Page 91 Complete Your CE Test Online - Click Here Hypochloremia Hypochloremia, or a deficiency of chloride is defined as a serum chloride level below 98 mEq/L. Chlorine is lost when fluid is lost from the gastrointestinal (GI) tract or from the kidneys[14] . Clients with hypochloremia often exhibit signs and symptoms of various other electrolyte imbalances (i.e. hypokalemia and hyponatremia) or metabolic alkalosis. The nerves are more irritable and excitable, potentially resulting in tetany, hyperactive deep tendon reflexes, and hypertonicity of the muscles[14] . Additional signs and symptoms include[14] : ● ● Muscle cramps. ● ● Muscle twitching. ● ● Muscle weakness. ● ● Irritability. ● ● Agitation. If levels continue to dangerously decrease, the client may develop seizures, arrhythmias, respiratory arrest, and coma[14] . Metabolic alkalosis Elevated bicarbonate levels may lead to metabolic alkalosis[2] . This imbalance is caused by a decrease in hydrogen ion production characterized by a blood pH above 7.45 and a bicarbonate level above 26 mEqu/L[14] . A variety of problems can lead to metabolic alkalosis. The most common cause is an excessive loss of acid from the GI tract. For example, prolonged periods of vomiting can cause a loss of hydrochloric acid from the stomach. Diuretic use is another cause. Thiazide and loop diuretics cause fluid loss as well as the loss of hydrogen, potassium, and chloride ions from the kidneys. Low potassium levels cause the kidneys to excrete hydrogen ions as they try to conserve potassium. Potassium moves out of the cells, hydrogen moves into the cells, and the result is alkalosis[14] . Signs and symptoms of metabolic alkalosis include[14] : ● ● In the early stages of metabolic alkalosis, slow, shallow respirations prevail. As the problem continues, hypoxemia (low levels of oxygen in the blood) develops, which stimulates and increases respirations. ● ● Anorexia. ● ● Apathy. ● ● Confusion. ● ● Cyanosis. ● ● Hypotension. ● ● Loss of reflexes. ● ● Twitching of muscles. ● ● Weakness. ● ● Nausea and vomiting. Complications of bulimia nervosa There are a number of potential complications of bulimia nervosa. These include the following problems: ● ● Suicide risk: Persons affected by bulimia nervosa have an increased risk of suicide. Clients should be assessed for suicidal ideation as well as the co-existence of other mental health disorders such as depression, obsessive-compulsive disorder, and other anxiety disorders[1] . ● ● Dental erosion: The acidic gastric contents expelled by vomiting destroy tooth enamel. This can lead to severe tooth decay and dental problems[2,9,12]. ● ● Esophageal damage leading to esophageal bleeding: Such bleeding can progress to hemorrhage[2,9] . ● ● Gastric rupture: The pressure and damage to the gastric area from prolonged episodes of vomiting can lead to significant bleeding, hemorrhage, and peritoneal infection because of the release of gastric contents following rupture[2,9,12] . ● ● Cardiac problems: Cardiac problems can occur as a result of electrolyte imbalances. Many of these imbalances affect the cardiac system and can cause dangerous, even life-threatening arrhythmias[1,2,9,12] . Diagnostic criteria The following statements summarize the diagnostic criteria for bulimia nervosa as identified in the DSM-5[1] : ● ● Recurrent episodes of binge eating. Binge eating is described as eating in a specific period of time, an amount of food that is definitely larger than most people would eat in a similar time period under similar circumstances. There must also be a feeling of a lack of control over eating during the binging episode. ● ● Recurrent inappropriate compensatory behaviors in order to prevent weight gain. Examples of inappropriate behaviors include self-induced vomiting, abuse of laxatives, diuretics, or other medications, fasting, and/or excessive exercise. ● ● Binging and purging occur on an average of at least once a week for three months. ● ● Self-evaluation is disproportionately influenced by body shape and weight. ● ● The binging and purging do not occur exclusively during episodes of anorexia nervosa. As part of the diagnosis, it should be specified if the affected person is in[1] : ● ● Partial remission: After full criteria for bulimia nervosa were met, some but not all of the criteria have been met for a sustained period of time. ● ● Full remission: After full criteria for bulimia nervosa were met, none of the criteria have been met for a sustained period of time. The severity of the disorder should also be documented. The following are the criteria for classifying the severity of bulimia nervosa[1] : ● ● Mild: An average of 1-3 episodes of inappropriate compensatory behaviors occurs per week. ● ● Moderate: An average of 4-7 episodes of inappropriate compensatory behaviors occurs per week. ● ● Severe: An average of 8-13 episodes of inappropriate compensatory behaviors occurs per week. ● ● Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors occurs per week. Treatment interventions for bulimia nervosa Most persons who are affected by bulimia nervosa are treated in outpatient settings. Since most clients have normal or almost-normal weight, the concerns about severe malnutrition are reduced. This is in contrast to persons suffering from anorexia nervosa, who are generally suffering from significant malnutrition[2,9,12,18] .