EATING DISORDERS

1
EATING DISORDERS

• RNSG 2213

2
Topics in this Presentation

• Covered
• Anorexia Nervosa
• Bulimia Nervosa

• Not Covered
• Overeating and Binge Eating Disorders
• Obesity and Bariatrics

3
Anorexia Nervosa
4
Anorexia Nervosa Incidence and Characteristics

• Females, 90 (male numbers are growing)
• Affects 3.7 of women
• Less common than bulimia
• 6 to 20 die as a result of the illness
• Higher death rate than any other psychiatric
  disorder

5
Anorexia Nervosa Characteristics, contd

• Onset
• adolescence to early adulthood
• age of onset is decreasing
• often insidious
• occurs during important life transitions
• No loss of appetite
• Deliberate Weight loss

6
Cultural Factors and Influences

• Weight and Shape
• very important in US culture
• Unrealistic ideals
• culture of thinness
• e.g. computer graphics make thin models even
  thinner

7
Beauty Queens
2008
1920s
8
Cultural Factors Influences, contd

• Epidemic of obesity and dieting
• thinness self-control

• ? Preoccupation with fitness

9
DSM IV-TR Criteria for Anorexia Nervosa

• Refusal to maintain normal weight
• Intense fear of gaining weight, even if
  underweight
• Body image disturbances
• In female adults or adolescents, absence of at
  least 3 consecutive menstrual cycles
• Types are Restricting and Binge/Purging

10
Psychosocial and Family Factors

• Fears of becoming adult or independent
• Rigid, competitive, perfectionistic
• Anxious, compulsive and obsessive
• the eating disorder is a way to have control
• Compliant people pleasers

11
Psychosocial and Family Factors, contd

• Correlates with childhood sexual abuse
• Family characteristics that correlate with
  anorexia
• over-controlling or rigid
• emphasis on appearance
• may have unusual eating habits

12
Food-Related Behaviors in Anorexia Nervosa

• Restricting intake, fasting
• Hoarding food
• Highly avoidant of certain foods
• Preoccupation with calories, meals, recipes, etc.
• Preparing/serving elaborate meals for others
• Rituals before and during eating
• become compulsions
• ?Many characteristic behaviors of Anorexia
  Nervosa are associated primarily with low
  weight/starvation symptoms

13
How Anorexics Get Rid of the Weight

• Use of laxatives and enemas
• Exercise

14
Purging Behavior in Anorexia

• Purgers and vomiters
• Eat normally in a social situations
• Amount of food eaten is not excessive
• Purge if no success with severe restricting
• (Not on the test)

15
Physical Assessment Metabolic Consequences
16
Anorexia More Metabolic Consequences

• GI slowed peristalsis, delayed gastric emptying
• Feel full much longer
• Reproductive loss of menses, loss of libido
• ? development of secondary sex characteristics
• Osteopenia or Osteoporosis bone mass loss may be
  irreversible

17
Other Physical Assessment Data

• Muscle wasting, weakness and fatigue
• Dehydration
• Pitting edema
• Electrolyte imbalance secondary to laxative,
  enema or emetic abuse and from starvation
• Hypocalcemia, hypokalemia

18
Anorexia Complications

• Heart failure, life threatening arrhythmias
• Cardiac ventricular dilation
• Decreased thickness of the ventricular wall
• Decreased oxygenation of
• cardiac muscle
• Renal failure
• Metabolic alkalosis or acidosis

19
Complication of Treatment Re-feeding Syndrome

• Severe Fluid Shifts from too rapid
  re-introduction of food
• Cardiovascular, neurological and hematologic
  complications
• Interventions
• Refeed slowly
• Close supervision of physical status

20
Nursing Diagnosis Critical thinking

• Write a nursing diagnosis for each of these
  consequences of Anorexia Nervosa
• 1) Hides food and is dishonest about intake
• 2) Heart Rate is persistently 48 bpm
• 3) Uses laxatives several times a week to
  achieve wt. loss

21
Nursing Diagnosis Critical thinking Some
possible choices

• 1a) Ineffective coping or
• 1b) R/F nutrition less than body requirements
  r/t dishonesty about intake and compensatory
  behaviors
• 2) R/F falls r/t hypotension
• 3a) Fluid volume deficit r/t laxative overuse
• 3b) Constipation (or Diarrhea) r/t altered
  gastric motility

22
Mental Health Problems Associated with Anorexia

• Anxiety
• If perceives loss of control over eating will
  lose weight by any means, e.g. exercising,
  laxatives, enemas or emetics
• Sexual dysfunctions, low sex drive
• Feelings of helplessness, inadequacy
• Obsessive-compulsive Disorder

