eating disorders rnsg 2213. topics covered: covered: anorexia nervosa anorexia nervosa bulimia...
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EATING DISORDERSEATING DISORDERS
RNSG 2213RNSG 2213
TopicsTopics
Covered:Covered: Anorexia Anorexia
NervosaNervosa
Bulimia NervosaBulimia Nervosa
Not Covered:Not Covered: Overeating and Overeating and
Binge Eating Binge Eating Disorder (DSM)Disorder (DSM)
ObesityObesity Bariatric SurgeryBariatric Surgery
Anorexia NervosaAnorexia Nervosa
Anorexia Nervosa:Anorexia Nervosa: Incidence and Incidence and CharacteristicsCharacteristics
Affects 3.7% of womenAffects 3.7% of women Less common than bulimiaLess common than bulimia 6 to 20% die as a result of the illness6 to 20% die as a result of the illness Higher death rate than any other Higher death rate than any other
psychiatric disorderpsychiatric disorder
Anorexia Nervosa Characteristics, Anorexia Nervosa Characteristics, cont’dcont’d
Females, 90% (Male numbers are growing)Females, 90% (Male numbers are growing)
Onset: Onset: Adolescence to early adulthoodAdolescence to early adulthood Age of onset is decreasingAge of onset is decreasing
Often insidiousOften insidious Occurs during important life transitionsOccurs during important life transitions
No loss of appetiteNo loss of appetite Deliberate Weight lossDeliberate Weight loss
Cultural InfluencesCultural Influences
Weight and Shape Weight and Shape are very importantare very important
Computer Graphics: Computer Graphics: make thin models make thin models even thinnereven thinner
Preoccupation with Preoccupation with food, eating, fitnessfood, eating, fitness
Unrealistic IdealsUnrealistic Ideals
DSM IV-TR CriteriaDSM IV-TR Criteria
Refusal to maintain normal weightRefusal to maintain normal weight Intense fear of gaining weight, even if Intense fear of gaining weight, even if
underweightunderweight Body image disturbancesBody image disturbances In female adults or adolescents, absence In female adults or adolescents, absence
of at least 3 consecutive menstrual of at least 3 consecutive menstrual cyclescycles
Types are: Restricting and Binge/Purging Types are: Restricting and Binge/Purging
Psychosocial FactorsPsychosocial Factors
May be avoidant or have May be avoidant or have
social problemssocial problems Rigid, competitive, perfectionisticRigid, competitive, perfectionistic Compulsive and obsessive Compulsive and obsessive HyperactiveHyperactive AnxiousAnxious Compliant “people pleasers”Compliant “people pleasers”
Food-Related Behaviors in Food-Related Behaviors in Anorexia NervosaAnorexia Nervosa
Restricting intake, fastingRestricting intake, fasting Hoarding foodHoarding food Highly avoidant of certain foodsHighly avoidant of certain foods Preoccupation with calories, meals, recipes, Preoccupation with calories, meals, recipes,
etc.etc. Preparing/serving elaborate meals for othersPreparing/serving elaborate meals for others Rituals before and during eating Rituals before and during eating
become compulsionsbecome compulsions
Purging Behavior in Purging Behavior in AnorexiaAnorexia
Purgers and vomitersPurgers and vomiters Eat normally in a social situationsEat normally in a social situations Amount of food eaten is not excessiveAmount of food eaten is not excessive Purge if no success with severe Purge if no success with severe
restrictingrestricting
(Not on the test)(Not on the test)
Metabolic ConsequencesMetabolic Consequences
Anorexia: More Anorexia: More ConsequencesConsequences
Decreased peristalsis is exacerbated Decreased peristalsis is exacerbated by overuse of laxatives or enemasby overuse of laxatives or enemas Delayed gastric emptyingDelayed gastric emptying Feel full much longerFeel full much longer
DehydrationDehydration
Anorexia: ConsequencesAnorexia: Consequences
Amenorrhea, decreased development of Amenorrhea, decreased development of secondary sex characteristicssecondary sex characteristics
