Page 84 Complete Your CE Test Online - Click Here If the client with anorexia nervosa is also purging, calluses on the knuckles and abrasions and scars on the backs of the hands may be evidence of tooth injury that occurred during self-induced vomiting. Additional evidence of self-induced vomiting includes dental caries and oral or pharyngeal abrasions[9] . Nursing consideration: The gravity of the clinical picture depends on the severity and extent of the disorder. These signs and symptoms are a reflection of the pathophysiology of the disease. Nurses must be able to correlate signs and symptoms with disease pathology in order to facilitate treatment and promote wellness. Pathophysiology Anorexia nervosa can lead to a state of near starvation. As a result, the body struggles to find sources of nourishment to maintain homeostasis and therefore fat stores are exhausted, adipose tissue is depleted and muscle mass is lost[12] . Lack of body fat can lead to a decrease in body temperature and intolerance to cold[9,12] . Alterations in body temperature and cold intolerance are also manifestations of metabolic changes caused by the disease process[9,12] . Here is a summary of the clinical manifestations of potential metabolic changes. Hypothyroidism Hypothyroidism exists when the thyroid gland fails to produce adequate amounts of certain hormones. Signs and symptoms of hypothyroidism that may be seen in clients with anorexia nervosa include[12,13] : ● ● Fatigue. ● ● Cold intolerance. ● ● Dry skin. ● ● Muscle weakness and muscle aches. ● ● Pain, swelling, and stiffness of the joints. ● ● Thinning hair. ● ● Bradycardia. ● ● Memory problems. ● ● Depression. There are a number of potential complications related to hypothyroidism including[9,12,13] : ● ● Cardiac problems: Effects of hypothyroidism on the cardiac system include slowing the heart rate (bradycardia), heart enlargement, heart failure, impaired pumping ability of the heart, and elevated LDL (bad) cholesterol. ● ● Mental health problems: Depression may develop early in the course of hypothyroidism and become worse over time. Hypothyroidism can also cause a decrease in mental functioning. ● ● Peripheral neuropathy: If hypothyroidism is not controlled/ treated over a long period of time, peripheral nerve damage can occur. Signs of peripheral nerve damage include numbness and tingling of affected extremities. ● ● Infertility: Inadequate levels of thyroid hormone interfere with ovulation and impair fertility. Cardiac problems Anorexia nervosa can adversely affect the cardiovascular system. Clients may exhibit[9,12] : ● ● Bradycardia. ● ● Hypotension. ● ● Loss of cardiac muscle mass. ● ● Arrhythmias. ● ● Cardiac arrest. Electrocardiogram (ECG) may provide evidence of cardiac compromise by showing bradycardia, arrhythmias, and, in some cases, a significantly prolonged QT interval[1] . Metabolic disturbances Electrolyte imbalances are often evident in persons with anorexia nervosa, particularly the following disturbances[12,14] : ● ● Hypokalemia: Hypokalemia is defined as a serum potassium level below 3.5 mEq/L. Intestinal fluids contain a considerable amount of potassium. Persons with anorexia nervosa who purge by inducing vomiting and/or abusing laxatives and diuretics are at risk for hypokalemia. Signs and symptoms of this electrolyte imbalance include skeletal muscle weakness, nausea, vomiting, decreased bowel sounds, constipation, paralytic ileus, and a weak irregular pulse. The patient’s ECG may show a flattened or inverted T wave, depression of the ST segment, and a characteristic U wave. Hypokalemia may also lead to cardiac arrest. ● ● Hypochloremia: Hypochloremia is an abnormally low level of chloride in the extracellular fluid, defined as a serum chloride level below 98 mEq/L. Chloride is lost via the gastrointestinal tract via such problems as vomiting or diarrhea. Abuse of laxatives or diuretics or self-induced vomiting leads to chloride loss. Signs and symptoms of hypochloremia include muscle cramps, weakness, agitation, irritability, twitching, tetany, and hyperactive deep tendon reflexes. If the imbalance continues, it can be life threatening or even fatal. Signs of dangerously severe hypochloremia are seizures, coma, arrhythmias, and respiratory arrest. ● ● Hypomagnesemia: Hypomagnesemia, an abnormally low level of serum magnesium, occurs when the serum magnesium level falls below 1.5 mEq/L. Hypomagnesemia may occur when the body’s gastrointestinal (GI) system and/or urinary system is impaired. Both of these body systems are responsible for regulating serum magnesium levels. Hypomagnesemia can occur in persons who suffer from anorexia nervosa when excessive amounts of magnesium are lost from the GI or urinary tract due to self-induced vomiting and/or abuse of laxatives and diuretics. Signs and symptoms of hypomagnesemia are usually vague and non-specific, and include weakness, muscle cramps, tachycardia, tremor, vertigo, ataxia (lack of muscle coordination during voluntary movements), and depression. If dangerously low magnesium levels are reached, clients may experience cardiac arrhythmias, weakness of the respiratory muscles, seizures, and laryngeal stridor.