will be the first to come to light as being out of whack, but you are fighting for your life to stay in your nursing program, aren't you? wouldn't you want to show that you investigated some of the physiology behind what the parathyroid gland does. if one of them gets nicked out during surgery it becomes a major issue for the rest of this patient's life and it isn't just a matter of replacing calcium for a few days while they are in the hospital. vitamin d plays a role in calcium metabolism and utilization in the body. see this previous thread (https://allnurses.com/nursing-student-assistance/hyperventilation-359604.html) where i addressed some of these issues of capopedal spasms and their relation to calcium. here's my interventions:

priority nursing diagnosis

risk for unstable blood calcium related to thyroidectomy secondary to thyroid cancer

monitor daily total serum calcium levels (normal is 8.2 mg/dl-10.2 mg/dl,
panic level is
monitor to see that baseline levels of the following have been established: serum phosphate (2.5 mg/dl-4.5 mg/dl,
panic level is 5
) and cholecalciferol [vitamin d] (15 pg/ml-60 pg/ml). if not, notify md and request orders for them.
monitor the patient for any of the following signs/symptoms/complaints: vomiting, diarrhea, nervousness, weakness, paresthesias (a sensation of numbness, prickling, or tingling), muscle stiffness and muscle cramps in the face or fingers, headaches, dysphagia, abdominal pain
perform the following specific assessments q8h:
- chvostek's sign - tapping the person just in front of the earlobe and below the zygomatic arch and the corner of the mouth will produce twitching of that corner of the mouth to twitching of all facial muscles on that side of the face
- trousseau's sign (carpopedal spasm) - a blood pressure cuff is inflated to between the diastolic and systolic pressures and allowed to remain inflated for 3 minutes while watching the patient for evidence of carpal spasm in that arm which is positive evidence of trousseau's sign
[*]
report any elevation or panic values of serum calcium or ionized calcium to the surgeon immediately
[*]
document and report positive results of either/or trousseus's or chvostek's sign to the physician.

littlelight98 · Mar 1, 2009

i can't thank you enough for your help!!! can you tell me more about how vit. d plays a role in calcium metabolism and utilization in the body?

Daytonite, BSN, RN · Mar 1, 2009

vitamin d is needed for calcium to be absorbed from food during the digestive process. calcium is primarily replaced by dietary means. natural foods: many of the dried legumes and vegetables, salmon, tofu, rhubarb, sardines, collard greens, spinach, turnip greens, okra, white beans, baked beans, broccoli, peas, brussel sprouts, sesame seeds, bok choy, almonds, and foods that are stated as being calcium-fortified: milk, cheese. without vitamin d it cannot be properly extracted from foods we ingest.

bones and teeth are the primary storage depositories for calcium. they are like bank savings accounts. we really need to build them up during childhood. after we get to adulthood, the body will "borrow" from the bank as it sees fit to maintain it's calcium supply in circulation and the cells. as you are learning, calcium ions are needed for many cellular activities. by the time we are aged, if we have not been maintaining good calcium replacement, our bones are ripe for breaking. elderly people keep the osteopaths in business. you should be taking 1500 mg a calcium a day as a supplementation even if you are in your 20s. the gi track can only absorb about 500/600 mg at a time so that needs to be divided into 3 doses over the day. calcium needs an acidic environment as well to enhance absorption. calcium citrate formulations absorb more efficiently than calcium carbonate if patients can tolerate it and the liquid forms of calcium have poor performance for absorption as well.

littlelight98 · Mar 1, 2009

I read and reread everything you said and all your links, and you are very helpful. Thank you so much!

littlelight98 · Mar 1, 2009

from the information you gave this is how i did my nursing interventions. am i on track? thanks again:

#1 intervention: monitor daily total serum calcium levels (normal is 8.0 mg/dl-10.4 mg/dl, panic level is

rationale with reference & pg. #: pt is at risk for hypoparathyroidism secondary to total thyroidectomy. therefore it is essential that calcium levels stay stable. calcium plays a major role in transmitting nerve impulses and helps regulate muscle contraction and relaxation, including cardiac muscle. calcium is instrumental in activating enzymes that stimulate many essential chemical reactions in the body, and it also plays a role in blood coagulation.

[smeltzer’s pg325]

evaluation: blood ca levels rose from 7.9 – 9.0 mg/dl 3 days postop

#2 intervention: monitor to see that baseline levels of the following have been established: serum phosphate (2.4 mg/dl-4.7 mg/dl, panic level is 5) and calcitriol [vitamin d] (0.25 mcg t.i.d po). if not, notify md and request orders for pt.

rationale with reference & pg. #: a risk after thyroid surgery, hypoparathyroidism impairs synthesis of pth. when less pth is synthesized, less phosphorus is excreted from the kidneys. the result elevated serum phosphorus levels which put the pt at risk for cardiac irregularities, hyperreflexia, muscle weakness, and olguria. vitamin d plays a role in calcium metabolism and utilization in the body.