Osteopenia or OsteoporosisOsteopenia or Osteoporosis Bone mass loss may be irreversibleBone mass loss may be irreversible
Weakness and fatigueWeakness and fatigue But will persist in excessive exercising to burn But will persist in excessive exercising to burn
caloriescalories
Anorexia: ComplicationsAnorexia: Complications
Heart failure, life Heart failure, life threatening arrhythmiasthreatening arrhythmias
Cardiac ventricular dilationCardiac ventricular dilation Decreased thickness of the Decreased thickness of the
ventricular wall ventricular wall Decrease oxygenation of the Decrease oxygenation of the
cardiac musclecardiac muscle
Renal failureRenal failure
Complications, cont’dComplications, cont’d
Electrolyte Electrolyte imbalanceimbalance HypokalemiaHypokalemia
HypocalcemiaHypocalcemia
Metabolic Metabolic imbalanceimbalance Metabolic Metabolic
AcidosisAcidosis
Metabolic Metabolic AlkalosisAlkalosis
Complication of Treatment: Complication of Treatment: Re-feeding SyndromeRe-feeding Syndrome
Severe Fluid Shifts from too rapid Severe Fluid Shifts from too rapid re-introduction of food re-introduction of food Extracellular to intracellularExtracellular to intracellular
Cardiovascular, neurological and Cardiovascular, neurological and hematologic complicationshematologic complications
Refeed slowlyRefeed slowly Close supervisionClose supervision
Nursing Diagnosis: Critical Nursing Diagnosis: Critical thinkingthinking
Write a nursing diagnosis for each of Write a nursing diagnosis for each of these consequences of Anorexia these consequences of Anorexia Nervosa:Nervosa: 1) Severe weight loss to 60% of average 1) Severe weight loss to 60% of average
body weightbody weight 2) Bradycardia2) Bradycardia 3) Overuse of laxatives to achieve wt. loss3) Overuse of laxatives to achieve wt. loss 4) Refeeding Syndrome4) Refeeding Syndrome
Nursing DiagnosisNursing Diagnosis: Critical thinking : Critical thinking Some possible choicesSome possible choices
1)1) Nutrition less than body requirements Nutrition less than body requirements r/t refusal to eat; r/t excessive exerciser/t refusal to eat; r/t excessive exercise
2)2) R/F falls r/t hypotensionR/F falls r/t hypotension3a)3a) Fluid volume deficit r/t laxative overuse Fluid volume deficit r/t laxative overuse3b)3b) Constipation r/t altered gastric motilityConstipation r/t altered gastric motility4a)4a) Imbalanced fluid volume r/t fluid shifts Imbalanced fluid volume r/t fluid shifts4b)4b) Impaired cardiac or peripheral tissue Impaired cardiac or peripheral tissue
perfusion r/t decreased cardiac outputperfusion r/t decreased cardiac output
Mental Health Problems Mental Health Problems Associated with AnorexiaAssociated with Anorexia
Fear of losing control (Anxiety)Fear of losing control (Anxiety) Low sex drive Low sex drive Feelings of helplessnessFeelings of helplessness
Feel abandoned or inadequateFeel abandoned or inadequate Combat by controlling what they eatCombat by controlling what they eat
Obsessive-compulsive disorderObsessive-compulsive disorder Major Depression Major Depression
(Dx and tx only after weight gain is established)(Dx and tx only after weight gain is established) Substance abuseSubstance abuse Personality disordersPersonality disorders
Etiology of AnorexiaEtiology of Anorexia
High levels of serotoninHigh levels of serotonin SSRIs are not effectiveSSRIs are not effective If used should not be If used should not be
started until weight started until weight
restoration is establishedrestoration is established
Etiology: Anorexia and the Etiology: Anorexia and the FamilyFamily
Emotional restraintEmotional restraint Enmeshed relationshipsEnmeshed relationships Rigid organizationRigid organization Tight controlTight control
Drive for thinness is a way to seek controlDrive for thinness is a way to seek control Avoidance of conflictAvoidance of conflict
