CHLORIDE DEFICIT (HYPOCHLOREMIA) Chloride control depends on the intake of chloride and the excretion 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, saltrestricted diets, GI tube drainage, and severe vomiting and diarrhea 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 hypochloremic metabolic alkalosis. Clinical Manifestations The signs and symptoms of hypochloremia are those of acid base and electrolyte imbalances. The signs and symptoms of hyponatremia, 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. Hyponatremia 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 addition 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 consciousness and muscle strength and movement. Changes are reported 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. CHLORIDE EXCESS (HYPERCHLOREMIA) Hyperchloremia exists when the serum level exceeds 106 mEq/L (106 mmol/L). Hypernatremia, bicarbonate loss, and metabolic acidosis can occur with high chloride levels. Hyperchloremic metabolic acidosis is also known as normal anion gap acidosis (see discussion in Acid Base Disturbances section of this chapter). It is usually caused by the loss of bicarbonate ions via the kidney or the GI tract with a

corresponding increase in chloride ions. Chloride ions in the form of acidifying salts accumulate and acidosis occurs with a decrease in bicarbonate ions. Clinical Manifestations The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis, hypervolemia, and hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished cognitive ability; and hypertension occur. If untreated, hyperchloremia can lead to a decrease in cardiac output, dysrhythmias, and coma. A high chloride level is accompanied by a high sodium level and fluid retention. Assessment and Diagnostic Findings The 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, the serum bicarbonate level is less than 22 mEq/L (22 mmol/L), and there is a normal anion gap of 8 to 12 mEq/L (8 12 mmol/L). Urine chloride excretion increases. Calculation of the serum anion gap is important in analyzing acid base disorders. The sum of all negatively charged electrolytes (anions) equals the sum of all positively charged electrolytes (cations) with several anions that are not routinely measured leading to an anion gap. It is based primarily on three electrolytes: sodium, chloride, and bicarbonate or serum CO2. A low anion gap may be attributed to hypoproteinemia, while an elevated anion gap can be due to metabolic acidosis. Medical Management Correcting the underlying cause of hyperchloremia and restoring electrolyte, fluid, and acid base balance are essential. Lactated Ringer s solution may be prescribed to convert lactate to bicarbonate in the liver, which will increase the base bicarbonate level and correct the acidosis. Sodium bicarbonate may be given IV to increase bicarbonate levels, which leads to the renal excretion of chloride ions as bicarbonate and chloride compete for combination with sodium. Diuretics may be administered to eliminate chloride as well. Sodium, fluids, and chloride are restricted. Nursing Management Monitoring vital signs, arterial blood gas values, and intake and output 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 discussed with the physician. The nurse teaches the patient about the diet that should be followed to manage hyperchloremia.