Prepared by:

Philip Winston Yap, PhRN, USRN

Fidel G. Yongque III, PhRN, USRN
Geraldine Malayo, CNN, RN
HYPOCALCEMIA
W H AT I S … ?

• Hypocalcemia (serum values lower than 8.6 mg/dL

[2.15 mmol/L]) occurs in a variety of clinical
situations.
E T I O L O G Y & R I S K FA C TO R S
E T I O L O G Y & R I S K FA C TO R S
 C L I N I C A L M A N I F E S TAT I O N S
• Tetany, the most characteristic manifestation of hypocalcemia
and hypomagnesemia, refers to the entire symptom complex
induced by increased neural excitability.
• Sensations of tingling may occur in the tips of the fingers,
around the mouth, and, less commonly, in the feet.
• Spasms of the muscles of the extremities and face may occur.
• Pain may develop as a result of these spasms.
• Hyperactive DTRs are another clinical sign associated with
tetany.
C L I N I C A L M A N I F E S TAT I O N S
 C L I N I C A L M A N I F E S TAT I O N S

•Seizures may occur because hypocalcemia

increases irritability of the central nervous
system as well as of the peripheral nerves
(Tocco, 2007).
•Mental changes such as depression, impaired
memory, confusion, delirium, and
hallucinations.
 C L I N I C A L M A N I F E S TAT I O N S

•Respiratory effects with decreasing calcium

include dyspnea and laryngospasm.
•Signs and symptoms of chronic
hypocalcemia include hyperactive bowel
sounds, dry and brittle hair and nails, and
abnormal clotting.
C L I N I C A L M A N I F E S TAT I O N S
DIAGNOSTIC STUDIES
• serum calcium
N: 9 - 10.5 mg/dL (TOTAL) • serum phosphorus
N: 4.5 - 5.6 mg/dL (IONIZED)
N: 3 - 4.5 mg/dL
• serum magnesium
N: 1.3 - 2.1 mEq/L

• Assessment includes the history and physical examination, including

electrolyte panel, an ECG and ABGs.
• Symptoms of hypocalcemia may occur with alkalosis.
• PTH levels are decreased in hypoparathyroidism.
• Magnesium and phosphorus levels need to be assessed to identify possible
causes of decreased calcium.
MEDICAL MANAGEMENT

A prolonged QT interval is seen on the ECG due

to prolongation of the ST segment, and torsades
de pointes, a type of ventricular tachycardia, may
occur.
MEDICAL MANAGEMENT
CALCIUM REPLACEMENT

• Increasing the dietary intake of calcium to at least

1000 to 1500 mg/day in the adult is recommended.
• Calcium-containing foods include milk products;
green, leafy vegetables; canned salmon; sardines; and
fresh oysters.
• Vitamin D therapy may be instituted to increase
calcium absorption from the GI tract; otherwise, the
amount of calcium absorbed may not satisfy the
body’s calcium requirement.
MEDICAL MANAGEMENT
MEDICAL MANAGEMENT
 MEDICAL MANAGEMENT
CALCIUM REPLACEMENT

Parenteral calcium salts include calcium gluconate, calcium

chloride, and calcium gluceptate.
Too-rapid IV administration of calcium can cause cardiac arrest,
preceded by bradycardia.
Therefore, calcium should be diluted in D5W and administered as a
slow IV bolus or a slow IV infusion using a volumetric infusion pump.
Calcium replacement can cause postural hypotension; therefore,
the patient is kept in bed during IV infusion, and blood pressure is
monitored.
 MEDICAL MANAGEMENT
CALCIUM REPLACEMENT
 MEDICAL MANAGEMENT
CALCIUM REPLACEMENT
• The IV site must be observed often for any evidence of
infiltration because of the risk of extravasation and
resultant cellulitis or necrosis.
• A 0.9% sodium chloride solution should not be used
with calcium because it increases renal calcium loss.
• Solutions containing phosphates or bicarbonate should
not be used with calcium because they cause
precipitation when calcium is added.
 NURSING MANAGEMENT
• Seizure precautions are initiated if
hypocalcemia is severe.
• The status of the airway is closely
monitored, because laryngeal
stridor can occur.
• Prepare tracheostomy set at
bedside.
• Safety precautions are taken, as
indicated, if confusion is present.
NURSING MANAGEMENT
NURSING MANAGEMENT

•It is important to teach the patient with

hypocalcemia what foods are rich in calcium.
•Advise the patient to consider calcium
supplements if sufficient calcium is not
consumed in the diet.
•Such supplements should be taken in divided
doses with meals.
 NURSING MANAGEMENT

•Alcohol and caffeine in high doses inhibit calcium

absorption, and moderate cigarette smoking
increases urinary calcium excretion.
•Cautioned to AVOID the overuse of laxatives and
antacids that contain phosphorus, because their
use decreases calcium absorption.
HYPERCALCEMIA
W H AT I S … ?

