Chloride Imbalance PDF

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Summary

Fluid/Electrolyte imbalance...

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Electrolyte: Chloride 96 mEq/L- 108 mEq/L Location/Function: major anion of the ECF, is found more in interstitial and lymph fluid compartments than in blood. Chloride is also contained in gastric and pancreatic juices, sweat, bile, and saliva. Sodium and chloride make up the largest electrolyte composition of the ECF and assist in determining osmotic pressure Regulation: The serum level of chloride reflects a change in dilution or concentration of the ECF and does so in direct proportion to the sodium concentration. Serum osmolality parallels chloride levels as well. Aldosterone secretion increases sodium reabsorption, thereby increasing chloride reabsorption. The choroid plexus, which secretes cerebrospinal fluid in the brain, depends on sodium and chloride to attract water to form the fluid portion of the cerebrospinal fluid. Bicarbonate has an inverse relationship with chloride. As chloride moves from plasma into the red blood cells (called the chloride shift), bicarbonate moves back into the plasma. Hydrogen ions are formed, which then help the release oxygen from hemoglobin. When the level of one of these three electrolytes (sodium, bicarbonate, or chloride) is disturbed, the other two are also affected. Chloride assists in maintaining acid–base balance and works as a buffer in the exchange of oxygen and CO2 in red blood cells Excretion: Chloride control depends on the intake of chloride and the excretion and reabsorption of its ions in the kidneys. A small amount of chloride is lost in the feces. HYPO – chloremia < 96 mEq/L HYPER – chloremia > 108 mEq/L Causes:  Addison disease, reduced chloride intake or absorption, untreated diabetic ketoacidosis, chronic respiratory acidosis, excessive sweating, vomiting, gastric suction, diarrhea, sodium and potassium deficiency, metabolic alkalosis; loop, osmotic, or thiazide diuretic use; overuse of bicarbonate, rapid removal of ascitic fluid with a high sodium content, IV fluids that lack chloride (dextrose and water), draining fistulas and ileostomies, heart failure, cystic fibrosis S/S:  Agitation, irritability, tremors, muscle cramps, hyperactive deep tendon reflexes, hypertonicity, tetany, slow shallow respirations, seizures, dysrhythmias, coma  Labs indicate: ↓ serum chloride, ↓ serum sodium, ↑ pH, ↑ serum bicarbonate, ↑ total carbon dioxide content, ↓ urine chloride level, ↓ serum potassium Diagnostics/Tests:  Sodium and potassium levels are also evaluated, because these electrolytes are lost along with chloride.  ABGs identifies the acid–base imbalance, which is usually metabolic alkalosis.  The urine chloride level, which is also measured, decreases in hypochloremia. Treatment:  correcting the cause of hypochloremia and the

Causes:  Excessive sodium chloride infusions with water loss, head injury (sodium retention), hypernatremia, kidney injury, corticosteroid use, dehydration, severe diarrhea (loss of bicarbonate), respiratory alkalosis, administration of diuretics, overdose of salicylates, Kayexalate, acetazolamide, phenylbutazone and ammonium chloride use, hyperparathyroidism, metabolic acidosis S/S:  Tachypnea, lethargy, weakness, deep rapid respirations, decline in cognitive status, ↓ cardiac output, dyspnea, tachycardia, pitting edema, dysrhythmias, coma  Labs indicate: ↑ serum chloride, ↑ serum potassium and sodium, ↓ serum pH, ↓ serum bicarbonate, normal anion gap, ↑ urinary chloride level Diagnostics/Tests:  serum chloride level is 108 mEq/L (108 mmol/L) or greater  the serum sodium level is greater than 145 mEq/L (145 mmol/L)  the serum pH is less than 7.35, and the serum bicarbonate level is less than 22 mEq/L (22 mmol/L).  Urine chloride excretion increases. Treatment:  Correcting the underlying cause of

contributing electrolyte and acid–base imbalances.  Normal saline (0.9% sodium chloride) or halfstrength saline (0.45% sodium chloride) solution is given by IV to replace the chloride.  If the patient is receiving a diuretic (loop, osmotic, or thiazide), it may be discontinued or another diuretic prescribed.  Ammonium chloride, an acidifying IV 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. Its use should be avoided in patients with impaired liver or renal function. Nursing Implications:  Nurse monitors the patient’s I&O, arterial blood gas values, and serum electrolyte levels.  Changes in the patient’s level of consciousness and muscle strength and movement are reported to the primary provider promptly.  Vital signs are monitored, and respiratory assessment is carried out frequently. Health Teachings:  nurse provides and educates the patient about foods with high chloride content, which include tomato juice, bananas, dates, eggs, cheese, milk, salty broth, canned vegetables, and processed meats.  A person who drinks free water (water without electrolytes) or bottled water and excretes large amounts of chloride needs instruction to avoid drinking this kind of water.

hyperchloremia and restoring electrolyte, fluid, and acid–base balance are essential.  Hypotonic IV solutions may be given to restore balance. Lactated Ringer solution may be prescribed to convert lactate to bicarbonate in the liver, which increases the bicarbonate level and corrects the acidosis.  IV sodium bicarbonate may be given to increase bicarbonate levels, which leads to the renal excretion of chloride ions because bicarbonate and chloride compete for combination with sodium.  Diuretics may be given to eliminate chloride as well.  Sodium, chloride, and fluids are restricted. Nursing Implications:  Monitoring vital signs, arterial blood gas values, and I&O is important to assess the patient’s status and the effectiveness of treatment.  Assessment findings related to respiratory, neurologic, and cardiac systems are documented, and changes are discussed with the primary provider. Health Teachings:  Nurse educates the patient about the diet that should be followed to manage hyperchloremia ( avoid tomato juice, bananas, dates, eggs, cheese, milk, salty broth, canned vegetables, and processed meats.)  Maintain adequate hydration....