- Acute: common result of fluid overload in Decrease BP

Sodium surgical patient Weight gain and edema

- Chronic: outside hospital setting; less
Imbalances serious neurological sequelae Labs indicate:
- Type of Hyponatremia: Exercise-
(Hyponatremia Vs associated hyponatremia- excess fluid
↓ serum and urine sodium

intake before exercise or prolonged ↓urine specific gravity and

Hypernatremia)
Sodium: 135 to 145 mEq/L (135 to 145
mmol/L)
Primary determinant of ECF and
osmolality
A loss or gain of sodium = loss or gain of
water
For muscle contraction and transmission
of nerve impulses
Eg. SIADH (Syndrome of Inappropriate
Antidiuretic Hormone)
Causes body to retain too much water
(water > sodium) Adrenal Insufficiency-
deficiency of aldosterone
HYPONATREMIA
- Serum Na < 135 mEqs/L
Acute or Chronic:
exercise → decrease serum sodium Osmolality
 Contributing Factors:
Use of diuretics
Loss of GI fluids
Renal disease (fluid overload)
Adrenal insufficiency
Excessive administration of water
supplements, D5W, hypotonic tube
feedings
SIADH
Oxytocin (causes water retention)
Hyperglycemia
Heart Failure
 S/S & Laboratory Findings:
Anorexia, nausea and vomiting
Headache, dizziness and confusion,  Assessment & Diagnostic Findings:
History and Physical Examinations esp.
seizures
Lethargy, muscle cramps and weakness Neurologic examination
Muscular twitching Evaluation of signs and symptoms; lab
Papilledema ( swollen eyes) tests
Dry skin, poor skin turgor, dry mucosa
Increase pulse
 Identifying hyponatremia with Muscle Cramps Treating the underlying condition
increased blood volume and Sodium replacement: usual daily
Coma & Increased Mean
decreased blood volume sodium requirement in adults is
Arterial Pressure (Map)
approximately 100 mEq, provided
there are not excessive losses
Hyponatremia with Hyponatremia with - sodium is consumed abundantly in a
normal diet
Increased or Normal Decreased Blood Volume - Lactated Ringer’s Solution or isotonic
Blood Volume  Causes: saline (0.9% NSS) as prescribed
 Causes: GI losses: diarrhea, vomiting, - TAKE NOTE: serum Na+ must not be
laxatives increased more than 12 mEqs/L in 24 hr
SIADH- impaired water secretion
Renal loss: diuretic, to avoid neurologic damage
Fluid shifts- eg edema, hypotonic IV hypoaldosteronism
solutions, hyperglycemia Water restriction ( for hyponatremia
 S/S:
↑ fluid intake Tremors with excess fluid)
 S/S: Personality Changes Administer small volumes of
Anxiety hypertonic sodium solution as
Muscle Weakness prescribed
Cold Skin
Headache Irritability  Pharmacologic Therapy:
Dizziness AVP receptor antagonists: IV
Lethargy conivaptan hydrochloride (Vaprisol)
Postural Hypotension
Apathy Clammy Skin - Limited to hospitalized patients (moderate
Dry Mucous Membrane to severe)
Convulsions - C/I: SEIZURES, delirium or coma (warrants
Seizure & Coma
Confusion Decreased Mean Arterial Pressure use of hypertonic saline)- produce lesions
(Map) that result to myelin destruction
Edema Lithium (Lithobid)- for SIADH;
Decreased Central Venous Pressure
Weight Gain (Cvp) antagonizes osmotic effect of ADH
Decreased Cardiac output
Elevated Bp
 Medical Management:
 Tolvaptan (Samsca): for significant therapy: normal salt and oral fluid Heatstroke
hypervolemic and euvolemic intake is encouraged Watery diarrhea
hyponatremia Burns
Diaphoresis