•Hypercalcemia (greater than 10.2 mg/dL

[2.6 mmol/L]) is a dangerous imbalance
when severe; in fact, hypercalcemic crisis
has a mortality rate as high as 50% if not
treated promptly.
E T I O L O G Y A N D R I S K FA C TO R S
• The most common
causes of
hypercalcemia are
malignancies and
hyperparathyroidism.
C L I N I C A L M A N I F E S TAT I O N S
• Confusion, impaired
memory, slurred speech,
lethargy, acute psychotic
behavior, or coma may
occur (Stewart, 2005).
C L I N I C A L M A N I F E S TAT I O N S
• Anorexia, nausea, vomiting, and constipation are
common symptoms of hypercalcemia.
• WOF! Dehydration and calcium reabsorption at the
proximal renal tubule.
• Abdominal and bone pain may also be present.
• Abdominal distention and paralytic ileus may
complicate severe hypercalcemic crisis.
C L I N I C A L M A N I F E S TAT I O N S

• Excessive urination due to disturbed renal tubular

function produced by hypercalcemia may occur.
• Severe thirst may occur with polyuria secondary to
high solute (calcium) load.
• Patients with chronic hypercalcemia may develop
symptoms similar to peptic ulcer disease because
hypercalcemia increases the secretion of acid and
pepsin in the stomach
 DIAGNOSTIC STUDIES

• Assessment includes the history and physical examination, including

electrolyte panel, and ECG.
• The double-antibody PTH test may be used to differentiate between
primary hyperparathyroidism and malignancy as a cause of hypercalcemia:
PTH levels are increased in primary or secondary hyperparathyroidism and
suppressed in malignancy
 DIAGNSTIC STUDIES

• Cardiovascular changes may include a variety of dysrhythmias

(ie, heart blocks) and shortening of the QT interval and ST
segment.
• The PR interval is sometimes prolonged
 DIAGNSTIC STUDIES
• X-rays may reveal bone
changes if the patient has
hypercalcemia secondary to a
malignancy, bone cavitation, or
urinary calculi.
• The Sulkowitch urine test
analyzes the amount of calcium
in the urine; in hypercalcemia,
dense precipitation is observed
due to hypercalciuria.
 MEDICAL MANAGEMENT
• Measures include administering fluids to dilute
serum calcium and promote its excretion by the
kidneys, mobilizing the patient, and restricting
dietary calcium intake.
• IV administration of 0.9% sodium chloride solution
temporarily dilutes the serum calcium level and
increases urinary calcium excretion by inhibiting
tubular reabsorption of calcium.
 MEDICAL MANAGEMENT
• Administering IV phosphate
can cause a reciprocal drop in
serum calcium.
• Furosemide (Lasix) is often
used in conjunction with
administration of a saline
solution; in addition to causing
diuresis, furosemide increases
calcium excretion.
 MEDICAL MANAGEMENT
• Calcitonin can be used to lower the serum calcium
level and is particularly useful for patients with heart
disease or renal failure who cannot tolerate large
sodium loads.
• Calcitonin reduces bone resorption, increases the
deposition of calcium and phosphorus in the bones,
and increases urinary excretion of calcium and
phosphorus (Karch, 2008).
 MEDICAL MANAGEMENT
• Skin testing for allergy to salmon
calcitonin is necessary before the
hormone is administered.
• Calcitonin is administered by
intramuscular injection rather
than subcutaneously, because
patients with hypercalcemia have
poor perfusion of subcutaneous
tissue.
 MEDICAL MANAGEMENT
• Corticosteroids may be used to
decrease bone turnover and
tubular reabsorption for patients
with sarcoidosis, myelomas,
lymphomas, and leukemias;
patients with solid tumors are less
responsive.
 MEDICAL MANAGEMENT
• Some bisphosphonates (e.g.,
etidronate disodium [Didronel],
pamidronate disodium [Aredia],
and ibandronate sodium
[Boniva]) inhibit osteoclast
activity.
• WOF! IV forms can cause fever,
transient leukopenia, eye
inflammation, nephrotic
syndrome, and jaw osteonecrosis
(Karch, 2008).
 MEDICAL MANAGEMENT
• Inorganic phosphate salts
can be administered orally
or by nasogastric tube (in
the form of Phospho-Soda
or Neutra-Phos), rectally
(as retention enemas), or
intravenously.
 NURSING MANAGEMENT
Interventions such as increasing patient mobility and
encouraging fluids can help prevent hypercalcemia, or
at least minimize its severity.
Hospitalized patients at risk for hypercalcemia should
be encouraged to ambulate as soon as possible.
Those who are outpatients and receive home care are
instructed about the importance of frequent
ambulation.
 NURSING MANAGEMENT
• When encouraging oral fluids, the nurse considers the
patient’s likes and dislikes.
• Fluids containing sodium should be administered unless
contraindicated, because sodium assists with calcium
excretion.
• Patients are encouraged to drink 3 to 4 quarts of fluid
daily.
• Adequate fiber in the diet is encouraged to offset the
tendency for constipation.
 NURSING MANAGEMENT

