 Welcome to nursing school explained and this video on chloride imbalances. So we'll look at causes, signs and symptoms, treatment as well as nursing considerations for hypo and hyperchloremia. Generally, chloride level is 98 through 106 in the serum, but keep in mind to always check the reference lab values for whatever lab you're working with to make sure that they are not just a little bit different and that you're determining whether the patient is within or not within normal range. Now chloride is a major electrolyte in the extra cellular fluid and it is regulated by anti-diuretic hormone as well as aldosterone and those two play a big role in the RAS system, the renin, angiotensin and aldosterone system that helps us regulate our blood pressure. So therefore it regulates fluid balance and blood pressure and it travels with sodium and water. So usually if sodium levels are low, chloride levels will be low. If sodium is high, chloride will be high and the chances that you see hypo or hyperchloremia are less likely than seen hypo or hypernatremia, but it is very possible, but the two usually move into the same direction and because they are regulated or they kind of attract water, so they always travel with the water, they have a big influence on our fluid balance and also blood pressure control. Causes for hypochloremia can be vomiting or diarrhea and that is mostly vomiting. So if you're losing a lot of stomach contents, hydrochloric acid will go with this so you'll use a lot of chloride that way. Also gastric suctioning for the same reasons, we're getting rid of some of those acids, burn injuries as well as SIADH with the syndrome of inappropriate anti-diarrheic hormone. So if there's a problem with the ADH that regulates our chloride, it can cause hypochloremia. Also diuretics might affect our chloride levels and then metabolic alkalosis also can cause chloride levels to drop. And then in terms of hyperchloremia, so causes here hypernatremia, like I said, they always kind of travel together and too much administration of sodium chloride, you might think, oh, sodium chloride, that's an isotonic fluid, we can never really give too much, but yes, you can give too much of sodium chloride and now the chloride levels will be too high and the patient might start to develop symptoms. And then because aldosterone is part of that RAS system and regulates blood pressure, which acts on the kidneys to help reabsorb or excrete more electrolytes to help us with the fluid balance, whenever there's something wrong with the kidneys such as an acute kidney injury or chronic kidney disease, we might also see abnormalities in chloride levels. And then dehydration, also termed fluid volume deficit, can cause hyperchloremia because in dehydration we're losing a lot of fluids, what remains are the electrolytes, so they are more concentrated and therefore the chloride levels will be high. And then in contrast to hypochloremia causing metabolic alkalosis, hyperchloremia can cause metabolic acidosis or is caused by metabolic acidosis. Signs and symptoms are very similar or pretty much the same as for sodium imbalances because we know those two go together, so always think level of consciousness, neural status when you think about sodium as well as chloride abnormalities. So for hypochloremia, blood pressure will be low because we're losing the chloride we can't keep the fluid in and the patient will have positive orthostatics. In response to low blood pressure, usually the heart rate goes up as the body is trying to compensate for the fluid loss. The patient might have those signs and symptoms of altered level of consciousness, irritable, confusion, restlessness and they might lead all the way to seizures or hallucinations. For hyperchloremia, it's the same thing, irritability, confusion, restlessness, altered level of consciousness or something is different from their usual mental status and it can also lead all the way to seizures. Treatment here for hypochloremia is isotonic IV fluids because typically we've lost some fluids, we have some signs of fluid volume deficit here and sodium chloride or normal saline contains 0.9% sodium chloride so if we replenish it, we're going to get this chloride level back up and then also a high sodium and chloride diet will help to elevate those levels. On the contrary for hyperchloremia, we still want to give the patient IV isotonic fluids because we know that most likely it's related to fluid volume deficit that these electrolytes are more concentrated, hemoconcentration but we don't want to give them sodium chloride because the chloride level is already high. So in addition, so we give them IV ringers lactate or lactated ringers because it kind of contains buffers. In addition to sodium and chloride, it contains other electrolytes as well as bicarbonate which will help counteract this metabolic acidosis here. So lactated ringers is a really good IV fluid to help with patients with metabolic acidosis. In terms of our nursing considerations, we want to keep a close eye on those vital signs, check the patient's level of consciousness because we said on both sides they can be altered in whatever way or shape or form. We want to check their lab values, sodium chloride and the serum osmolarity, all these values that give us information about the patient's fluid volume status. We want to check daily weights and eyes and nose whenever we talk about fluid balance to see how much fluid the patient is retaining, how well the kidneys are working. We want to make sure we initiate fall precautions because of their altered state as well as seizure precautions because we know that they are likely or at risk for having seizures. And then we want to check their IV side because we're going to have to make sure to administer the treatment here to make sure that they get back into the normal levels with their chloride. Please also watch the other videos about the other electrolyting balances and if you want a bigger, better review on how fluid balance is regulated with the RAS system as well as what other mechanisms we have for controlling our blood pressure, please go to my Fluid and Electrolyte playlist where I have all the videos that explain that. I'll make sure to put all the videos in the description below so that you have easy access and reference to those. Thanks so much for watching, see you soon.