Hypernatremia Excess corticosteroid

 Nursing Management:
Monitor intake and output, as well as
body weight
Be alert for GI manifestations such as
vomiting , anorexia
Monitor for neurological changes such
as lethargy, confusion
Monitor for lab values: serum sodium,
urine sodium and specific gravity
Encourage foods and fluids with high
sodium (canned or processed foods,
iced tea, lemonade or fruit drinks) for
patient with abnormal losses of
sodium when in general diet.
Ex: broth made with one beef cube
contains approximately 900 mg of
sodium; 8 oz of tomato juice contains
approximately 700 mg of sodium
Restrict fluid intake as ordered (if
primary problem is water retention
For patients with IV: Assess for signs
of circulatory overload (eg cough,
dyspnea and puffy eyelids, excess
weight gain in 24 hours)
For patient with SIADH and on lithium
- Serum Sodium level >145 mEq/L (145
mmol/L)
- Gain of sodium in excess water or loss of
water in excess of sodium
 Causes:
Water loss: px loses more water than
Na+ →↑serum Na+ concentration and
↑ concentrations PULLS fluid OUT of
the cell
o Diabetes insipidus , watery
diarrhea,
Excess sodium: hypertonic saline
solution (D5LR, D5NSS), Cushing’s
syndrome
 Clinical Manifestations:
Increased plasma
Cellular Dehydration (water moves out
of the cell) and more concentrated ECF
Primary characteristic: Thirst
 Contributing Factors:
Fluid deprivation
Hypertonic tube feeding w/o adequate
water supplements
Diabetes insipidus
Excess sodium chloride administration
Saltwater near-drowning victims
 S/S
Thirst
Elevated body temp
Swollen dry tongue
Lethargy, restlessness
Twitching, hyperreflexia
Hyperreflexia
Increased BP and pulse
 Laboratory Findings:
↑serum Na
↑urine specific gravity and osmolality
↓urine sodium
↓ CVP
 Medical Management:
Gradual lowering of the serum sodium
level by the infusion of a hypotonic
electrolyte solution (e.g., 0.3% sodium
chloride) or an isotonic nonsaline
solution (e.g., dextrose 5% in water
[D5W])
Diuretics
 Serum sodium level is reduced at a rate
no faster than 0.5 to 1 mEq/L/h
Desmopressin acetate (synthetic ADH)
for diabetes insipidus

 Nursing Management:

Monitor fluid losses and gains

Obtain medication history

Monitor for clinical signs and symptoms

Provide oral fluids at regular intervals- for

patients unable to perceive thirst

Consult with primary provider to

plan an alternative route of
intake(unconscious patient or intake
remains inadequate); enteral or
parenteral route

Ensure adequate water intake for

pxs with diabetes insipidus

Monitor for patient’s response to

parenteral fluids

NOTE: Too-rapid reduction in the serum

sodium causes movement of fluid into brain
cells and dangerous cerebral edema.

POTASSIUM
IMBALANCES
- Normal range: 3.5 – 5.2 mmol/L
mEq/L (3.5 to 5 mmol/L)
- Influences both skeletal and cardiac
muscle activity
- Commonly associated with various
diseases, injuries, medications (ACE
inhibitors) and acid-base imbalances
- Regulated by kidneys to maintain balance:
80% K+ excreted by kidneys, 20% by
bowel and sweat
- When pH is low, the excess H+ ion in the
blood move into the cells. To maintain
electric equilibrium, potassium moves
out of the cell in response.
Hypokalemia (Potassium
Deficit)
- Serum potassium level below 3.5 mEq/L
(3.5 mmol/L)
 Causes:
Inadequate intake of Potassium
Increased urine production: aldosterone
stimulation (hyperaldosteronism)
Movement of Potassium into the cells:
anabolism, alkalosis, treatment of DKA
with insulin, refeeding syndrome,
treatment of acidosis
Increased GI losses, bulimia
Excess perspiration
Medications: antibiotics, diuretics,
laxatives
 S/S:
 MEDICAL MANAGEMENT:
Fatigue, anorexia Increase intake in the daily diet or by oral
Muscle weakness, leg cramps
potassium supplements
Polyuria Cautious iv replacement
Decreased bowel motility (Reduced therapy for severe hypokalemia
neural conduction in ENS)
(serum level of 2 meqs/l)
Weak pulse Dietary intake of potassium in the
Ventricular dysrhythmia average adult is 50 to 100 meq/day
 LABORATORY FINDINGS: Food high in k+: fruits (banana and
ECG changes: flat T avocado), vegetables, legumes, whole
waves or inverted T grains
waves or both
Potassium acetate or potassium
Prominent U wave phosphate may be prescribed
ST depression,
prolonged PR
 NURSING MANAGEMENTS:
interval
↑urine Potassium
Monitor early presence of s/s in patients
at risk: fatigue, anorexia paresthesia
e.g patients receiving digitalis or digoxin
Encourage to take in foods high in
potassium like bananas, melon, citrus
fruits, fresh and frozen vegetables (avoid
 canned vegetables), lean meats, milk, - Tomatoes, tomato juice and tomato sauce  Contributing Factors:
and whole grains - Tuna Oliguric Kidney injury

