Eating Disorder Unfolding Case Study

1. Eating DisorderUnfolding Case Study Linda Manfrin-Ledet, DNS, APRN Amanda Eymard, DNS, RN, CNE Scott Bellanger, BSN, RN

2. Review Materials Prior to Unfolding Case Study • Forcano, L. Alvarez, E., Santamaria, J.J., Jimenez-Murcia, S., Granero, R. Penelo, E. …Fernandez-Aranda, F. (2011). Suicide attempts in anorexia nervosa subtypes. Comprehensive Psychiatry, 52(4), 352-358. • Quality and Safety Education for Nurses (QSEN). www.qsen.org • Stuart , G. (2013). Principles and Practice of Psychiatric Nursing (10th ed.). Chapter 24, pages 477-497.

3. Introduction Jamie is a 14-year-old female that recently transfer to a new high school after her family moved across states. This is her third residence and school change in the last 5 years. Jamie’s father is in the military service and recently returned home after a tour in Iraq for 6 months. Jamie has a two year history of restricted food intake. Jamie is 5’6” tall and weighs 98 pounds. She is on the dance team at school and is an honor roll student.

4. Continued The school nurse notices that Jamie frequently eats only an apple during lunch. The nurse is also concerned that Jamie seems to get easily fatigued during the dance team practices. Jamie is very thin and fragile in appearance. She does not seem as strong, physically, as she did in past practices during the beginning of the school year.

5. Reflect on the patient • What are the school nurse’s concerns about Jamie? • Reflect on Jamie’s background and the impact that her background may have on her present state.

6. In general, what are some predisposing factors for the development of eating disorders (ED)? • Personal Factors? • Family Factors? • Sociocultural?

7. Theory Burst Personal Factors • Weight • Puberty/maturation • Body image disturbance • Restricted eating • Perfectionism • Stress • Poor coping skills • Substance abuse • History of abuse Family Factors • Parental attitudes • Family functioning Sociocultural Factors • Media influences • Social pressure • Peer pressure and attitudes about weight • Teasing • Activities that have an emphasis on beauty or fitness

8. Which of these predisposing factors are specific to Jamie?

9. Jamie’s dad was not able to be around over the last several months. It will be important to work with a family therapist to allow the patient to discuss her feelings about dad not being around. • In regards to the living situation, Jamie’s family moved 3 times in the last 5 years. • Meeting many new people, losing friends, and not having a solid foundation can create a tremendous amount of stress which can antagonize the ED.

10. QSEN Highlight Evidence-Based Practice (EBP): “Integrate best current expertise and patient/family preferences and values for delivery of optimal care.” Skills: “Base individualized care plan on patient values, clinical expertise and evidence.”

11. Which related medical diagnoses (DSM-IV-TR) do you suspect of Jamie? • Anorexia nervosa • Bulimia nervous • Binge eating disorder

12. Answer • Anorexia nervosa

13. Theory Burst Anorexia nervosa: is a serious, life-threatening, mental disorder that is characterized by self-imposed starvation, intense and irrational beliefs about one’s body image, and excessive weight loss. It’s onset is usually between the ages of 13-20 years of age, but this illness can occur in any age group. It occurs mostly in females (94%), but it can occur in males. For some, this is a chronic illness, but many recover within 5 years. Vomiting, purging, bulimia, and obsessive-compulsive personality symptoms are associated with a least favorable outcome.

14. Theory Burst Symptomology associated with anorexia nervosa • Prolonged loss of appetite • Refusal to eat • Morbid fear of obesity • Preoccupation with food • Distorted body image • Perception of being “fat,” when they are severely underweight or emaciated

15. As the school nurse, what are the next steps in regard to Jamie?

16. Answer • Review Jamie’s health record on file. • Assess record for any health issues which correlate with weight loss, and fatigue. • Possibly contact Jamie’s parents. • Possibly consult the guidance counselor at Jamie’s school.

17. Communication! • Talk with Jamie in private setting about concerns and observations. Therapeutic relationships are essential in the recovery process. • Make family contact in the presence of Jamie. QSEN Highlight Patient-centered Care - Skills: “Remove barriers to presence of families and other designated surrogates based on patient preferences.”

18. Give examples of therapeutic communication techniques to use during communication with Jamie and her family :

19. Answer

20. Theory Burst • The development of eating disorders are rarely about food. It is important for the patient to gain insight on the causes of the eating disorder.

21. Assess Jamie’s history • What questions would the nurse ask Jamie and her parents while assessing Jamie’s history?

22. Answer • Stressors? • Medical history? • Medication history? • Previous hospitalizations? • Eating habits? • Attitudes toward food? • Perceptions of Jamie’s body image? • Exercise history? • Any previous psych history? • History of suicide attempts?***

23. Theory Burst • Depressive symptoms, severe anxiety, and purging in individuals with anorexia nervosa is a sign of elevated risk for suicide (Forcano et al., 2011) Forcano, L. Alvarez, E., Santamaria, J.J., Jimenez-Murcia, S., Granero, R. Penelo, E. …Fernandez-Aranda, F. (2011). Suicide attempts in anorexia nervosa subtypes. Comprehensive Psychiatry, 52(4), 352-358.