Odd eating habitsOdd eating habits Emphasis on appearanceEmphasis on appearance
Bulimia NervosaBulimia Nervosa
BulimiaBulimia
Means to have an insatiable Means to have an insatiable appetitiveappetitive
Begins in adolescentsBegins in adolescents Primarily in womenPrimarily in women 4% of young adults4% of young adults Symptom overlap with Anorexia, Symptom overlap with Anorexia,
making diagnosis difficultmaking diagnosis difficult
Bulimia CharacteristicsBulimia Characteristics
Hide their eating-disordered behaviorsHide their eating-disordered behaviors Lack of weight lossLack of weight loss Coexisting mental disorders:Coexisting mental disorders:
Major DepressionMajor Depression Personality disordersPersonality disorders Post traumatic Stress DisorderPost traumatic Stress Disorder
Purging develops as a way to compensate Purging develops as a way to compensate for massive amounts of food eatenfor massive amounts of food eaten
Restrictive eating….then purging….cycleRestrictive eating….then purging….cycle
Binge EpisodeBinge EpisodeMassive Amounts of FoodMassive Amounts of Food
Binge EatingBinge Eating
Feelings of lack of controlFeelings of lack of control Often done in secretOften done in secret High calorie-High carbohydrateHigh calorie-High carbohydrate Consumed in less than 2 hoursConsumed in less than 2 hours Addicted to the high experienced when Addicted to the high experienced when
eatingeating
Purging = Compensatory Purging = Compensatory Behavior for Binge EatingBehavior for Binge Eating
May use manual stimulation, May use manual stimulation, laxatives, and/or emetics laxatives, and/or emetics
Over time, self-induced vomiting Over time, self-induced vomiting occurs with minimal stimulationoccurs with minimal stimulation
Post-purging: sense of relief, calm Post-purging: sense of relief, calm
Consequences and Consequences and Complications of PurgingComplications of Purging
Electrolyte Electrolyte imbalances imbalances
Metabolic AcidosisMetabolic Acidosis Metabolic AlkalosisMetabolic Alkalosis CardiomyopathyCardiomyopathy Enlarged salivary Enlarged salivary
glandsglands Erosion of dental Erosion of dental
enamelenamel Russell’s sign Russell’s sign PancreatitisPancreatitis
DifferencesDifferences in Bulimia from in Bulimia from AnorexiaAnorexia
Lowered serotonin activityLowered serotonin activity Binge eating raises levels of Binge eating raises levels of
serotoninserotonin Treatment with SSRI, particularly Treatment with SSRI, particularly
fluoxetine (Prozac)fluoxetine (Prozac) Depression; shame; hide their eatingDepression; shame; hide their eating
Bulima: Associated Family Bulima: Associated Family CharacteristicsCharacteristics
Mood disordersMood disorders Substance abuseSubstance abuse ConflictConflict DisorganizedDisorganized Lacking nurturanceLacking nurturance
Food is a symbolic form of nurturingFood is a symbolic form of nurturing Evidence Bulimia is a response to chaosEvidence Bulimia is a response to chaos
Management of Eating Management of Eating DisordersDisorders
AnorexiaAnorexia Increase weight to Increase weight to
90% of average 90% of average body weight body weight
Increase self-Increase self-esteemesteem
Decrease need for Decrease need for perfection (provided perfection (provided by thinness)by thinness)
BulimiaBulimia Stabilize weight Stabilize weight
without purgingwithout purging
Management of Eating Management of Eating DisordersDisorders
Both Anorexia and Bulimia:Both Anorexia and Bulimia: Inpatient treatment for medical Inpatient treatment for medical
stabilization and dietary managementstabilization and dietary management Long-term outpatient tx. addresses Long-term outpatient tx. addresses
psychosocial issuespsychosocial issues
Management: Starvation Management: Starvation Phase of AnorexiaPhase of Anorexia
Assess labs:Assess labs: Monitor intake/output Monitor intake/output Assess for cardiovascular, neurological Assess for cardiovascular, neurological