•Safety precautions are implemented,

as necessary, when mental symptoms
of hypercalcemia are present.
•The patient and family are informed
that these mental changes are
reversible with treatment.
 NURSING MANAGEMENT
• Increased calcium increases the effects of digitalis;
therefore, the patient is assessed for signs and
symptoms of digitalis toxicity.
• Because ECG changes (premature ventricular
contractions, paroxysmal atrial tachycardia, and
heart block) can occur, the cardiac rate and rhythm
are monitored for any abnormalities.
 REFERENCES
• Hinkle, Janice L., Cheever, Kerry H. (2022). Bruner and Suddarth’s Textbook
of Medical- Surgical Nursing, 15th Edition, Wulters Kluwer
• Black, Joyce M., Hawks, Jane, Hokanson (2008). Medical-Surgical Nursing
Clinical Management for Patient Outcomes, 8th Edition, Elsevier (Singapore)
Pte Ltd.

• Doenges, Marilynn E. et. al. (2016). Nurse’s Pocket Guide Diagnoses,

Prioritized Interventions, and Rationales, 15th Edition, F.A. Davis Company.
• Taylor, Carol, Lynn, Pamela, Bartlett, Jennifer L. (2019). Fundamentals of
Nursing: The Art & Science Patient-Centered Care, 9th Edition, Wolters
Kluwer.
HYPOPHOSPHATEMIA
 W H AT I S … ?
• Hypophosphatemia is indicated by a value below 2.5 mg/dL
(0.8 mmol/L).
• Although it often indicates phosphorus deficiency,
hypophosphatemia may occur under a variety of
circumstances in which total body phosphorus stores are
normal.
• Conversely, phosphorus deficiency is an abnormally low
content of phosphorus in lean tissues that may exist in the
absence of hypophosphatemia.
E T I O L O G Y A N D R I S K FA C TO R S
• Refeeding after starvation,
• alcohol withdrawal,
• diabetic ketoacidosis,
• respiratory and metabolic alkalosis,
• magnesium, potassium,
• hyperparathyroidism,
• vomiting, diarrhea,
• hyperventilation,
• vitamin D deficiency associated with malabsorptive
disorders,
• burns, acid–base disorders,
• parenteral nutrition, and
• diuretic and antacid use
E T I O L O G Y A N D R I S K FA C TO R S
C L I N I C A L M A N I F E S TAT I O N S
• Paresthesias,
• muscle weakness, bone pain
and tenderness,
• chest pain,
• confusion,
• cardiomyopathy, respiratory
failure,
• seizures, tissue hypoxia, and,
• increased susceptibility to
infection,
• nystagmus
DIAGNOSTIC STUDIES
serum phosphorus
serum calcium
N: 3 - 4.5 mg/dL
N: 9 - 10.5 mg/dL (TOTAL)
serum magnesium
N: 1.3 - 2.1 mEq/L N: 4.5 - 5.6 mg/dL (IONIZED)

