Eating Disorders

Eating Disorders Bulimia Nervosa Anorexia Nervosa

Eating Disorders Significant health problem among children, adolescents and young WOMEN 1% of young women ages 12 to 25 affected by anorexia nervosa

Eating Disorders: Epidemiology Affects more women than men Depression commonly affects the clients Anorexia= 1% Bulimia= 3-5%

Eating Disorders: Etiology Biological factors= postulated changes in the neurotransmitters Psychoanalytical= disturbed relationships, usually between mother and child, distorted body image with misperception of internal needs and anxiety control is by body control.

Eating Disorders: Etiology 3. Socio-cultural= thinness is promoted by media and culture 4. Cognitive-behavioral= obsessive compulsive behavior and avoidant behavior are vulnerable to eating disorders 5. Physical and sexual abuse

Eating Disorders: Distortions attributed to eating disorders Selective abstraction = “I’m still fat” Superstitious thinking

Eating Disorders: Anorexia Weight less than ideal Intense fear of becoming fat Body image disturbance Engages in exercise and peculiar food habits Lack of sense of control

Bulimia Binge eating and purging Binges commonly lead to feelings of loss of control, guilt, humiliation

Eating Disorders: Personality traits Anorexia Resistance to acknowledging they have a problem Hyper-rigid behaviors Difficulty learning from experience Inflexible thinking Social introversion Limited social spontaneity

Bulimia Feeling of helplessness Variable moods= fatigue, agitation Sense of loss of control Low self-esteem leading to self doubt Self-conscious Sensitive to rejection from others

Eating Disorders: Personality traits Anorexia Younger (18-20) Unable to maintain body weight at 85% expected Amenorrhea Starvation Intense fear of becoming obese

Bulimia Older (24-30 yo) Weight fluctuates considerably

Amenorrhea Binge eating Fears loss of control

Eating Disorders: Personality traits Anorexia Prefers HEALTH food Preoccupation with buying and preparing foods Rigorous exercise Views self as OVERWEIGHT

Bulimia Prefers HIGH calorie foods Repeated CRASH dieting, use of laxatives and diuretics Aware that behavior is ABNORMAL

Anorexia Nervosa A syndrome manifested by self-induced starvation resulting from FEAR of fatness rather than from true loss of appetite. Onset: adolescent years Female more than male

Anorexia Nervosa FEATURES of Anorexia Nervosa Relentless pursuit of thinness Amenorrhea Refusal to maintain ideal weight Distorted body image Fear of loss of control Alexithymia: lack of awareness, mistrust of others and self, starvation-induced depression

Anorexia Nervosa FEATURES of Anorexia Nervosa The patient is pre-occupied with foods that prevent weight gain and is fearful of foods that increase weight They are usually the achievers and perfectionist Death usually occurs from starvation, suicide or electrolyte imbalance

Anorexia Nervosa: FINDINGS Physical Symptoms

Cold intolerance, constipation, lethargy

Physical Signs

Younger, breast atrophy, dry skin, bradycardia, hypotension, hypokalemia

Cardiovascular complications

ECG abnormalities, Prolonged QT intervals, myocardial damage

Hematologic

Anemia and Leukopenia

Gastrointestinal

Decreased gastric motility, delayed gastric emptying

Renal

Dehydration, polyuria and peripheral edema

Endocrine

Amenorrhea due to starvation

Skeletal

Osteopenia and skeletal fractures

Anorexia Nervosa: FINDINGS Refusal to eat Loss of appetite Feelings of lack of control Excessive exercise Weight Loss

Bulimia Nervosa A syndrome of binge eating followed by self-induced vomiting or “purging” that is also accompanied by an excessive preoccupation with weight and body shape More prevalent than AN Has LATE onset than AN

Bulimia Nervosa The client indulges in eating binges followed by purging behaviors

Bulimia Nervosa The measures to gain weight control include use of laxative, cathartics, enemas, and diuretics The patient may resort to periods of strict dieting, fasting and strenuous exercise

Bulimia Nervosa This disorder usually begins in late adolescence and follows a chronic course over many years There is a HIGH rate of depression and the families of the client may be overly preoccupied with food and physical appearance They tend to have less SUPEREGO control

Bulimia Nervosa Physical Features of the BN Thin body with swollen cheeks due to enlarge salivary glands Signs of fluid retention Erosion of the tooth enamel Skin is dry with cuts and abrasions over the knuckles (Russel’s sign) Electrolyte imbalances

Bulimia Nervosa Features of the BN Pre-occupied with body shape and weight Consumes high calorie food in secret with guilt about secretive eating Attempts to lose weight through diets, vomiting, laxatives enemas, cathartics, amphetamines and diuretics Low self-esteem and mood swings Self-mutilating behavior: suicide thoughts and attempts at suicide

