EATING DISORDERS

1. EATING DISORDERS RNSG 2213

2. Covered: Anorexia Nervosa Bulimia Nervosa Not Covered: Overeating and Binge Eating Disorder (DSM) Obesity Bariatric Surgery Topics

3. Anorexia Nervosa

4. 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

5. 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

6. Weight and Shape are very important Computer Graphics: make thin models even thinner Preoccupation with food, eating, fitness Unrealistic Ideals Cultural Influences

7. 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

8. Psychosocial Factors • May be avoidant or have social problems • Rigid, competitive, perfectionistic • Compulsive and obsessive • Hyperactive • Anxious • Compliant “people pleasers”

9. 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

10. 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)

11. Metabolic Consequences

12. Anorexia: More Consequences • Decreased peristalsis is exacerbated by overuse of laxatives or enemas • Delayed gastric emptying • Feel full much longer • Dehydration

13. 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

14. Anorexia: Complications • Heart failure, life threatening arrhythmias • Cardiac ventricular dilation • Decreased thickness of the ventricular wall • Decrease oxygenation of the cardiac muscle • Renal failure

15. Electrolyte imbalance Hypokalemia Hypocalcemia Metabolic imbalance Metabolic Acidosis Metabolic Alkalosis Complications, cont’d

16. 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

17. 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

18. 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

19. 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

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

21. 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

22. Bulimia Nervosa

23. Bulimia • Means to have an insatiable appetitive • Begins in adolescents • Primarily in women • 4% of young adults • Symptom overlap with Anorexia, making diagnosis difficult

24. 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

25. Binge EpisodeMassive Amounts of Food

26. 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

27. 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

28. Consequences and Complications of Purging • Electrolyte imbalances • Metabolic Acidosis • Metabolic Alkalosis • Cardiomyopathy • Enlarged salivary glands • Erosion of dental enamel • Russell’s sign • Pancreatitis

30. 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

31. 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

32. Anorexia Increase weight to 90% of average body weight Increase self-esteem Decrease need for perfection (provided by thinness) Bulimia Stabilize weight without purging Management of Eating Disorders

33. Management of Eating Disorders • Both Anorexia and Bulimia: • Inpatient treatment for medical stabilization and dietary management • Long-term outpatient tx. addresses psychosocial issues

34. 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

35. 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

36. Critical Thinking: Nursing Interventions • Give rationales for each of the following interventions listed on next slide 

37. 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 Reward for weight gain Nurse Patient Relationship: Some Interventions for Eating Disorders

38. 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

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

40. Milieu Management, cont’d • Weighing • Family Therapy • Group Therapy Which groups would be best for clients with eating disorders? • Dietitian • Follow-up Therapy (outpatient)

41. 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?