Monitoring fluid intake and output is Potassium is given if there is ADEQUATE Use of Potassium- conserving diuretics
necessary URINE OUTPUT.
Addison’s disease / hypoaldosteronism
NEVER give Potassium by IV push or
Oral route is ideal (mild to moderate): Intramuscularly Stored bank blood transfusion (serum
absorbs K+ well. Administration of IV potassium is done potassium concentration of stored blood
with extreme caution using an infusion increases due to red blood cell
pump. deterioration)
Caution must be used when selecting a
FOODS RICH IN POTASSIUM: ACE inhibitors, NSAIDS and cyclosporine
premixed solution of IV fluid containing
- Apricots and apricot juice KCl, as the concentrations range from 10
- Avocados to 40 mEq/100 Ml Burns
- Cantaloupe and honeydew melon Monitor BUN, creatinine levels and urine
- Fat-free or low-fat (1 percent) milk output  S/S:
Respiratory Distress
- Fat-free yogurt
Diarrhea
- Grapefruit and grapefruit juice (talk to Irritability
your healthcare provider if Hyperkalemia Anxiety
Muscle Weakness
- you’re taking a cholesterol-lowering drug) (Potassium Excess) Paresthesia
- Greens Abdominal
- Serum potassium level greater than 5
- Halibut Cramping
mEq/L [5 mmol/L])
- Lima beans Anuria
- More dangerous because cardiac arrest is Ecg Changes
- Molasses
more frequently associated with high Hyperreflexia
- Mushrooms
serum potassium levels
- Oranges and orange juice  LABORATORY FINDINGS:
 Causes:
- Peas ECG: tall tented T waves, prolonged PR
Decrease renal excretion of K+
- Potatoes interval and QRS duration, absent P
Excess IV potassium administration
- Prunes and prune juice waves and ST depression
Insulin deficiency, acidosis (low pH, high
- Raisins and dates
K+)
- Spinach
 MEDICAL MANAGEMENT:
Obtain ECG tracing
 NURSING MANAGEMENT:
Repeat serum potassium levels without IV
infusing potassium solution
Restriction of dietary potassium and
potassium containing medication to
correct balance
Sodium polystyrene sulfonate
(Kayexelate): oral or as an enema
IV Calcium Gluconate (for severe
hyperkalemia): antagonizes action of
hyperkalemia on the heart but does not ↓
serum K+ concentration
IV Sodium bicarbonate: treat metabolic
acidosis→ shift K+ into cells
IV administration of regular insulin and a
hypertonic dextrose solution
Loop diuretics, such as furosemide,
increase excretion of water by inhibiting
sodium, potassium, and chloride
reabsorption in the ascending loop of
Henle and distal renal tubule
Beta-2 agonists, such as albuterol
(Proventil, Ventolin), are highly effective
in decreasing potassium
Peritoneal dialysis and hemodialysis- for
long term
Close monitoring for signs of
hyperkalemia to patients with kidney
disease; muscle weakness and
dysrhythmias.
Encourage px to adhere to the prescribed
potassium restriction
Avoid potassium-rich foods
such as vegetables, legumes,
whole- grain breads, lean meat,
milk, eggs, coffee, tea, and
cocoa
Foods with minimal K+
content are butter, margarine,
cranberry juice or sauce,
ginger ale, gumdrops or
jellybeans, hard candy, root
beer, sugar, and honey
Caution patients to use salt substitutes
sparingly, or other supplementary forms
of K+ or K+ conserving diuretics.
 - Calcium is absorbed from foods in the
presence of normal gastric acidity and
vitamin D
- Controlled by PTH and calcitonin
o Trousseau sign = carpopedal spasm
induced by inflating a bp cuff
 S/S:
 Seizures/convulsions

