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02.13 Eating Disorders (Anorexia Nervosa, Bulimia Nervosa)

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Overview

  1. Broad definition: very disturbed eating habits that profoundly affect one’s mental and physical health
  2. These affect men and women

Nursing Points

General

  1. Anorexia Nervosa
    1. Preoccupation with food
    2. Very distorted body image and low self esteem
    3. Deathly afraid of becoming overweight or obese
    4. May have actual phobias of various foods
    5. This can result in death
    6. They are typically an overachiever or perfectionist who exercises compulsively
  2. Bulimia Nervosa
    1. Consumes food in binge-episodes, followed by purging
  3. Binge-Eating Disorder
    1. Recurrent and persistent episodes of binge eating
    2. Absence of compensatory behaviors (such as purging or exercising).
    3. May be a response to many feelings (depression, guilt, loneliness, boredom, inadequacy)
      1. Eating eases pain of above feelings but doesn’t provide pleasure, happiness or euphoria

Assessment

  1. Anorexia Nervosa
    1. May completely refuse to eat and deny any appetite
    2. Physical assessment findings:
      1. Low body temp
      2. Bradycardia
      3. GI upset/issues
      4. Hypotension
      5. Electrolyte disturbances
        1. Common
        2. Life-threatening
      6. Hormonal imbalances
      7. Sleep disturbances
      8. Cyanosis
      9. Lanugo: fine, downy, soft, and white hair that grows on extremities.  
      10. Bone degeneration
      11. Amenorrhea: 3+ months of no menstrual period
  2. Bulimia Nervosa
    1. Similar to above listed for anorexia nervosa
    2. Labile moods
    3. Dental issues or esophageal varices related to vomiting
    4. Low libido
    5. Desires to control their eating
    6. Helplessness and hopelessness when eating/purging
    7. May use enemas, diuretics, laxatives, cathartics (meds that speed up defecation or induce purging), amphetamines (like Adderall or Ritalin to aid in weight loss)
  3. Compulsive Overeating
    1. Binge-like eating without purging
      1. Eating much more rapidly than normal
      2. Eating until feeling uncomfortably full
      3. Eating large amounts of food when not feeling physically hungry
      4. Eating alone because of being embarrassed by how much one is eating
      5. Feeling disgusted with oneself, depressed, or very guilty after overeating
    2. Helplessness and hopelessness related to eating habits
    3. Typically overweight or obese

Therapeutic Management

  1. Addressing physiological medical issues is the priority
    1. IE assessing and correcting electrolyte imbalances
    2. Must stabilize medically FIRST
  2. Ensure safety
    1. Assess self-harm and suicide risk
    2. Assess if there’s a plan
    3. Establish a contract PRN
  3. Establish rapport and trust
  4. Validate feelings, do not judge
  5. Promote exploring and establishing their own identity based in reality
  6. Attempt to explore any triggers or precipitants
    1. Calorie counts on menus
    2. Family members praising for weight loss
    3. Receiving criticism

Nursing Concepts

  1. Mood Affect
  2. Nutrition
  3. Coping

Patient Education

  1. Identify and avoid triggers
  2. Explain to them the processes in the inpatient environment
    1. Schedule
    2. How mealtimes work
    3. How intake and output is monitored
    4. How weigh ins work (same time, in same clothes, on same scale)
    5. Inform if any activity restrictions will be ordered
    6. Discuss medication plan
    7. Discuss therapy plan
    8. Discuss family / support system, concerns, and their level of involvement if applicable

Reference Links

Study Tools

Video Transcript

Okay, guys, in this lesson we’re going to talk about eating disorders.

Generally speaking, an eating disorder is any condition of abnormal or disordered eating habits that ultimately affect a person’s physical or mental health. Specifically, we’re going to cover Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder.

