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EATING DISORDERS. RNSG 2213. Covered: Anorexia Nervosa Bulimia Nervosa. Not Covered: Overeating and Binge Eating Disorders Obesity and Bariatrics. Topics in this Presentation. Anorexia Nervosa. Females, 90% (male numbers are growing) Affects 3.7% of women Less common than bulimia

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Eating disorders


RNSG 2213

Topics in this presentation


Anorexia Nervosa

Bulimia Nervosa

Not Covered:

Overeating and Binge Eating Disorders

Obesity and Bariatrics

Topics in this Presentation

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

Anorexia Nervosa: Incidence and Characteristics

Anorexia nervosa characteristics cont d
Anorexia Nervosa Characteristics, cont’d

  • Onset:

    • adolescence to early adulthood

    • age of onset is decreasing

    • often insidious

    • occurs during important life transitions

  • No loss of appetite

  • Deliberate Weight loss

Cultural factors and influences
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

Eating disorders

Beauty Queens



Cultural factors influences cont d

Preoccupation with fitness

Epidemic of obesity and dieting

thinness = self-control

Cultural Factors & Influences, cont’d

Dsm iv tr criteria for anorexia nervosa
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

Psychosocial and family factors
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”

Psychosocial and family factors cont d
Psychosocial and Family Factors, cont’d

  • Correlates with childhood sexual abuse

  • Family characteristics that correlate with anorexia:

    • over-controlling or rigid

    • emphasis on appearance

    • may have unusual eating habits

Food related behaviors in anorexia nervosa
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

How anorexics get rid of the weight
How Anorexics Get Rid of the “Weight”

  • Use of laxatives and enemas

  • Exercise

Purging behavior in anorexia
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)

Anorexia more metabolic consequences
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

Other physical assessment data
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

Anorexia complications
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

Complication of treatment re feeding syndrome
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

Nursing diagnosis critical thinking
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

Nursing diagnosis critical thinking some possible choices
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

Mental health problems associated with anorexia
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

Mental health disorders associated with anorexia nervosa cont d
Mental Health Disorders Associated with Anorexia Nervosa, cont’d

  • Major Depression

    • (Dx and tx only after weight gain is established)

  • Substance abuse: laxatives and enemas rather than alcohol or illegal drugs

  • Personality disorders

Neurobiology of anorexia
Neurobiology of Anorexia cont’d

  • High levels of serotonin

    • SSRIs are not effective

    • If used should not be started until weight

      restoration is established

Bulimia nervosa
Bulimia Nervosa cont’d

Bulimia nervosa1
Bulimia Nervosa cont’d

  • Age of onset: adolescence to young adulthood

  • Primarily in women

  • 4% of young adults

  • Symptoms overlap with Anorexia, making diagnosis difficult

Bulimia characteristics
Bulimia Characteristics cont’d

  • 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...bingeing…purging


Binge eating episode
Binge Eating Episode cont’d

  • 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

Purging compensatory behavior for binge eating
Purging = Compensatory Behavior for Binge Eating cont’d

  • May use manual stimulation, laxatives, and/or emetics

  • Over time, self-induced vomiting occurs with minimal stimulation

  • Post-purging: sense of relief, calm

Consequences and complications of purging
Consequences and Complications of Purging cont’d

  • Electrolyte imbalances

  • Metabolic Acidosis

  • Metabolic Alkalosis

  • Cardiomyopathy

  • Enlarged salivary glands

  • Erosion of dental enamel

  • Russell’s sign

  • Pancreatitis

Etiology psychosocial and family factors in bulimia
Etiology: Psychosocial and Family Factors in Bulimia cont’d

  • 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

Etiology neurobiology of bulimia
Etiology cont’d: Neurobiology of Bulimia

  • Lowered serotonin activity

  • Binge eating raises levels of serotonin

  • Treat with SSRI, particularly fluoxetine (Prozac)

Management of eating disorders

Goals for client with Anorexia Nervosa cont’d

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

Management of Eating Disorders

Management of eating disorders cont d
Management of Eating Disorders, cont’d cont’d

  • Both Anorexia and Bulimia:

    • Inpatient treatment for medical stabilization and dietary management

    • Long-term outpatient tx. addresses psychosocial issues

Interventions starvation phase of anorexia
Interventions cont’d: 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

Nurse patient relationship

Anorexia Nervosa cont’d

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

Nurse Patient Relationship

Critical thinking nursing interventions
Critical Thinking: Nursing Interventions cont’d

Give rationales for interventions listed on next slide 

Some interventions for eating disorders

Do not confront denial, but encourage feelings identification



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

Some Interventions for Eating Disorders

Psychopharmacology identification

  • 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

Milieu management
Milieu Management identification

  • 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


  • Encourage the patient to talk to staff when they feel the need to purge

Milieu management cont d
Milieu Management, cont’d identification

  • Dietitian: individual planning and consultation

  • Weighing protocols

  • Group Therapy

    Which groups would be best for clients with eating disorders?

Eating disorders

Art Therapy & identification

Expressive Arts

Meditation &




Other interventions
Other Interventions identification

  • Family Involvement: teaching and family therapy

  • Follow-up therapy (outpatient)