Hypochloremia refers to a serum chloride level below 95 mEq/L. Normal serum chloride level is 95 to 108 mEq/L. Chloride is the major anion in the extracellular fluid (ECF). The intracellular level of chloride is only about 1 mEq/L. Chloride is regulated in the body primarily through its relationship with sodium. Serum levels of both sodium and chloride often parallel each other.
A main function of chloride in the body is to join with hydrogen to form hydrochloric acid (HCl). HCl aids in digestion and activates enzymes, such as salivary amylase. Chloride plays a role in maintaining the serum osmolarity and body water balance. The normal serum osmolarity ranges between 280 and 295 mOsm/L.
Chloride deficit leads to a number of physiological alterations such as ECF volume contraction, potassium depletion, intracellular acidosis, and increased bicarbonate generation. Hypochloremia, similar to hyponatremia, also causes a decrease in the serum osmolarity. This decrease means that there is a decrease in sodium and chloride ions in proportion to water in the ECF. When there is a body water excess, chloride also may be decreased along with sodium, preventing reabsorption of body water by the kidneys.
The most common cause of hypochloremia is gastrointestinal (GI) abnormalities, including prolonged vomiting, nasogastric suctioning, loss of potassium, and diarrhea. Loss of potassium, which occurs as a result of gastric suctioning and vomiting, further leads to hypochloremia because potassium frequently combines with chloride to form potassium chloride (KCl). Chloride is also lost through diarrhea, which has a high chloride content.
Other causes of hypochloremia are dietary changes, renal abnormalities, acid-base imbalances, and skin losses. Diets low in sodium can contribute to hypochloremia, as can medications such as thiazide and loop diuretics. Another common cause in hospitalized patients is the combination of stopping all oral intake during an illness and placing patients on intravenous (IV) fluid.
Nursing care plan assessment and physical examination
Ask about any recent signs and symptoms that deviate from past health patterns that could cause hypochloremia, such as vomiting and diarrhea. Ask the patient to list all medications, especially diuretics, which contribute to chloride loss. Obtain a history of past illnesses and surgeries. If the patient is already hospitalized, review the records for prolonged dextrose administration and a history of gastric suctioning.
Physical findings depend on the cause of the chloride deficit. Inspect the patient for tetany-like symptoms, such as tremors and twitching; these neuromuscular symptoms are present with hypochloremia associated with hyponatremia. If hypochloremia is caused by metabolic alkalosis secondary to the loss of gastric secretions, respiratory and neuromuscular symptoms appear. Assess the patient’s respirations and note the depth and rate; the patient’s breathing may become shallow and depressed with severe hypochloremia. If the chloride deficit is not corrected, eventually a decrease in blood pressure occurs.
In most cases, hypochloremia is a result of GI abnormalities. Assess the patient’s tolerance and coping ability to handle the discomfort. If the patient is upset about changes in nerves and muscles, explain that the symptoms disappear when chloride is supplemented.
Nursing care plan primary nursing diagnosis: Altered protection related to neuromuscular changes.
Nursing care plan intervention and treatment plan
Treatment of hypochloremia involves treating the underlying cause and replacing the chloride. Careful monitoring of fluid and electrolyte status is critical. Monitor serum chloride levels and report any levels less than 95 mEq/L. Observe for decreases in serum potassium and sodium, and note any increase in serum bicarbonate, which indicates metabolic alkalosis. Maintain strict intake and output records, noting any excessive gastric secretion loss, emesis, and diarrhea. Weigh the patient at the same time each day. In mild hypochloremia, replacement of chloride can be accomplished orally with salty broth. If the condition is severe, IV fluid replacement is necessary. If the patient is hypovolemic, administration of 0.9% sodium chloride increases fluid volume, as well as serum chloride levels. Ammonium chloride can also be given for replacement, and if metabolic alkalosis is present, potassium chloride is administered. Dietary changes are seldom necessary.
Institute safety measures for patients who develop neuromuscular symptoms, with particular attention to changes in level of consciousness and risks to airway patency. Have emergency equipment for airway and breathing maintenance available at all times. Educate those at risk in preventive measures. Teach patients the complications of medication therapy and how to maintain fluid and electrolyte balance nutritionally.
Nursing care plan discharge and home health care guidelines
Caregivers of the elderly and infants should be alerted to the effect of vomiting and diarrhea on chloride levels. Teach the patient to report any signs and symptoms of neuromuscular hyperactivity. Teach the patient to maintain a healthy diet with all the components of adequate nutrition. Teach the patient the name, dosage, route, action, and side effects of all medications, particularly those that affect chloride and sodium balance in the body.