So let’s go through each one of these. Clients with Anorexia Nervosa typically eat very very little, if anything, and may only consume water. We often find that they are preoccupied with food, almost obsessed. They have a distorted body image and low self-esteem – they don’t see what we see when we look at them, they see themselves as being overweight or not good enough, even when the world can see they are actually skin and bones. They tend to be terrified of gaining weight and might even have phobias of certain foods. Physiologically we see a decrease in their metabolism and vitals, low heart rate, low blood pressure, low temperature, and then we see them develop something called lanugo. Lanugo is a fine layer of hair that develops all over the body. It’s almost like the body is trying desperately to insulate itself because they’ve lost that layer of fat and their temperature is so low. One of the most significant complications of Anorexia Nervosa is the electrolyte disturbances. You can imagine if you aren’t consuming any nutrients and you’re drinking only water, if that – your electrolytes will be significantly out of whack – this can be life threatening, especially because we know the effect that can have on our cardiac system. We will also see hormonal imbalances – many of these female clients will stop getting their period. And because of the hormone changes and electrolyte imbalances, we often see bone degeneration like osteoporosis. Keep in mind, this has more to do with altered thought processes than just physical symptoms – and it can affect males and females.

Bulimia Nervosa is a little different. They have the same issues with preoccupation with food, distorted body image, low self-esteem, fear of gaining weight and phobias of certain foods – they’ll even have some of the same physical findings in terms of a low heart rate and blood pressure – however, the big difference is that they actually do eat. Clients with bulimia nervosa go through cycles of binging and purging. So they’ll eat a TON of food, even to the point of being super uncomfortable…then they’ll purge – which means doing something to get it out of their system. Commonly this involves vomiting, but it could also be diuretics, laxatives, enemas, and even things to increase burning off the food like amphetamines or excessive exercise. There’s usually a lot of guilt associated with these binging and purging cycles and we see their moods tend to be very labile, which means they swing pretty easily. During these cycles, they tend to feel helpless to stop it and it creates a significant emotional cycle as well. They may also have some electrolyte abnormalities depending on the severity of their purging and how much gets absorbed, but the biggest complication is the erosion of their tooth enamel because of the stomach acid when they vomit so much. So we may start to see their teeth yellow and decay.

The last one we’ll review quickly is binge eating disorder, which used to be called compulsive overeating. They’ll have significant binging episodes without any purging – they’ll eat super fast, eat until they are uncomfortably full, or even eat when they aren’t hungry at all. They may even begin to eat meals alone or in their car because they’re ashamed to let people see how much they’re eating. I’ve even heard a patient talk about ordering an extra drink in the drive through so they wouldn’t think it was all for her. It is common for this binge eating to be a coping mechanism or triggered by emotions – good and bad ones. Again, these clients will feel helpless to stop. Of course, the most significant complication would be obesity and everything that comes along with it – but not everyone with binge eating disorder will be overweight and not everyone who is overweight has binge eating disorder – remember there is an underlying psychological pathology here that distorts their thinking about food.

So the #1 priority for any of these clients is to make sure they’re stable medically – fluid & electrolyte replacement, evaluate for arrhythmias, etc. If they aren’t medically stable, nothing else we do will matter. From there, we will be sure to do a self-harm assessment – remember their self-image is distorted. We want to establish rapport and trust because there is a lot of fear and anxiety involved. We help them identify their feelings and triggers as well. Also, we want to manage their expectations. We make sure they know the plan – how much and how often will we require them to eat? How often will they be weighed? How do weigh-ins work? Those are all things they need to know to be emotionally prepared – again the idea of eating or stepping on a scale may elicit serious anxiety. And of course we want to involve the support system if appropriate – but sometimes the family can be one of their triggers, so make sure you’re evaluating the big picture there.

Top priority nursing concepts for a client with an eating disorder – of course nutrition and making sure they’re getting the right amount. Fluid & Electrolyte balance to prevent any serious complications like arrhythmias. And coping, the emotions are deep and need to be addressed.

So remember that these conditions involve disordered, abnormal eating habits that affect the person’s health. The 3 types we talked about are Anorexia, Bulimia, and Binge-Eating Disorder. Remember to address their emotions, validate their feelings, identify triggers and establish a good rapport. We also want to manage their expectations, set small goals, talk about the routine, and involve the support system if it’s appropriate. And, as always, safety first – stabilize them medically first before addressing the underlying emotions, and always do a self-harm assessment.

That’s it for eating disorders, make sure you check out all of the resources attached to this lesson, including the patient story. Now, go out and be your best self today – Happy nursing!

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