Chapter 18 Eating Disorders

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Chapter 18 Eating Disorders
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• Eating disorders can be viewed on a continuum
  the anorexic eats too little or is starving, the
  bulimic eats in a chaotic way, and the obese
  person eats too much. There is much overlap among
  the eating disorders 50 of clients with
  anorexia exhibit bulimic behavior and 35 of
  normal-weight clients with bulimia have a history
  of anorexia. More than 90 of cases of anorexia
  nervosa and bulimia occur in females.

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Anorexia Nervosa

• Life-threatening eating disorder characterized
  by
• Clients refusal or inability to maintain a
  minimally normal body weight
• Intense fear of gaining weight or becoming fat
• Significantly disturbed perception of the shape
  or size of the body-most difficult to resolve
  successfully
• Steadfast refusal by client to acknowledge the
  problem is severe or that there is even a problem
  at all

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• 85 of expected body weight or less
• Amenorrheaat least 3 consecutive cycles-nurse to
  suspect anorexia-esp if weight loss is an issue
• Total absorption in quest for thinness and weight
  loss

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• Onset and Clinical Course
• Anorexia typically begins between 14 and 18 years
  of age. Unrealistic perception of body size.
• Ability to control weight give pleasure to the
  client.
• Client may feel empty emotionally and be unable
  to identify or express emotional feelings.
• As illness progresses, depression and labile
  moods are common.

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• Client is socially isolated, mistrustful of
  others may believe that others are trying to
  make her fat and ugly
• Long-term studies show that after 21 years, 50
  had fully recovered,
• 25 had intermediate outcomes, 10 still met
  criteria for anorexia, and 15 had died from
  causes related to anorexia

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Bulimia Nervosa

• Characterized by recurrent episodes of binge
  eating(uncontrollable craving for food),
  inappropriate compensatory behaviors to avoid
  weight gain (purging self-induced vomiting, use
  of laxatives, diuretics, enemas, emetics,
  fasting, excessive exercise).
• Binge eating is done in secret and the client
  recognizes the eating behavior as pathologic,
  causing feelings of guilt, shame, remorse, or
  contempt. Clients with bulimia are usually in
  normal weight range but may be underweight or
  overweight.

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• Dentists may be the first to discover bulimia due
  to loss of tooth enamel, caries, chipped or
  ragged teeth.

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• Onset and Clinical Course
• Begins about age 18 or 19
• Binge eating begins after an episode of dieting.
• Between binges, eating may be restrictive.
• Food is hidden in the car, desk at work, and
  secret locations around the house.
• Behavior may continue for years before it is
  discovered.

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• About 50 of clients recover completely, 20
  continue to meet all criteria for bulimia, 30
  have episodic bouts of bulimia. One third of
  fully recovered clients have a relapse. Death
  rate for bulimia is estimated at 0 to 3.

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Etiology

• Specific etiology for eating disorders is
  unknown, but initially dieting may be the
  stimulus that leads to the eating disorder.

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• Biologic Factors
• Genetic vulnerability
• Disruptions in the nuclei of the hypothalamus
  relating to hunger and satiety (satisfaction of
  appetite)
• Neurochemical changes are seen, but it is not
  known if these changes cause the disorders or are
  a result of eating disorders

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Developmental Factors Anorexia Nervosa

• Struggle to develop autonomy and identity (lack
  of control, fear of growing up and maturing)
• Overprotective or enmeshed families that lack
  clear roles and boundaries
• Body image disturbance and body image
  dissatisfaction

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Developmental Factors Bulimia Nervosa

• Separation-individuation difficulties (excessive
  anxiety over growing up, leaving home and
  becoming independent).
• Body image dissatisfaction.

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Family Influences

• Families of anorexic clients are often rigid and
  overprotective avoid interpersonal conflict by
  ignoring it stifle the clients attempts at
  autonomy and identity formation
• Families of bulimic clients are chaotic, lack
  clear boundaries, are achievement-oriented
  client feels pressure to be successful, to please
  others, to maintain harmony

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Sociocultural Factors

• Image of ideal woman as thin and perfectly toned
  in U.S. and westernized countries
• Books, magazines, TV promote this thin image as
  well as numerous beauty industries (weight
  loss, plastic surgery, body-building, etc.)
• Being overweight is often equated with being
  lazy, lacking willpower, being bad or
  unsuccessful.
• Pressure from peers, parents, and coaches may
  also contribute to the development of eating
  disorders.

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Cultural Considerations

• Eating disorders are more prevalent in countries
  where food is prevalent and beauty is linked to
  being thin.
• Immigrants from cultures where eating disorders
  are rare may develop eating disorders as they
  assimilate the thin ideal body image.
• Eating disorders are equally common among
  Hispanic and white women but are less common
  among African American and Asian women.

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Treatment Anorexia Nervosa

• Setting depends on severity of illness. More
  medically compromised clients require inpatient
  care risk of suicide is significant.
• Outpatient therapy is more likely to be effective
  for those who have been ill less than 6 months,
  who are not bingeing and purging, and who have
  parents who participate in family therapy.
• Medical management focuses on weight restoration,
  nutritional rehabilitation, rehydration,
  correction of electrolyte imbalances.