• The nurse should keep in mind that glucose or insulin administration causes a
slight decrease in the serum phosphorus level.
• PTH levels are increased in hyperparathyroidism.
• Serum magnesium may decrease due to increased urinary excretion of
magnesium.
• Alkaline phosphatase is increased with osteoblastic activity.
• X-rays may show skeletal changes of osteomalacia or rickets.
MEDICAL MANAGEMENT
PHOSPHORUS REPLACEMENT

• Serum phosphate levels should

be closely monitored and
correction initiated before
deficits become severe.
• Adequate amounts of
phosphorus should be added to
parenteral solutions, and
attention should be paid to the
phosphorus levels in enteral
feeding solutions.
MEDICAL MANAGEMENT
PHOSPHORUS REPLACEMENT

• Aggressive IV phosphorus correction is usually limited

to the patient whose serum phosphorus levels
decrease to less than 1 mg/dL (0.3 mmol/L) and
whose GI tract is not functioning.
• Possible dangers of IV administration of phosphorus
include tetany from hypocalcemia and calcifications
in tissues (blood vessels, heart, lung, kidney, eyes)
from hyperphosphatemia.
MEDICAL MANAGEMENT
PHOSPHORUS REPLACEMENT

• IV preparations of phosphorus are

available as sodium or potassium
phosphate.
• The rate of phosphorus administration
should not exceed 10 mEq/h, and the
site should be carefully monitored
because tissue sloughing and necrosis
can occur with infiltration.
NURSING MANAGEMENT

• The nurse identifies patients who are at risk for

hypophosphatemia and monitors them.
• Careful attention is given to preventing infection,
because hypophosphatemia may alter the
granulocytes.
• Monitors serum phosphorus levels and documents and
reports early signs of hypophosphatemia
(apprehension, confusion, change in LOC).
NURSING MANAGEMENT
• If the patient experiences mild hypophosphatemia, foods
such as milk and milk products, organ meats, nuts, fish,
poultry, and whole grains should be encouraged.
• With moderate hypophosphatemia, supplements such as
Neutra-Phos capsules (250 mg phosphorus/capsule; 7 mEq
sodium and potassium), K-Phos (250 mg
phosphorus/tablet; 14 mEq potassium), and Fleet’s
Phospho-Soda (815 mg phosphorus/5 mL) may be
prescribed.
HYPERPHOSPHATEMIA
W H AT I S … ?

•Hyperphosphatemia is a serum
phosphorus level that exceeds 4.5
mg/dL (1.45 mmol/L) in adults.
E T I O L O G Y A N D R I S K FA C TO R S
• Acute and chronic renal failure,
• excessive intake of phosphorus,
• vitamin D excess,
• respiratory and metabolic acidosis,
• hypoparathyroidism,
• volume depletion,
• leukemia/lymphoma treated with
cytotoxic agents,
• increased tissue breakdown,
• rhabdomyolysis
E T I O L O G Y A N D R I S K FA C TO R S
C L I N I C A L M A N I F E S TAT I O N S
• Tetany,
• tachycardia,
• anorexia, nausea and vomiting,
• muscle weakness,
• signs and symptoms of
hypocalcemia;
• hyperactive reflexes;
• soft tissue calcifications in lungs,
heart, kidneys, and cornea
DIAGNOSTIC STUDIES
serum calcium serum phosphorus
N: 3 - 4.5 mg/dL
serum magnesium
N: 1.3 - 2.1 mEq/L
• Assessment includes the history and physical examination, including
electrolyte panel, an ECG and ABGs.
• Symptoms of hypocalcemia may occur with alkalosis.
• PTH levels are decreased in hypoparathyroidism.
• Magnesium and phosphorus levels need to be assessed to identify possible
causes of decreased calcium.
DIAGNOSTIC STUDIES

• A prolonged QT interval is seen on the ECG due to prolongation of

the ST segment, and torsades de pointes, a type of ventricular
tachycardia, may occur.
DIAGNSTIC STUDIES
• X-rays may show skeletal
changes with abnormal
bone development.

• BUN and creatinine levels

are used to assess renal
function.
MEDICAL MANAGEMENT
• When possible, treatment is directed at the underlying
disorder.