and complicationsand complications Refeed slowly; careful dietary Refeed slowly; careful dietary
supervisionsupervision Intravenous lines and feeding tubes if Intravenous lines and feeding tubes if
client refuses foodclient refuses food
Nurse Patient RelationshipNurse Patient Relationship
Anorexia NervosaAnorexia Nervosa Usually forced into Usually forced into
tx.tx. Tx means loss of Tx means loss of
control over eatingcontrol over eating Nurse is the enemyNurse is the enemy
Bulimia NervosaBulimia Nervosa More likely to want More likely to want
help: break the cyclehelp: break the cycle More likely to enter More likely to enter
treatment of their on treatment of their on volitionvolition
Tendency to Tendency to manipulatemanipulate
Hide the degree of Hide the degree of the problemthe problem
Critical ThinkingCritical Thinking: Nursing : Nursing InterventionsInterventions
Give rationales for each of the Give rationales for each of the following interventions listed on next following interventions listed on next
slide slide
Nurse Patient Relationship: Nurse Patient Relationship: Some Some Interventions for Eating Interventions for Eating
DisordersDisorders Do not confront Do not confront
denial, but encourage denial, but encourage feelings identificationfeelings identification
HonestyHonesty CollaborateCollaborate TEACHTEACH patient about patient about
their disordertheir disorder Assist to identify Assist to identify
positive qualitiespositive qualities Eat with the clientEat with the client
Set appropriate limitsSet appropriate limits Encourage decision Encourage decision
making concerning making concerning issues other than foodissues other than food
Behavior modification:Behavior modification: Patient inputPatient input Reward for weight Reward for weight
gaingain
PsychopharmacologyPsychopharmacology
Anxiolytics when re-feeding is Anxiolytics when re-feeding is occurringoccurring
SSRI for BulimiaSSRI for Bulimia Equally effective for depressed and non-Equally effective for depressed and non-
depressed patientsdepressed patients Psychotherapy for AnorexiaPsychotherapy for Anorexia
Use antidepressant for co-morbid severe Use antidepressant for co-morbid severe depressiondepression
Milieu ManagementMilieu Management
OrientationOrientation Warm nurturing environmentWarm nurturing environment
Convey an understanding of their fearsConvey an understanding of their fears Close observationClose observation
Do we let these patient go to the rest room alone?Do we let these patient go to the rest room alone?
Should we let them go to their room right after a Should we let them go to their room right after a meal?meal?
Nonjudgmental confrontationNonjudgmental confrontation CONSISTENCYCONSISTENCY
Encourage the patient to talk to staff when Encourage the patient to talk to staff when they feel the need to purgethey feel the need to purge
Milieu Management, cont’dMilieu Management, cont’d
WeighingWeighing Family TherapyFamily Therapy Group TherapyGroup Therapy
Which groups would be best for clients Which groups would be best for clients with eating disorders?with eating disorders?
DietitianDietitian Follow-up Therapy (outpatient)Follow-up Therapy (outpatient)
Scenarios: CommunicationScenarios: Communication
1) Two clients on the eating disorders unit 1) Two clients on the eating disorders unit are overheard discussing recipes and meal are overheard discussing recipes and meal plans in the day room. How should the plans in the day room. How should the nurse respond?nurse respond?
2) An inpatient with Anorexia Nervosa 2) An inpatient with Anorexia Nervosa complains of feeling very full after eating complains of feeling very full after eating and says she is being given too much to and says she is being given too much to eat. How should the nurse respond?eat. How should the nurse respond?
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