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EATING DISORDERS. RNSG 2213. Covered: Anorexia Nervosa Bulimia Nervosa. Not Covered: Overeating and Binge Eating Disorder (DSM) Obesity Bariatric Surgery. Topics. Anorexia Nervosa. Affects 3.7% of women Less common than bulimia 6 to 20% die as a result of the illness

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Anorexia Nervosa

Bulimia Nervosa

Not Covered:

Overeating and Binge Eating Disorder (DSM)


Bariatric Surgery

anorexia nervosa incidence and characteristics
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
  • Females, 90% (Male numbers are growing)
  • 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 influences
Weight and Shape are very important

Computer Graphics: make thin models even thinner

Preoccupation with food, eating, fitness

Unrealistic Ideals

Cultural Influences
dsm iv tr criteria
DSM IV-TR Criteria
  • 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 factors
Psychosocial Factors
  • May be avoidant or have

social problems

  • Rigid, competitive, perfectionistic
  • Compulsive and obsessive
  • Hyperactive
  • Anxious
  • Compliant “people pleasers”
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
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 consequences
Anorexia: More Consequences
  • Decreased peristalsis is exacerbated by overuse of laxatives or enemas
    • Delayed gastric emptying
    • Feel full much longer
  • Dehydration
anorexia consequences
Anorexia: Consequences
  • Amenorrhea, decreased development of secondary sex characteristics
  • Osteopenia or Osteoporosis
    • Bone mass loss may be irreversible
  • Weakness and fatigue
    • But will persist in excessive exercising to burn calories
anorexia complications
Anorexia: Complications
  • Heart failure, life threatening arrhythmias
  • Cardiac ventricular dilation
    • Decreased thickness of the ventricular wall
    • Decrease oxygenation of the cardiac muscle
  • Renal failure
complications cont d
Electrolyte imbalance



Metabolic imbalance

Metabolic Acidosis

Metabolic Alkalosis

Complications, cont’d
complication of treatment re feeding syndrome
Complication of Treatment: Re-feeding Syndrome
  • Severe Fluid Shifts from too rapid re-introduction of food
    • Extracellular to intracellular
  • Cardiovascular, neurological and hematologic complications
  • Refeed slowly
  • Close supervision
nursing diagnosis critical thinking
Nursing Diagnosis: Critical thinking

Write a nursing diagnosis for each of these consequences of Anorexia Nervosa:

  • 1) Severe weight loss to 60% of average body weight
  • 2) Bradycardia
  • 3) Overuse of laxatives to achieve wt. loss
  • 4) Refeeding Syndrome
nursing diagnosis critical thinking some possible choices
Nursing Diagnosis: Critical thinking Some possible choices
  • Nutrition less than body requirements r/t refusal to eat; r/t excessive exercise
  • R/F falls r/t hypotension

3a) Fluid volume deficit r/t laxative overuse

3b)Constipation r/t altered gastric motility

4a) Imbalanced fluid volume r/t fluid shifts

4b) Impaired cardiac or peripheral tissue perfusion r/t decreased cardiac output

mental health problems associated with anorexia
Mental Health Problems Associated with Anorexia
  • Fear of losing control (Anxiety)
  • Low sex drive
  • Feelings of helplessness
    • Feel abandoned or inadequate
    • Combat by controlling what they eat
  • Obsessive-compulsive disorder
  • Major Depression
    • (Dx and tx only after weight gain is established)
  • Substance abuse
  • Personality disorders
etiology of anorexia
Etiology of Anorexia
  • High levels of serotonin
    • SSRIs are not effective
    • If used should not be

started until weight

restoration is established

etiology anorexia and the family
Etiology: Anorexia and the Family
  • Emotional restraint
    • Enmeshed relationships
    • Rigid organization
    • Tight control
      • Drive for thinness is a way to seek control
    • Avoidance of conflict
  • Odd eating habits
    • Emphasis on appearance
  • Means to have an insatiable appetitive
  • Begins in adolescents
  • Primarily in women
  • 4% of young adults
  • Symptom overlap with Anorexia, making diagnosis difficult
bulimia characteristics
Bulimia Characteristics
  • Hide their eating-disordered behaviors
  • Lack of weight loss
  • Coexisting mental disorders:
    • Major Depression
    • Personality disorders
    • Post traumatic Stress Disorder
  • Purging develops as a way to compensate for massive amounts of food eaten
  • Restrictive eating….then purging….cycle
binge eating
Binge Eating
  • Feelings of lack of control
  • Often done in secret
  • High calorie-High carbohydrate
  • Consumed in less than 2 hours
  • Addicted to the high experienced when eating
purging compensatory behavior for binge eating
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
consequences and complications of purging
Consequences and Complications of Purging
  • Electrolyte imbalances
  • Metabolic Acidosis
  • Metabolic Alkalosis
  • Cardiomyopathy
  • Enlarged salivary glands
  • Erosion of dental enamel
  • Russell’s sign
  • Pancreatitis
differences in bulimia from anorexia
Differences in Bulimia from Anorexia
  • Lowered serotonin activity
  • Binge eating raises levels of serotonin
  • Treatment with SSRI, particularly fluoxetine (Prozac)
  • Depression; shame; hide their eating
bulima associated family characteristics
Bulima: Associated Family Characteristics
  • Mood disorders
  • Substance abuse
  • Conflict
  • Disorganized
  • Lacking nurturance
    • Food is a symbolic form of nurturing
  • Evidence Bulimia is a response to chaos
management of eating disorders

Increase weight to 90% of average body weight

Increase self-esteem

Decrease need for perfection (provided by thinness)


Stabilize weight without purging

Management of Eating Disorders
management of eating disorders1
Management of Eating Disorders
  • Both Anorexia and Bulimia:
    • Inpatient treatment for medical stabilization and dietary management
    • Long-term outpatient tx. addresses psychosocial issues
management starvation phase of anorexia
Management: Starvation Phase of Anorexia
  • Assess labs:
  • Monitor intake/output
  • Assess for cardiovascular, neurological and complications
  • Refeed slowly; careful dietary supervision
  • Intravenous lines and feeding tubes if client refuses food
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 on volition

Tendency to manipulate

Hide the degree of the problem

Nurse Patient Relationship
critical thinking nursing interventions
Critical Thinking: Nursing Interventions
  • Give rationales for each of the following interventions listed on next slide 
nurse patient relationship 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

Reward for weight gain

Nurse Patient Relationship: Some Interventions for Eating Disorders
  • 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
  • Orientation
  • Warm nurturing environment
    • Convey an understanding of their fears
  • Close observation

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
  • Encourage the patient to talk to staff when they feel the need to purge
milieu management cont d
Milieu Management, cont’d
  • Weighing
  • Family Therapy
  • Group Therapy

Which groups would be best for clients with eating disorders?

  • Dietitian
  • Follow-up Therapy (outpatient)
scenarios communication
Scenarios: Communication

1) Two clients on the eating disorders unit are overheard discussing recipes and meal plans in the day room. How should the nurse respond?

2) An inpatient with Anorexia Nervosa complains of feeling very full after eating and says she is being given too much to eat. How should the nurse respond?