Hypocalcemia (Calcium  Mental changes: depression,

CALCIUM
IMBALANCES
- NORMAL TOTAL SERUM CALCIUM: 8.6 to
10.2 mg/dL (2.2 to 2.6 mmol/L)
- Calcium is found in the ECF but less than
1% of total body Calcium is there.
- Major component of bones and teeth;
99% of body’s Calcium is located in
skeletal system
- Plays a major role in TRANSMITTING
NERVE IMPULSES, helps regulate MUSCLE
CONTRACTION AND RELAXATION
including Cardiac muscle
- Plays a role in BLOOD COAGULATION
impaired memory
Deficit)  Dyspnea and laryngospasm
- Serum Calcium Level < 8.6 mg/dL (2.15
 Tingling fingers
mmol/L)
 hyperactive bowel sounds, dry and
brittle hair and nails, and abnormal
 Causes:
Hypoparathyroidism- common
Thyroid and Parathyroid surgery 
clotting- if severe
ECG TRACING: prolonged QT
Massive transfusion of citrated blood intervals due to prolongation of ST
Pancreatitis Torsades de pointes- type of
Decreased intake: decreased absorption ventricular tachycardia may occur;
(diarrhea, gastric surgery) inadequate due to long QT interval
Vitamin D consumption, magnesium

deficiency
Diuretics
Hyperphospatemia
Osteoporosis
 Clinical Manifestations:
o Tetany = most characteristic of
hypocalcemia and hypomagnesemia; 
involuntary contraction of muscles,
spasm, or tremors.
o Chvostek sign = Twitching of facial
muscles in response to tapping over
the area of facial nerve
 Calcium- containing foods include milk
products, cheese, soy; green, leafy
Hypercalcemia (Calcium
vegetables (spinach); salmon; canned Excess)
sardines; and fresh oysters
 Nursing Managements - Serum Calcium > 10.2mg/dL (2.6 mmol/L)
 CAUSES:
SEIZURE Precaution if severe
Malignancies and hyperparathyroidism
Monitor status of airway- laryngeal Immobility ( multiple fractures and
stridor
spinal injury)
Educate px about foods rich in Calcium Thiazide diuretics- potentiate action of
 Assessment and Diagnostic Findings:
Calcium supplements PTH
Evaluate serum Calcium levels and
Serum albumin levels (some Calcium Advise px to limit intake of alcohol and Vitamin A and D intoxication
in blood is bound to protein) and pH caffeine in high doses; limit smoking Hypophosphatemia, hyperthyroidism
Magnesium: low Mg may cause low Avoid overuse of laxatives and Digoxin toxicity
Ca antacids that contain phosphorus →
Parathyroid hormone: Decreased decrease Calcium absorption
levels indicate hypoparathyroidism
which is related to low calcium
Phosphorus: elevated Phosphorus
may cause low Ca
 Medical Managements:
Calcium Replacements: IV Calcium
gluconate (best option) and Calcium
chloride (More irritating to IV site) – IV
site must be observe for evidence of
infiltration  Sign and Symptoms:
Vitamin D supplements
Muscle Weakness
Regular sun exposure (7am -9am)
atleast 10 – 30 minutes Nausea
Calcium supplements must be given in Vomiting Abdominal Cramps
divided doses of no higher than 500 mg Constipation
to promote calcium absorption Bone Pain
Polyuria And Polydipsia Solution → increases urinary Ca+
Dehydration secretion
Flank Pain IV phosphate- also drops serum
Calcium Stones Calcium
Bradycardia
Furosemide- together with saline
Hypercalcemic crisis: acute rise in
solution→ increases Ca+ excretion
serum Ca+ level to 17mg/dl or more –
severe thirst and polyuria Calcitonin- useful for patients with
ECG findings: shortening QT interval heart and kidney disease; reduces bone
resorption ; given IM
and ST segment, prolonged PR
interval. more severe: ventricular Bisphosphonates e.g Pamidronate
dysrhythmia. disodium (Aredia) and Ibandronate
XRAY: Bone cavitation, urinary calculi sodium (Boniva)- inhibits osteoclast
activity; often used for malignant
disease
Plicamycin: cytotoxic antibiotics that
decreases bone resorption. Used with
neoplastic disorders
Corticosteroids: competes with Vitamin
D for absorption in small intestine→
 MEDICAL MANAGEMENT: decreases calcium absorption
Treating the underlying cause is very
important (e.g. hyperparathyroidism,  NURSING MANAGEMENT:
chemotherapy for malignancy) Monitor for patients at risk of
hypercalcemia: S/S

