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Chapter: Medical Surgical Nursing: Fluid and Electrolytes: Balance and Distribution

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Chloride Deficit (Hypochloremia)

Chloride control depends on the intake of chloride and the ex-cretion and reabsorption of its ions in the kidneys.

CHLORIDE DEFICIT (HYPOCHLOREMIA)

Chloride control depends on the intake of chloride and the ex-cretion and reabsorption of its ions in the kidneys. Chloride is produced in the stomach as hydrochloric acid; a small amount of chloride is lost in the feces. Chloride-deficient formulas, salt-restricted diets, GI tube drainage, and severe vomiting and diar-rhea are risk factors for hypochloremia. As chloride decreases (usually because of volume depletion), sodium and bicarbonate ions are retained by the kidney to balance the loss. Bicarbonate accumulates in the ECF, which raises the pH and leads to hypo-chloremic metabolic alkalosis.

Clinical Manifestations

The signs and symptoms of hypochloremia are those of acid–base and electrolyte imbalances. The signs and symptoms of hypo-natremia, hypokalemia, and metabolic alkalosis may also be noted. Metabolic alkalosis is a disorder that results in a high pH and a high serum bicarbonate level as a result of excess alkali intake or loss of hydrogen ions. With compensation, the PaCO2 increases to 50 mm Hg. Hyperexcitability of muscles, tetany, hyperactive deep tendon reflexes, weakness, twitching, and muscle cramps may result. Hypokalemia can cause hypochloremia, resulting in cardiac dysrhythmias. In addition, because low chloride levels parallel low sodium levels, a water excess may occur. Hyponatre-mia can cause seizures and coma.

Assessment and Diagnostic Findings

The normal serum chloride level is 96 to 106 mEq/L (96–106 mmol/L). Inside the cell, the chloride level is 4 mEq/L. In addi-tion to the chloride level, sodium and potassium levels are also evaluated because these electrolytes are lost along with chloride. Arterial blood gas analysis identifies the acid–base imbalance, which is usually metabolic alkalosis. The urine chloride level, which is also measured, decreases in hypochloremia.

Medical Management

 

Treatment involves correcting the cause of hypochloremia and contributing electrolyte and acid–base imbalances. Normal saline (0.9% sodium chloride) or half-strength saline (0.45% sodium chloride) solution is administered IV to replace the chloride. The physician may reevaluate whether patients receiving diuretics (loop, osmotic, or thiazide) should discontinue these medications or change to another diuretic.

 

Foods high in chloride are provided; these include tomato juice, salty broth, canned vegetables, processed meats, and fruits. A patient who drinks free water (water without electrolytes) or bottled water will excrete large amounts of chloride; therefore, this kind of water should be avoided. Ammonium chloride, an acidifying agent, may be prescribed to treat metabolic alkalosis; the dosage depends on the patient’s weight and serum chloride level. This agent is metabolized by the liver, and its effects last for about 3 days.

Nursing Management

The nurse monitors intake and output, arterial blood gas values, and serum electrolyte levels, as well as the patient’s level of con-sciousness and muscle strength and movement. Changes are re-ported to the physician promptly. Vital signs are monitored and respiratory assessment is carried out frequently. The nurse teaches the patient about foods with high chloride content.

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