• Measures to decrease the serum phosphate level and

bind phosphorus in the GI tract of these patients
include vitamin D preparations, such as calcitriol,
which is available in both oral (Rocaltrol) and
parenteral (Calcijex, paricalcitol [Zemplar]) forms.
MEDICAL MANAGEMENT
•IV administration of calcitriol
does not increase the serum
calcium unless its dose is
excessive, thus permitting
more aggressive treatment
of hyperphosphatemia with
calcium-binding antacids
(calcium carbonate or
calcium citrate)
MEDICAL MANAGEMENT
• Administration of Amphojel with meals is effective but can
cause bone and central nervous system toxicity with long-
term use.

• Restriction of dietary phosphate, forced diuresis with a

loop diuretic, volume replacement with saline, and dialysis
may also lower phosphorus.

• Surgery may be indicated for removal of large calcium and

phosphorus deposits.
NURSING MANAGEMENT

•If a low-phosphorus diet is prescribed,

the patient is instructed to AVOID
phosphorus-rich foods such as hard
cheeses, cream, nuts, meats, whole-
grain cereals, dried fruits, dried
vegetables, kidneys, sardines,
sweetbreads, and foods made with milk.
NURSING MANAGEMENT
• When appropriate, the nurse instructs the patient to
avoid phosphate-containing substances such as
laxatives and enemas.

• The nurse also teaches the patient to recognize the

signs of impending hypocalcemia.

• Monitor for changes in urine output.

REFERENCES
• Hinkle, Janice L., Cheever, Kerry H. (2022). Bruner and Suddarth’s
Textbook of Medical- Surgical Nursing, 15th Edition, Wulters Kluwer
• Black, Joyce M., Hawks, Jane, Hokanson (2008). Medical-Surgical
Nursing Clinical Management for Patient Outcomes, 8th Edition,
Elsevier (Singapore) Pte Ltd.

• Doenges, Marilynn E. et. al. (2016). Nurse’s Pocket Guide Diagnoses,

Prioritized Interventions, and Rationales, 15th Edition, F.A. Davis
Company.
• Taylor, Carol, Lynn, Pamela, Bartlett, Jennifer L. (2019). Fundamentals
of Nursing: The Art & Science Patient-Centered Care, 9th Edition,
Wolters Kluwer.
HYPOMAGNESEMIA
W H AT I S … ?

•Hypomagnesemia refers to a below-

normal serum magnesium
concentration (1.3 mg/dL [0.62
mmol/L]) and is frequently
associated with hypokalemia and
hypocalcemia.
E T I O L O G Y & R I S K FA C TO R S
C L I N I C A L M A N I F E S TAT I O N S
• The respiratory center is depressed
when serum magnesium levels exceed
10 mEq/L (5 mmol/L).
• Coma, atrioventricular heart block,
and cardiac arrest can occur when the
serum magnesium level is greatly
elevated and not treated.
• High levels of magnesium also result in
platelet clumping and delayed
thrombin formation (Chernecky &
Berger, 2007).
C L I N I C A L M A N I F E S TAT I O N S
DIANOSTIC STUDIES
serum calcium serum phosphorus
N: 3 - 4.5 mg/dL

serum magnesium
N: 1.3 - 2.1 mEq/L

• Assessment includes the history and physical examination, including

electrolyte panel, an ECG and ABGs.
• Symptoms of hypocalcemia may occur with alkalosis.
• PTH levels are decreased in hypoparathyroidism.
• Magnesium and phosphorus levels need to be assessed to identify
possible causes of decreased calcium.
DIANOSTIC STUDIES

• PVCs, flat or inverted T waves, depressed ST segment,

prolonged PR interval, and widened QRS
MEDICAL MANAGEMENT
MAGNESIUM REPLACEMENT

• Mild magnesium deficiency

can be corrected by diet
alone.
• Principal dietary sources of
magnesium include green
leafy vegetables, nuts,
seeds, legumes, whole
grains, seafood, peanut
butter, and cocoa.
MEDICAL MANAGEMENT
MAGNESIUM REPLACEMENT

•If necessary, magnesium

salts can be
administered orally in an
oxide or gluconate form
to replace continuous
losses but can produce
diarrhea.
MEDICAL MANAGEMENT
MAGNESIUM REPLACEMENT