 Pharmacologic Therapy: Increase patient mobility

Ambulate as possible (for hospitalized
Administration of fluids to dilute serum
calcium such as 0.9% Sodium Chloride patients)
 Encourage fluids; fluids containing
sodium assists with Calcium excretion
(2.8 to 3.8 L of fluid daily) unless
contraindicated
Adequate fiber in diet : for
constipation
Cardiac rate and rhythm are
monitored for any abnormalities
PHOSPHORUS
IMBALANCES
- Normal serum phosphorus (HPO4) level
Hypophosphotamia
2.5 to 4.5 mg/dl (0.8 to 1.45mmol/L)
- Value < 2.5mg/dl (0.8 mmol/L)
- Phosphorus is the main anion of the cell
- Abnormally low content of phosphorus in
- Stored with Calcium in bones and teeth
lean tissues
- Regulated by Parathyroid hormone:
 CAUSES:
phosphate reabsorption in the kidney and
Inadequate intake: TPN (total parenteral
allows shift of phosphate from bone to
nutrition) with inadequate phosphorus
plasma
Refeeding after starvation, alcohol
 FUNCTION OF PHOSPHORUS:
withdrawal, respiratory and metabolic
Nerve and muscle function and red
alkalosis, burns, diarrhea
blood cells
Medications: phosphate binding antacids
Acid/base balance
(aluminum,calcium,magnesium),
Component of ATP
diuretics, laxative abuse
CHO, CHON, and fat metabolism
Low magnesium levels and low Potassium
Part of structure of bones and teeth
levels
Hyperparathyroidism
 S/S:
Paresthesia, muscle weakness, bone pain,
seizures, tissue hypoxia.
Confusion, respiratory failure, nystagmus
( repetitive uncontrolled movement of the
eyes)
Insulin resistance and hyperglycemia-
causes slight decrease in serum
phosphorus levels
 LABORATORY FINDINGS:
Increased PTH levels
Low serum magnesium levels
 Increased Alkaline Phosphatase – due to to avoid rapid shifts of phosphorus into
increased osteoblastic activity the cells.
Xray: changes in bone density; Encourage patient to take in foods rich
osteomalacia (softening of bones) or in Phosphorus such as milk and milk
rickets products, organ meats, fish, poultry
and whole grains
Hyperphosphotemia
Serum Phosphorus levels >4.5mg/dl (1.45
mmol/L)
 CAUSES:
Hypoparathyroidism, acute or chronic
renal failure
 MEDICAL MANAGEMENT: Excessive Vitamin D intake and
Treating the underlying cause phosphorus supplements, excessive
IV preparation of phosphorus: sodium use of laxatives and enemas (absorbs
or potassium phosphate phosphorus)
IV site should be monitored: may cause Respiratory acidosis and metabolic
tissue sloughing and necrosis due to acidosis, diabetic ketoacidosis,
infiltration infection
Avoid phosphate binders such as Neoplastic disease (leukemia,
aluminum, magnesium and calcium lymphoma), increased tissue
antacids catabolism (trauma, crush injury),
tumor lysis syndrome, chemotherapy,
 NURSING MANAGEMENT: rhabdomyolysis (breakdown of
Gradually introduce parenteral striated muscle)
solutions ( for malnourished patients)-
 S/S:
Tetany (low calcium; high
phosphorus): inverse relationship
Signs and symptoms of hypocalcemia
Muscle weakness (pulls Calcium out
of your bones),Tachycardia, nausea
and vomiting
Soft tissue calcifications in lungs,
heart, kidneys and cornea
 LABORATORY FINDINGS:
BUN, Creatinine: to assess renal
status
PTH levels are low:
hypoparathyroidism
XRAY: Skeletal changes with
abnormal development
Low serum Calcium levels
 MEDICAL MANAGEMENT:
Treatment of underlying disorder
 Vitamin D preparation: calcitriol, sweetbreads, and foods made with
which is available in both oral milk
(Rocaltrol) and parenteral (Calcijex, AVOID phosphate containing laxatives
paricalcitol [Zemplar]) formscan help and enemas (absorbs phosphates;
reduce PTH levels. also causes hypocalcemia)
Phosphate binders: Sevelamer Monitor for changes in urine output
(Renvela); binds to Phosphorus in the
GI tract to decrease absorption;
prevents hypocalcemia
Calcium binding Antacids: calcium
carbonate or calcium citrate - binds
phosphorus and decreases absorption
Loop diuretics (Lasix)
Dialysis - severe