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Treatment Anorexia Nervosa

• Generally client is supervised during meals to
  ensure eating and after meals while using
  bathroom to prevent purging. Up 2 hours after
  closely watched. Nurse will sit quietly with
  client while he or she eats.
• Weight gain and adequate intake are often
  criteria for judging treatment effectiveness.
• Many drugs have been studied and tried, but few
  show success. Fluozetine (Prozac) may help
  prevent relapse but only when weight has been
  gained because it can cause weight loss due to
  appetite suppressant.
• Family therapy- resolve family conflicts-restoring
  control issues

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Treatment Bulimia Nervosa

• Most clients are treated on outpatient basis
  inpatient only if bingeing and purging behavior
  is out of control or medical status is
  compromised
• Cognitive-behavioral therapy has been effective
  designed to change clients thinking and actions
  about food, eating, weight, body image, and
  self-concept-Have client write about all feelings
  and experience related to food-self- monitoring.
• Medications are marginally effective
  antidepressants do improve mood, reduce
  preoccupation with shape and weight, reduce
  bingeing and purging behaviors

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Application of the Nursing Process Eating
Disorders

• Assessment
• Many assessment tools have been developed to
  identify eating disorders and measure progress
  toward achieving outcomes.
• History Client with anorexia is described by
  parents as a model child, no trouble, dependable,
  before onset of anorexia. Clients with bulimia
  are eager to please and conform, avoid conflict,
  but may have history of impulsive behavior. Self
  imposed dieting-leading to severe weight loss.

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• Assessment (contd)
• General appearance and motor behavior Clients
  with anorexia are slow, lethargic, even
  emaciated slow to respond to questions,
  difficulty deciding what to say, reluctant to
  answer questions fully often wear baggy clothes
  or layers to hide weight or keep warm limited
  eye contact unwilling to discuss problems or
  enter treatment. Clients with bulimia generally
  have a normal appearance, are open and talkative.

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Application of the Nursing Process Eating
Disorders

• Mood and affect Moods are labile, corresponding
  to eating or dieting behavior. Clients with
  anorexia may look sad and anxious and seldom
  smile or laugh. Clients with bulimia are
  initially cheerful but express intense emotions
  of guilt, shame, and embarrassment when
  discussing bingeing and purging behaviors.

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Application of the Nursing Process Eating
Disorders (contd)

• Ask clients with eating disorders about suicidal
  ideas and self-harm urges both are common.
• Thought processes and content Clients spend most
  of their time thinking about food, dieting,
  food-related issues. Body image disturbance can
  be almost delusional. Clients with anorexia may
  have paranoid ideas about their family and health
  care professionals being the enemy, trying to
  make them fat.

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Application of the Nursing Process Eating
Disorders (contd)

• Sensorium and intellectual processes generally
  alert, oriented, intact exception is the
  severely malnourished client with anorexia, who
  may have mild confusion, slowed mental processes,
  and difficulty with concentration and attention.

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Application of the Nursing Process Eating
Disorders (contd)

• Judgment and insight Clients with anorexia have
  very limited insight and poor judgment about
  health status. Giving factual information has no
  effect. Restrictive dieting continues despite
  failing health and malnutrition. Clients with
  bulimia have insight into the pathologic nature
  of their eating behavior but feel out of control
  and unable to change that behavior.

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Application of the Nursing Process Eating
Disorders (contd)

• Self-concept Low self-esteem is prominent in
  clients with eating disorders they see
  themselves only in(anorexics) terms of their
  ability to control food intake and weight and
  judge themselves harshly and see themselves as
  bad if they eat certain foods or fail to lose
  weight. Other personal characteristics are
  overlooked or ignored. Clients see themselves as
  powerless, helpless, and ineffective.

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• Roles and relationships Eating disorders
  interfere with clients abilities to fulfill
  roles and have satisfying relationships. The
  client with anorexia may have failing grades in
  school, in sharp contrast to previous high-level
  performance. She withdraws from her peers,
  believing others will not understand. The client
  with bulimia is ashamed of bingeing and purging
  and hides it from others. The amount of time
  spent buying and consuming food can interfere
  with role performance at work and home.

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Application of the Nursing Process Eating
Disorders

• Physiologic and self-care considerations
  Clients health status is directly related to
  severity of self-starvation and purging behavior.
  Excessive exercise may lead to exhaustion. Many
  clients have trouble sleeping. Frequent vomiting
  causes sores in the mouth and dental problems.(
  need good oral hygiene) Thorough medical
  evaluation is essential.

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• Data Analysis
• Nursing diagnoses may include
• Imbalanced Nutrition Less Than/More Than Body
  Requirements
• Ineffective Coping
• Disturbed Body Image initial goal for treating
  the severely malnourished client
• Other diagnoses such as Deficient Fluid Volume,
  Constipation, Fatigue, and Activity Intolerance
  may be indicated.

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• Outcomes
• The client will
• Establish adequate nutritional eating patterns
• Eliminate use of compensatory behaviors such as
  laxatives, enemas, diuretics and excessive
  exercise
• Demonstrate non-food-related coping mechanisms
• Verbalize feelings of guilt, anger, anxiety, or
  excessive need for control
• Verbalize acceptance of body image with stable
  body weight

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• Intervention
• Establishing nutritional eating patterns
• Helping client identify emotions and develop
  coping strategies
• Dealing with body image issues
• Client and family education

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• Evaluation
• Evaluation may involve use of an assessment tool
  to measure progress.
• Body weight within 5 to 10 of normal
• No medical complications from starvation or
  purging
• Positive progress-the client identifies healthy
  ways of coping with anxiety

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Community-Based Care

• In addition to outpatient treatment, includes
  individual or group therapy and self-help groups
• Prevention and early detection are essential.
• Nurses play a key role in educating parents,
  children, and young people on issues of
  unrealistic ideal images in the media
  realistic ideas about body size and shape,
  resisting peer pressure to diet, improving
  self-esteem, coping strategies for dealing with
  emotions and life issues

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• Routine screening for eating disorders in high
  school and colleges and universities might prove
  useful.

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Self-Awareness Issues

• Feelings of frustration when client rejects help
• Being seen as the enemy if you must ensure the
  client eats
• Dealing with own issues about body image and
  dieting

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www.mentalhealthscreening.org/eat/NEDScolleges_04.
htm

• Eating disorder screen