[williams, pg 172,173]

[smeltzer’s pg325]

evaluation: phosphorus levels [2/11 4.3 mg/dl, 2/12 3.0 mg/dl]. calcitriol [vitamin d] (0.25 mcg t.i.d po) given on schedule

#3 intervention: rationale with reference & pg. #: monitor the patient for any of the following signs/symptoms/complaints: vomiting, diarrhea, nervousness, weakness, paresthesias (a sensation of numbness, prickling, or tingling), muscle stiffness and muscle cramps in the face or fingers, headaches, dysphagia, abdominal pain.

rationale with reference & pg. #: these signs are indicative of hypocalcemia.

[williams, pgs 149,150]

evaluation: no complaints or signs of hypocalcemia

#4 intervention: perform the following specific assessments q8h: chvostek's sign - tapping the person just in front of the earlobe and below the zygomatic arch and the corner of the mouth will produce twitching of that corner of the mouth to twitching of all facial muscles on that side of the face. trousseau's sign (carpopedal spasm) - a blood pressure cuff is inflated to between the diastolic and systolic pressures and allowed to remain inflated for 3 minutes while watching the patient for evidence of carpal spasm in that arm which is positive evidence of trousseau's sign

rationale with reference & pg. #: testing for trousseau’s and chvostek’s signs can help diagnose tetany and hypocalcemia.

[williams, pgs 149,150]

evaluation: trousseau’s/chvostek’s signs not indicated because by postop day 3 serum calcium levels reflected improvement from 7.9 mg/dl to 9.0 mg/dl.

#5 intervention: report serum calcium 10.4 mg/dl to the surgeon immediately.

rationale with reference & pg. evaluation calcium levels above 10.4 indicate hypercalcemia. calcium levels below 8.0 indicate hypocalcemia.

[williams, pg 26]

evaluation: on postop day one pts serum calcium levels reflected 7.9 mg/dl. by postop day 3 serum calcium levels reflected improvement from 7.9 mg/dl to 9.0 mg/dl.

#6 intervention: document and report positive results of either/or trousseau’s or chvostek's sign to the physician.

rationale with reference & pg. #: trousseau’s and chvostek’s signs can help diagnose tetany and hypocalcemia, and any positive signs must be documented and reported at once. reporting to the dr. ultimately benefits the pt. the dr. needs this information to properly tend to the pt. the hospital and the community benefit from prompt reporting and documenting. documentation provides necessary information to the pts insurance provider, government agencies, and when necessary, law enforcement personnel.

[kozier, pg 74]

evaluation: trousseau’s/chvostek’s signs not documented because by postop day 3 serum calcium levels reflected improvement from 7.9 mg/dl to 9.0 mg/dl.

littlelight98 · Mar 1, 2009

in your opening statem you helped me to see that, "for actual nursing problems, the sequence of interventions is always: assessment, nursing care, teaching, management." i have a question regarding "management." you mean to say that the patient is the one who will manage his/her situation, right? otherwise, if the rn manages care after teaching the patient then it's more of a rest-home or retirement-home, or rehab type setting, right? i mean to say that from the little i've seen the hospitals are trying to turn out the patients as quickly as possible. thanks again for all you do.