 NURSING MANAGEMENT:
Monitor patients at risk for
hyperphosphatemia
Low phosphorus diet as prescribed
(refined oils: sunflower oil, palm oil),
fruits, vegetables, eggwhite: good low
phosphorus source of CHON, soymilk;
no meat (more phosphorus is easily
absorbed)
AVOID phosphorus-rich foods, such as
hard cheeses, cream, nuts, meats,
whole- grain cereals, dried fruits,
dried vegetables, sardines,
MAGNESIUM
IMBALANCES
- Normal serum magnesium level is 1.3 to
2.3 mg/dL (0.62 to 0.95 mmol/L)
Magnesium (Mg++) is an abundant
intracellular cation
- Activator for many intracellular enzyme
systems
- Carbohydrate and protein metabolism
- Important in neuromuscular function;
sedative effect at neuromuscular junction
- Is controlled by Vitamin D; regulated by
kidneys
- Excretion is affected by 3 things:
1. ↑ PTH → ↓ Mg Excretion
2. ↓ Sodium and Calcium excretion →
↓ Mg Excretion
3. ↓ blood volume → ↓ Mg Excretion
Hypomagnesia
- < to normal serum Mg of 1.3 mg/dl/0.62
mmol/L
- Associated with HYPOKALEMIA and
HYPOCALCEMIA
 CAUSES:
Decreased intake: decreased GI
absorption- malabsorption
Increased magnesium excretion:
diuretics
Excess GI loss (vomiting, diarrhea,
nasogastric suction, fistula)
Alcoholism, cirrhosis, hyperthyroidism,
hypothyroidism, pancreatitis,
preeclampsia, hemodialysis,
hypercalcemia, hypothermia, burns,
sepsis, wound debridement