• IV magnesium sulfate must be

administered by an infusion
pump and at a rate not to
exceed 150 mg/min, or 67 mEq
over 8 hours.
• WOF! Rapid bolus can produce
alterations in cardiac
conduction leading to heart
block or asystole.
MEDICAL MANAGEMENT
MAGNESIUM REPLACEMENT

• VS must be assessed frequently during magnesium

administration to detect changes in cardiac rate or
rhythm, hypotension, and respiratory distress.
• Monitoring urine output is essential before, during,
and after magnesium administration; the physician is
notified if urine volume decreases to less than 100 mL
over 4 hours.
• Calcium gluconate must be readily available to treat
hypocalcemic tetany or hypermagnesemia.
NURSING MANAGEMENT
•The nurse should be aware of patients at risk for
hypomagnesemia and observe them for its signs
and symptoms.

•Patients receiving digitalis are monitored closely,

because a deficit of magnesium can predispose
them to digitalis toxicity.

•SEIZURE Precaution please!

NURSING MANAGEMENT
•Alcohol and caffeine in high doses inhibit
calcium absorption, and moderate cigarette
smoking increases urinary calcium excretion.

•Cautioned to AVOID the overuse of laxatives

and antacids that contain phosphorus,
because their use decreases calcium
absorption.
NURSING MANAGEMENT
•Dysphagia screening

•Instructs the patient about the need to consume

magnesium-rich foods.

•For patients experiencing hypomagnesemia from

abuse of alcohol, the nurse provides teaching,
counseling, support, and possible referral to alcohol
abstinence programs or other professional help.
HYPERMAGNESEMIA
W H AT I S … ?

•Hypermagnesemia (serum levels

over 2.3 mg/dL [0.95 mmol/L]) is a
rare electrolyte abnormality,
because the kidneys efficiently
excrete magnesium.
E T I O L O G Y & R I S K FA C TO R S
• Oliguric phase of renal failure
(particularly when magnesium-
containing medications are
administered),
• adrenal insufficiency,
• excessive IV magnesium
administration,
• diabetic ketoacidosis, and
• hypothyroidism
C L I N I C A L M A N I F E S TAT I O N S
• Flushing,
• hypotension,
• muscle weakness,
• drowsiness,
• hypoactive reflexes,
• depressed respirations,
• cardiac arrest and
coma,
• diaphoresis.
DIAGNOSTIC STUDIES
serum phosphorus
serum calcium

serum magnesium

• Assessment includes the history and physical examination,

including electrolyte panel, and an ECG.
• As creatinine clearance decreases to less than 3.0 mL/min,
the serum magnesium levels increase.
DIAGNOSTIC STUDIES

• ECG findings may include a

prolonged PR interval, tall T
waves, a widened QRS, and a
prolonged QT interval, as well as
an atrioventricular block.
MEDICAL MANAGEMENT

•All parenteral and oral magnesium salts are

discontinued.

•In emergencies, such as respiratory

depression or defective cardiac conduction,
ventilatory support and IV calcium gluconate
are indicated.
MEDICAL MANAGEMENT
•In addition, hemodialysis with a magnesium-
free dialysate can reduce the serum
magnesium to a safe level within hours.

•Administration of loop diuretics (Lasix) and

sodium chloride or lactated Ringer’s IV
solution enhances magnesium excretion in
patients with adequate renal function.
NURSING MANAGEMENT
• Nurse monitors the vital signs, noting hypotension and
shallow respirations.
• Observes for decreased DTRs and changes in the level
of consciousness.

• Cautioned to check with their health care providers

before taking OTC medications containing magnesium.
• Caution is essential when preparing and administering
magnesium-containing fluids parenterally.
REFERENCES
• Hinkle, Janice L., Cheever, Kerry H. (2022). Bruner and Suddarth’s
Textbook of Medical- Surgical Nursing, 15th Edition, Wulters Kluwer
• Black, Joyce M., Hawks, Jane, Hokanson (2008). Medical-Surgical
Nursing Clinical Management for Patient Outcomes, 8th Edition,
Elsevier (Singapore) Pte Ltd.