Other Eating Disorders 1. PICA= persistent eating of a non-nutritive substance. This is considered acceptable for children less than 18 months. This is believed to be due to ZINC and IRON deficiencies or related to lack of parenteral supervision

Other Eating Disorders 2. RUMINATION= eating disorder characterized by repeated regurgitation of food with resultant weight loss or failure to gain weight 3. OBESITY

The Nursing Process for Eating Disorders ASSESSMENT Psychosocial assessment begins when the nurse establishes a trusting relationship with the client and families The nurse must identify the reason for hospitalization and a complete family assessment

The Nursing Process for Eating Disorders ASSESSMENT Other parts of assessment include a biological history and medical history Nutritional assessment is also very important PHYSICAL examination and laboratory exams should be included

The Nursing Process for Eating Disorders ASSESSMENT Other assessment components: 1. 2. 3. 4.

Mental status examination Substance abuse history Family and social history Past and present psychiatric treatment

The Nursing Process for Eating Disorders DIAGNOSES

Imbalanced Nutrition: Less than body requirements related to dysfunctional eating patterns Disturbed body image related to fear of weight gain Powerlessness related to lack of control over food avoidance Anxiety Constipation/Diarrhea Decreased cardiac output Ineffective coping

The Nursing Process for Eating Disorders PLANNING  To maintain ideal body weight  To provide insight and teach coping skills

The Nursing Process for Eating Disorders IMPLEMENTATION for Anorexia Nervosa Weigh the patient at specific and regular intervals (About 2x-3x a week) with minimal clothing (hospital gown), patient facing away from the weighing scale Provide for safety and physical needs STAY with the patient and observe her within 1 to 2 hours AFTER EATING Encourage the client to share feelings to staff

The Nursing Process for Eating Disorders IMPLEMENTATION for Anorexia Nervosa Teach relaxation techniques Discuss factors interfering with client’s inability to eat Document intake and output Educate the client about the negative effects of dietary restriction and LOW weight and the rationale for normal weight Instruct the client on how to increase caloric intake and developing strategies for coping with anxiety

The Nursing Process for Eating Disorders IMPLEMENTATION for Bulimia 1. Encourage development of behavioral diary 2. Encourage expression of feelings 3. Educate about the physical consequences of binging, selfinduced vomiting and use of drugs 4. Limit exercising, frequent weighing and obsessive caloric counting

The Nursing Process for Eating Disorders IMPLEMENTATION for Bulimia 5. Stay with client after eating for 1-2 hours 7. Reinforce healthy coping 8. Monitor F and E status

General Interventions Assess the client’s nutritional status Establish a CONTRACT with the client concerning the diet plan for the day Assist the client in identifying precipitators of the eating disorder Encourage the client to state feelings about the eating behavior Encourage behavior modification

General Interventions Convey an accepting and nonjudgmental attitude Provide POSITIVE reinforcement for accomplishments SUPERVISE client during mealtimes and few hours after SET A TIME LIMIT FOR EACH MEAL Provide a pleasant atmosphere for eating

General Interventions Monitor for signs of physical complications related to the eating disorder WEIGH client daily with same scale, same time, same clothing (hospital gown) and AFTER VOIDING Encourage participation in diversional activities ASSESS AND MANAGE SUICIDAL BEHAVIORS

General Interventions LIMIT SETTING: 

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Restrict use of bathroom for 2 hours after eating Accompany to bathroom to ensure that they will not self-induce vomiting Stay with client during meals DO NOT accept excuses to leaving the area Limit Eating to 20 minutes

General Interventions DIET     

HIGH protein HIGH carbohydrates Serve foods preferred by patient Small frequent feedings NGT if patient refuses to eat

General Interventions DRUG 

Antidepressant drugs may be given after correcting the electrolyte and nutritional imbalances

Treatment modalities for Eating disorders PSYCHOTHERAPY 

Individual psychotherapy= anorexia is considered food phobia. Goal of therapy is to remove the phobia, restore weight and restructure cognitive process

FAMILY therapy 

Helping family define the problem in the context of eating behaviors

Treatment modalities for Eating disorders GROUP THERAPY 

The group composed of patient and a nurse talk openly about their concerns

Treatment modalities for Eating disorders BEHAVIORAL THERAPY

PHARMACOTHERAPY 

Fluoxetine (Prozac)

NUTRITIONAL THERAPY 

Dietician should be consulted

The Nursing Process for Eating Disorders EVALUATION Evaluate response to treatment Bulimia should have abstained from purging and decrease time to count the calories of food Anorexia nervosa should stabilize her weight without loss and able to ingest food