Daytonite, BSN, RN · Mar 1, 2009

littlelight98 said:
from the information you gave this is how I did my nursing interventions. am I on track? thanks again:
#1 intervention: monitor daily total serum calcium levels (normal is 8.0 mg/dl-10.4 mg/dl, panic level is
rationale with reference & pg. #: pt is at risk for hypoparathyroidism secondary to total thyroidectomy. therefore it is essential that calcium levels stay stable. calcium plays a major role in transmitting nerve impulses and helps regulate muscle contraction and relaxation, including cardiac muscle. calcium is instrumental in activating enzymes that stimulate many essential chemical reactions in the body, and it also plays a role in blood coagulation.
[smeltzer's pg325]
evaluation: blood ca levels rose from 7.9 - 9.0 mg/dl 3 days postop
#2 intervention: monitor to see that baseline levels of the following have been established: serum phosphate (2.4 mg/dl-4.7 mg/dl, panic level is 5) and calcitriol [vitamin d] (0.25 mcg t.I.d po). if not, notify md and request orders for pt.
rationale with reference & pg. #: a risk after thyroid surgery, hypoparathyroidism impairs synthesis of pth. when less pth is synthesized, less phosphorus is excreted from the kidneys. the result elevated serum phosphorus levels which put the pt at risk for cardiac irregularities, hyperreflexia, muscle weakness, and olguria. vitamin d plays a role in calcium metabolism and utilization in the body.
[williams, pg 172,173]
[smeltzer's pg325]
evaluation: phosphorus levels [2/11 4.3 mg/dl, 2/12 3.0 mg/dl]. calcitriol [vitamin d] (0.25 mcg t.I.d po) given on schedule
#3 intervention: rationale with reference & pg. #: monitor the patient for any of the following signs/symptoms/complaints: vomiting, diarrhea, nervousness, weakness, paresthesias (a sensation of numbness, prickling, or tingling), muscle stiffness and muscle cramps in the face or fingers, headaches, dysphagia, abdominal pain.
rationale with reference & pg. #: these signs are indicative of hypocalcemia.
[williams, pgs 149,150]
evaluation: no complaints or signs of hypocalcemia
#4 intervention: perform the following specific assessments q8h: chvostek's sign - tapping the person just in front of the earlobe and below the zygomatic arch and the corner of the mouth will produce twitching of that corner of the mouth to twitching of all facial muscles on that side of the face. trousseau's sign (carpopedal spasm) - a blood pressure cuff is inflated to between the diastolic and systolic pressures and allowed to remain inflated for 3 minutes while watching the patient for evidence of carpal spasm in that arm which is positive evidence of trousseau's sign
rationale with reference & pg. #: testing for trousseau's and chvostek's signs can help diagnose tetany and hypocalcemia.
[williams, pgs 149,150]
evaluation: trousseau's/chvostek's signs not indicated because by postop day 3 serum calcium levels reflected improvement from 7.9 mg/dl to 9.0 mg/dl.
#5 intervention: report serum calcium 10.4 mg/dl to the surgeon immediately.

rationale with reference & pg. evaluation calcium levels above 10.4 indicate hypercalcemia. calcium levels below 8.0 indicate hypocalcemia.
[williams, pg 26]
evaluation: on postop day one pts serum calcium levels reflected 7.9 mg/dl. by postop day 3 serum calcium levels reflected improvement from 7.9 mg/dl to 9.0 mg/dl.
#6 intervention: document and report positive results of either/or trousseau's or chvostek's sign to the physician.
rationale with reference & pg. #: trousseau's and chvostek's signs can help diagnose tetany and hypocalcemia, and any positive signs must be documented and reported at once. reporting to the Dr. ultimately benefits the pt. the Dr. needs this information to properly tend to the pt. the hospital and the community benefit from prompt reporting and documenting. documentation provides necessary information to the pts insurance provider, government agencies, and when necessary, law enforcement personnel.
[kozier, pg 74]
evaluation: trousseau's/chvostek's signs not documented because by postop day 3 serum calcium levels reflected improvement from 7.9 mg/dl to 9.0 mg/dl.

you are on the right track.

Daytonite, BSN, RN · Mar 1, 2009

littlelight98 said:
in your opening statem you helped me to see that, "for actual nursing problems, the sequence of interventions is always: assessment, nursing care, teaching, management." I have a question regarding "management." you mean to say that the patient is the one who will manage his/her situation, right? otherwise, if the RN manages care after teaching the patient then it's more of a rest-home or retirement-home, or rehab type setting, right? I mean to say that from the little I've seen the hospitals are trying to turn out the patients as quickly as possible. thanks again for all you do.

no, that is not what I am saying. think bigger. we run the show for the care of our patient's, kiddo. we're the boss. the buck stops with us.

by management, I mean. . .manage/refer/contact/notify (managing the care on behalf of the patient or caregiver). as you develop a care plan for a patient, you are managing their care. there will be times when you will want or need to refer them to another healthcare professional to handle some of their care. when you find something wrong with the patient's labwork or a piece of the equipment they use is not working and you need to call someone, you contact the appropriate professional for the patient (you act as a liaison). you notify doctors, pharmacists, dieticians, physical therapists, and others on the healthcare team on behalf of the patient for interventions that need to be carried out by them.

in the hospital or nursing home, other services like dietary departments and physical therapy might be doing things for our patients, but we nurses are still running the show and know exactly what these people are doing with our patients--or we better. that is part of our management function of our job. years ago these services were done by nurses. over the years they were gradually farmed out to these healthcare professions that arose to assist us. mark no mistake about it. . .we're still in charge.