• Doenges, Marilynn E. et. al. (2016). Nurse’s Pocket Guide Diagnoses,

Prioritized Interventions, and Rationales, 15th Edition, F.A. Davis
Company.
• Taylor, Carol, Lynn, Pamela, Bartlett, Jennifer L. (2019). Fundamentals
of Nursing: The Art & Science Patient-Centered Care, 9th Edition,
Wolters Kluwer.
HYPOCHLOREMIA
W H AT I S … ?

•Hypochloremia is
a serum chloride
level below 97
mEq/L (97
mmol/L).
E T I O L O G Y & R I S K FA C TO R S
C L I N I C A L M A N I F E S TAT I O N S
• The signs and symptoms • Agitation & irritability,
of hyponatremia, • tremors,
hypokalemia, and • muscle cramps,
metabolic alkalosis may • hyperactive DTRs,
also be present.
• hypertonicity,
• tetany,
• Metabolic alkalosis is a • slow shallow
disorder that results in a
high pH and a high serum • respirations,
bicarbonate level as a • seizures,
result of excess alkali • dysrhythmias,
intake or loss of hydrogen • coma
ions.
C L I N I C A L M A N I F E S TAT I O N S
DIANOSTIC STUDIES
serum chloride
N: 95 - 105 mEq/L
MEDICAL MANAGEMENT

• Increase dietary intake of salt with

meals either through enteral or
parenteral.
• The usual daily sodium
requirement in adults is
approximately 100 mEq, provided
there are not excessive losses.
• IV Potassium & IV Sodium chloride
• Rehydration
• Limit or reduce diuretic use
MEDICAL MANAGEMENT
• 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.
• Its use should be AVOIDED in patients with
impaired liver or renal function.
NURSING MANAGEMENT
•Monitors the patient’s I&O, ABGs, and serum
electrolyte levels.

•Changes in the patient’s LOC and muscle strength

and movement are reported to the physician
promptly.

•Vital signs are monitored, and respiratory

assessment is carried out frequently.
NURSING MANAGEMENT
• Nurse provides and teaches the patient about foods with
high chloride content.

• Foods high in chloride 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
W H AT I S … ?

•Hyperchloremia exists when the serum

level of chloride exceeds 107 mEq/L
(107 mmol/L).

•Hypernatremia, bicarbonate loss, and

metabolic acidosis can occur with high
chloride levels.
E T I O L O G Y & R I S K FA C TO R S
C L I N I C A L M A N I F E S TAT I O N S
• The signs and symptoms • Tachypnea,
of hyperchloremia are the • lethargy,
same as those of • weakness,
metabolic acidosis: • deep rapid respirations,
hypervolemia and • decline in cognitive status,
hypernatremia. • cardiac output,
• A high chloride level is • dyspnea,
accompanied by a high • tachycardia,
sodium level and fluid • pitting edema,
retention. • dysrhythmias &coma
C L I N I C A L M A N I F E S TAT I O N S
DIANOSTIC STUDIES
MEDICAL MANAGEMENT
• Hypotonic IV solutions may be
administered to restore balance.

• Lactated Ringer’s solution may be

prescribed to convert lactate to
bicarbonate in the liver, which
increases the bicarbonate level
and corrects the acidosis.
MEDICAL MANAGEMENT
•IV sodium bicarbonate may
be administered to increase
bicarbonate levels.
•Diuretics may be
administered to eliminate
chloride as well.
•Sodium, chloride, and fluids
are restricted
NURSING MANAGEMENT
• Monitor VS, ABG values, and I&O are 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 physician.

• Teaches the patient about the diet that should be

followed to manage hyperchloremia and maintain
adequate hydration.
REFERENCES
• Hinkle, Janice L., Cheever, Kerry H. (2022). Bruner and Suddarth’s
Textbook of Medical- Surgical Nursing, 15th Edition, Wulters Kluwer
• Black, Joyce M., Hawks, Jane, Hokanson (2008). Medical-Surgical
Nursing Clinical Management for Patient Outcomes, 8th Edition,
Elsevier (Singapore) Pte Ltd.

• Doenges, Marilynn E. et. al. (2016). Nurse’s Pocket Guide Diagnoses,

Prioritized Interventions, and Rationales, 15th Edition, F.A. Davis
Company.
• Taylor, Carol, Lynn, Pamela, Bartlett, Jennifer L. (2019). Fundamentals
of Nursing: The Art & Science Patient-Centered Care, 9th Edition,
Wolters Kluwer.