23
Mental Health Disorders Associated with Anorexia
Nervosa, contd

• Major Depression
• (Dx and tx only after weight gain is established)
• Substance abuse laxatives and enemas rather than
  alcohol or illegal drugs
• Personality disorders

24
Neurobiology of Anorexia

• High levels of serotonin
• SSRIs are not effective
• If used should not be started until weight
• restoration is established

25
Bulimia Nervosa
26
Bulimia Nervosa

• Age of onset adolescence to young adulthood
• Primarily in women
• 4 of young adults
• Symptoms overlap with Anorexia, making diagnosis
  difficult

27
Bulimia Characteristics

• Often develops after period of dieting
• Weight loss NOT a characteristic sign of bulimia
• Purging develops as a way to compensate for
  massive amounts of food eaten
• Restrictive eating...bingeingpurging
• cycle

28
Binge Eating Episode

• Precipitated by feelings of lack of control or
  anxiety
• Often done in secret
• High calorie-High carbohydrate intake
• Consumed in less than 2 hours
• Become addicted to the high experienced when
  eating

29
Purging Compensatory Behavior for Binge Eating

• May use manual stimulation, laxatives, and/or
  emetics
• Over time, self-induced vomiting occurs with
  minimal stimulation
• Post-purging sense of relief, calm

30
Consequences and Complications of Purging

• Electrolyte imbalances
• Metabolic Acidosis
• Metabolic Alkalosis
• Cardiomyopathy
• Enlarged salivary glands
• Erosion of dental enamel
• Russells sign
• Pancreatitis

31
(No Transcript)
32
Etiology Psychosocial and Family Factors in
Bulimia

• Depression, low self-esteem
• Shame will hide the excessive eating
• Associated family characteristics
• Mood disorders
• Lack of nurturing
• food is a form of self-nurturing
• Substance abuse
• Family conflict or disorganization
• evidence Bulimia is a response to chaos

33
Etiology Neurobiology of Bulimia

• Lowered serotonin activity
• Binge eating raises levels of serotonin
• Treat with SSRI, particularly fluoxetine (Prozac)

34
Management of Eating Disorders

• Goals for client with Anorexia Nervosa
• Increase weight to 90 of average body weight for
  height
• Increase self-esteem
• Decrease need for perfection (provided by
  thinness)

• Goals for client with Bulimia
• Stabilize weight without purging

35
Management of Eating Disorders, contd

• Both Anorexia and Bulimia
• Inpatient treatment for medical stabilization and
  dietary management
• Long-term outpatient tx. addresses psychosocial
  issues

36
Interventions Starvation Phase of Anorexia

• Assess labs
• Monitor intake/output
• Assess for cardiovascular, neurological
  complications
• Refeed slowly careful dietary supervision
• Intravenous lines and feeding tubes if
  client refuses food

37
Nurse Patient Relationship

• Anorexia Nervosa
• Usually forced into tx.
• Tx means loss of control over eating
• Nurse is the enemy

• Bulimia Nervosa
• More likely to want help break the cycle
• More likely to enter treatment of their own
  volition
• Tendency to manipulate
• Hide the degree of the problem

38
Critical Thinking Nursing Interventions

• Give rationales for interventions listed on next
  slide ?

39
Some Interventions for Eating Disorders

• Do not confront denial, but encourage feelings
  identification
• Honesty
• Collaborate
• TEACH patient about their disorder
• Assist to identify positive qualities
• Eat with the client

• Set appropriate limits
• Encourage decision -making concerning issues
  other than food
• Behavior modification
• Patient input
• Rewards for weight gain

40
Psychopharmacology

• Anxiolytics when re-feeding is occurring
• SSRI for Bulimia
• Equally effective for depressed and non-depressed
  patients
• Psychotherapy for Anorexia
• Use antidepressant for co-morbid severe depression

41
Milieu Management

• Orient to program and goals of treatment
• Warm nurturing environment
• Convey an understanding of their fears
• Close observation during and after meals
• Do we let these patient go to the rest room
  alone?
• Should we let them go to their room right after a
  meal?
• Nonjudgmental confrontation of eating disordered
  behavior
• CONSISTENCY
• Encourage the patient to talk to staff when they
  feel the need to purge

42
Milieu Management, contd

• Dietitian individual planning and consultation
• Weighing protocols
• Group Therapy
• Which groups would be best for clients with
  eating disorders?

43
Art Therapy Expressive Arts
Meditation Relaxation
Movement Therapy
44
Other Interventions

• Family Involvement teaching and family therapy
• Follow-up therapy (outpatient)