CHLORIDES

The chloride blood test measures the levels of chloride in the blood. Chloride is an electrolyte

that helps balance the amount of fluid inside and outside of cells. It also helps maintain blood

volume, blood pressure, and the pH of body fluids.

The normal range for chloride is between 98 and 106 milliequivalents per liter (mEq/L).

High levels

Chloride levels above the normal range cause a condition known as

hyperchloremia. Hyperchloremia happens when the volume of chloride ions rises, which might
be due to a number of factors.

Possible causes include:

 Severe dehydration reduces the amount of fluids in the body, which means the levels of
electrolytes increase because they cannot dissolve as they usually would.

 Diarrhea and excessive urination causes the body to lose water, which leads to increases
in the concentration levels of bicarbonate and chloride

 Metabolic acidosis occurs when the pH of blood is lower than usual, and chloride levels
are elevated. This has a serious effect on the body.

 Kidney disease. The kidneys help to balance electrolytes in the body so irregularities
might signal a kidney problem.

 Chemotherapy can cause vomiting that may lead to dehydration and hyperchloremia. It
can also cause damage to the kidneys, affecting the way they can balance electrolytes in
the body.

Newborn babies often have hyperchloremia because their chloride levels rise in the week after
birth. However, this is nothing to worry about, as the levels rise naturally and do not indicate a
health problem.
Hyperchloremia is common in critically ill people.

Low levels

Low levels of chloride cause a condition known as hypochloremia. Hypochloremia happens

when the volume of chloride ions decreases.

Possible causes include:

 Low salt intake in the diet – table salt, or sodium chloride, is a primary source of dietary
salt.

 Metabolic alkalosis, when the pH of blood is higher than usual.

 Certain medications, such as diuretics and laxatives, as these may reduce the amount of
fluid in the body.

 Addison's Disease, which is when the adrenal glands that sit on top of the kidneys do
not make enough of the hormones needed to maintain a healthy electrolyte balance.
When this happens, chloride levels can fall.

Treatment

Hydration can be a treatment for hyperchloremia.

Treatments vary according to the type of electrolyte balance a person has.

Most people can manage hyperchloremia with some lifestyle changes. For example, if
dehydration is causing the hyperchloremia, treatment will likely include hydration, which may
involve drinking lots of water every day.

People should eat a healthful, balanced diet and avoid caffeine and alcohol as they are
diuretics.

However, anyone who experiences any symptoms that might suggest kidney problems should
see a doctor as soon as possible.
If someone develops hypochloremia due to a medication they are taking, the doctor may adjust
the dosage or prescribe a different drug. If hypochloremia is mild and due to diet irregularities,
the doctor may recommend that the person increases their salt intake.

PHOSPHATES

High phosphorus levels

Excess phosphorus will likely build up in your bloodstream if you have impaired kidney function.
Avoiding high-phosphorus foods, such as milk, nuts, beans, and liver, can help lower your
phosphorus levels. Sometimes, however, you may need to take medications to prevent your
body from absorbing the phosphorus.

Besides reduced kidney function, high phosphorus levels may be due to:

 certain medications, such as laxatives that contain phosphates

 dietary problems, such as consuming too much phosphate or vitamin D

 diabetic ketoacidosis, which occurs when your body runs out of insulin and begins to
burn fatty acids instead

 hypocalcemia, or low serum calcium levels

 hypoparathyroidism, or impaired parathyroid gland function, which leads to low levels

of parathyroid hormone

 liver disease

Low phosphorus levels

Low phosphorus levels may be due to a range of nutritional problems and medical conditions,
including:

 chronic use of antacids

 lack of vitamin D

 not getting enough phosphorus in your diet

  malnutrition

 alcoholism

 hypercalcemia, or high serum calcium levels

 hyperparathyroidism, or overactive parathyroid glands, which leads to high levels of

parathyroid hormone

 severe burns

BENEDICT’S TEST
Hypoglycemia
This occurs when the level of insulin in the blood is greater than glucose, lowering glucose to
levels below 70 mg/dL (3.9 mmol/L). Some call this an “insulin reaction” because it often occurs
when too much insulin is given to a patient. It may also occur with excessive physical activity
without eating enough carbohydrates. Because sulfonylureas stimulate insulin release,
reminding patients to eat regular meals may reduce hypoglycemic excursions. If someone
consistently has high blood glucose levels greater than 200 mg/dL (11.1 mmol/L), hypoglycemic
symptoms may be experienced when blood glucose lowers into a normal range (between 80
and 150 mg/dL; 4.4 and 8.3 mmol/L, respectively). A small (15 g) carbohydrate and protein
snack will help abate these symptoms because it will increase the blood glucose slightly and the
protein will maintain the blood glucose for a longer period of time. It is important to
communicate the need to attain normal glucose levels at a slower progress to avoid these
symptoms from occurring. The brain is at risk when glucose dips below 70 mg/dL (3.9 mmol/L).