24. QSEN Highlight • “Safety: Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.” (www.qsen.org/competencies/pre-licensure-ksas/#safety)

25. ***If suicidal ideation is present….. What should the nurse do next?

26. Answer • Remain with Jamie at all times. • Notify Jamie’s parents. • Notify Jamie’s doctor. • Arrange for transportation to mental health hospital

27. What are the signs and symptoms/clinical presentation that the nurse should assess? • Physical signs and symptoms? • Psychological signs and symptoms? • Behavioral signs and symptoms?

28. Physical signs and symptoms in anorexia nervosa • Low body mass index (BMI) • Emaciation, weight loss • Hypotension • Bradycardia • Cardiac arrhythmias • Dehydration • Lethargy • Amenorrhea • Hunger denied • Constipation • Abdominal pain • Muscle weakness • Cold intolerance • Lanugo • Dental caries • Hand calluses • Knuckle abrasions • Poor skin turgor

29. Psychological signs and symptoms in anorexia nervosa • Distorted body image • Depression • Irritability • Anxiety • Socially withdrawn • Self-deprecating thoughts • Insomnia • Substance abuse • Impaired concentration • Decreased libido

30. Behavioral signs and symptoms in anorexia nervosa • Cutting food into tiny pieces • Ritualistic behaviors with food • Regularly eating alone • Preoccupation with food or weight loss • Binging • Purging or self-inducted vomiting • Excessive use of laxatives, diuretics, enemas, or diet pills • Excessive exercise • Frequently evaluation/measuring of self

31. Mental Health Hospital Jamie is admitted to a mental health hospital. What are some of the criteria for hospitalization for individuals with an ED?

32. Answer • More than 15% below normal body weight • Activity Intolerance • Life threatening lab values such as low hemoglobin, low hematocrit, potassium, hypotension, bradycardia • Imbalanced nutrition less than body requires • Electrolyte Imbalance • Disturbed Body Image • Anxiety

33. As the school nurse, call the hospital admitting physician with a report using SBAR: • Situation • Background • Assessment • Recommendation

34. What are common nursing diagnoses for patients with an ED?

35. Answers:Nursing Diagnoses • Imbalanced Nutrition, less than body required • Risk for Electrolyte Imbalance • Fatigue • Risk for Activity Intolerance • Disturbed Body Image • Powerlessness • Chronic or Situational Low Self-Esteem • Risk for Self Mutilation

36. QSEN Highlight Patient-centered Care: “Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.”

37. What lab test should the nurse evaluate or anticipate for Jamie?

38. Admit labs to obtain a baseline: • CBC, CMP, TSH, MG, Phosphorus, Pre-albumin, Amylase, Direct bilirubin, urine drug test, Urinalysis, Urine Pregnancy Test, Estrodial. • Anorexia Nervosa can affect these labs. It is important to monitor these labs weekly for any deterioration in the patient’s condition.

39. Theory Burst • Amylase level needs to be monitored. • Amylase level may increase due to secretions associated with purging behaviors.

40. What are common nursing interventions to include in the treatment plan for Jamie?

41. Education regarding anorexia nervosa, and what to expect during treatment to reduce patient’s anxiety • Monitor meals for restrictive behaviors • Monitor and document I/O • Supervise patient for 2 hours after each meal and snack to make sure patient is not purging food (vomiting, over exercising) • Administer medications as ordered and monitor the effects and possible side effects • A full physical exam should be performed • A psychiatric exam and history • Monitor for edema, order support hose if needed • Admit and weekly lab tests

42. More interventions: • Family sessions, individual sessions, sessions with their nutritionist and psychiatrist. An inter-professional team approach is best to yield the highest success rate. • Dental consult if history of purging • Orthostatic vitals daily • Weigh consistently while inpatient • Provide dietary information, education and meal planning. The nutritionist will create a meal plan so the patients gains (usually ½ lb. a day) • A balanced diet to improve activity intolerance, fatigue, electrolyte imbalance and imbalanced nutrition

43. What are common medications that may be administered to a patient with a diagnosed eating disorder?

44. Common Medications for patients with an ED: • Multivitamins • Fiber supplements (make sure patient takes with full glass of water) • Calcium supplements due to osteopenia and osteoporosis. • Medications for relief of constipation. • Anti-anxiety medications as needed. • Selective Serotonin Reuptake Inhibitors (SSRIs) are sometimes prescribed due to the high levels of depression associated with ED. • Synthroid if hypothyroidism is indicated. • Medications used to treat indigestion are common.

45. What are common treatment goals?

46. Treatment goals for Jamie: • Restore weight (0.5lbs daily). • Positive self image. • Normal body weight, decrease of ED behaviors, decease in anxiety r/t food. • Have balanced nutritional intake. • Exhibit lab values within normal ranges. • Increase patient’s energy level. • Correct body image distortions. • Identify social support systems.

47. QSEN Highlight Patient-centered Care: Knowledge – “Describe strategies to empower patients or families in all aspects of the health care process.”