 S/S:
o Paresthesia, insomnia, loss of appetite,
mood changes, confusion, fatigue,
weakness, hallucinations
 LABORATORY FINDINGS:
o ECG: may see changes related to
magnesium, potassium or calcium
deficiencies. flat or inverted T waves;
depressed ST segment. Prolonged PR
interval and widened QRS
o Serum Albumin: if albumin is
decreased it may cause decreased
magnesium level
o Serum Calcium and Potassium:
decreased ( Mg helps to transport Ca
and K in and out of the cells)
o Serum Ionized Mg: decreased – tends
to reflect intracellular magnesium
o Serum Magnesium: decreased (can be Monitor urine output
normal despite low intracellular Seizure precaution
magnesium)
o Serum Potassium:
decreased –
hypokalemia may
be resistant to
replacement if the
cause is a problem
with the sodium-
potassium pump –
magnesium may Hypermagnesia:
need to be repleted > 3.0 mg/dl (1.25 mmol/L)
first
o Low Urine Magnesium  Causes:
Kidney injury: common cause (kidneys
normally excrete magnesium)
Diabetic ketoacidosis
Use of Mg antacids (Maalox, Riopan,
Mylanta) or laxatives (Milk of
o Magnesium)
 MANAGEMENT: Opioids and anticholinergics
Diet: green leafy vegetables, nuts,  LABORATORY FINDINGS:
seeds, legumes, whole grains, - ECG: AV block, prolonged PR interval, tall
seafood, peanut butter, and cocoa T waves and widened QRS and high
IV or IM Magnesium Sulfate: must be serum Mg levels
given via Infusion pump
Vital signs must be assessed
frequently : cardiac rate, hypotension
and respiratory distress

 Management:
Treat underlying cause: if magnesium is
high due to medication
D/c the medication (antacids or
laxatives that have magnesium: Maalox,
Mylanta, Mag Citrate, Milk of Magnesia,
Mag-Sulfate)
Loop diuretics and NSS/PLR IV solution
will help increase magnesium excretion,
as long as patient has adequate renal
function.
IV Ca gluconate: counteract
neuromuscular effects of Mg if
Hypermagnesemia is severe.
Dialysis with a low magnesium
dialysate (pt with severe renal
impairment)
 NURSING MANAGEMENT:
o STRICT intake and output
o Place patient under cardiac monitoring
o Watch for hypotension, bradycardia and
respiratory depression (shallow
respiration)
o Assess neuromuscular function:
decreased deep tendon reflex and
change in LOC
CHLORIDE
IMBALANCES
- Normal range: 97-107 mEqs/L (97-107
mmol/L)
- Found more in interstitial and lymph fluid
compartments than in blood; also
contained in gastric, pancreatic juices,
sweat, bile and saliva
- Largest electrolyte composition of the
ECF and assist in determining osmotic
pressure
- Produced in the stomach; combines with
HCL
- Dependent with sodium
-
Hypochloremia
- < 96 mEqs/L
 CAUSES: Parallel to hyponatremia
Diarrhea and prolonged vomiting
Excessive sweating
Loop, osmotic diuretics
Addison’s disease
 SIGNS/SYMPTOMS
Agitation, irritability, muscle cramps
Dysrhythmias, seizures and coma
S/S of hyponatremia ang hypokalemia,
metabolic acidosis(alkalosis)
 LABORATORY FINDINGS:
Decrease serum chloride, decrease
serum sodium, increase pH, increase
 serum bicarbonate, increase total CO2
content
Decrease urine Chloride level and
decrease potassium
 Management:
0.9% NSS or 0.45% NaCl IV for
replacement
Discontinue diuretics
Ammonium chloride- treats met.
Alkalosis
Diet rich in high chloride content:
tomato juice, bananas, dates, cheese,
eggs, milk, salty broth , canned
veggies and processed meats
Instruct to avoid drinking free water
without electrolytes (excretes large
amounts of chloride)
 LABORATORY FINDINGS:
Increased CL, increase K+ and Na+, low
pH, low HCO3, increase urinary
chloride level
 MANAGEMENT:
Hypotonic solutions may be given
PLR solution may be prescribed:
corrects acidosis
IV sodium bicarbonate: excretes excess
chloride ions
Diuretics
Vital signs, I & O, blood gas values
Maintain adequate hydration

Hyperchloremia
- > 108 mEqs/L
 S/S: (Associated with)
Hypernatremia; dehydration
Corticosteroids, resp. alkalosis,
metabolic acidosis
Head injury (causes water retention)
Tachypnea, lethargy, weakness ,
decrease cardiac output, lethargy,
dyspnea