Symptoms of hypoglycemia include:

 Shaking, sweating, or clammy skin

 Sudden nervousness, confusion, headache, or irritability
 Rapid heart rate
 Dizziness, weakness, or fatigue
 Hunger and nausea

Severe hypoglycemia is glucose less than 40 mg/dL (2.2 mmol/L), which can cause
unconsciousness and death. A significant concern is hypoglycemia unawareness if a patient
experiences frequent episodes of low blood sugar. Asking patients if they experience
hypoglycemic events and symptoms is essential because if they do, they may need to reduce
medications or further evaluate their medication routine. One possible cause of hypoglycemic
events is inappropriate insulin dosing, such as more frequently than every 4 hours, which is
referred to “insulin stacking.” This occurs when there is still active insulin working in the body at
the time a patient checks blood glucose and doses with more insulin to lower the glucose level.

Treatment
Teaching a patient the “Rule of 15” is the appropriate management for hypoglycemia. If you
suspect hypoglycemia, instruct the patient to check blood glucose. If the result is lower than 70
mg/dL (3.9 mmol/L), instruct the patient as follows:

1. Consume 15 g of fast-acting carbohydrates, such as 4 ounces of juice or regular soda

(NOT diet), 1 tablespoon of jelly or sugar, or 3 glucose tablets. Although some consider a
candy bar appropriate for treatment, the fat in the candy actually slows digestion of the
glucose and delays recovery of blood glucose.
2. Check blood glucose 15 minutes later. If the result is higher than 70 mg/dL (3.9 mmol/L),
instruct the patient to eat something with protein and carbohydrates to maintain their
glucose level if the next planned meal is more than 1 hour away.
3. Consume an additional 15 g of carbohydrates if glucose remains less than 70 mg/dL. (3.9
mmol/L).2

Hyperglycemia
All forms of diabetes cause hyperglycemia if they are not properly treated. During an episode of
hyperglycemia, the insides of blood vessels becomes irritated and damaged when glucose is
elevated, similar to sandpaper or chards of glass rubbing an interior vessel wall. Most
complications of diabetes arise when the smaller blood vessels of the body become even
smaller from this damage. Frequent problems occur in the brain, eyes, heart, kidneys, and
peripheral nerves, which have smaller vascularity and are affected first. Resulting stroke,
blindness, myocardial infarction, renal disease, and peripheral neuropathy become chronic
conditions to manage. Common symptoms include the following:

 Polyuria
 Polydipsia
 Polyphagia
 Weight loss
 Random glucose greater than 200 mg/dL (11.1 mmol/L)
 Frequent infection
 Blurry vision

In the clinic, you may see a woman with frequent urinary tract infections, wounds that are not
healing, or complaints of vision impairment. A random blood glucose test is recommended to
determine whether hyperglycemia is present and whether a referral is necessary for further
evaluation of this blood glucose elevation. Glucose and ketones are not normal findings in the
urine and represent blood glucose elevation, which requires follow-up testing and management
for possible diabetes.3
Treatment
More frequent blood glucose monitoring with accurate record keeping is important during any
illness. The following sick day guidelines are important to review with patients:

 Monitor glucose every 4 hours.

 Take usual medications, especially long-acting insulin for an individual with type 1
diabetes. If the patient is unable to eat, contact their health care provider for
medication adjustments.
 Stay hydrated. Drink at least 1 glass of water per hour.
 If the patient has type 1 diabetes, check urine ketones every 4 hours.
 Monitor for symptoms of ketoacidosis, such as fruity-smelling breath, nausea and
vomiting, stomach cramps, and unconsciousness.

For the patient with hyperglycemia and diabetes, steroid treatment should be prescribed only
when necessary and often with instructions to contact the endocrinologist or provider
responsible for diabetes management. Steroids increase blood glucose, usually at higher levels
in the evening and at an increased level over time. The patient should also be instructed to
increase blood glucose monitoring while taking steroids and will often require higher doses of
insulin for the duration of the steroid treatment. As the steroid dose tapers, the insulin dose
may also gradually decrease.

Other medications that elevate blood glucose include beta-blockers, thiazide diuretics and
statins in higher doses, and some antipsychotics, such as clozapine and olanzapine. Antiviral
medications used for HIV and hepatitis C, such as protease inhibitors, also elevate blood
glucose.4