Eating Disorders: Nursing Care and Client Characteristics

Eating Disorders: Nursing Care and Key Characteristics

Anorexia Nervosa (AN)

• Emotional and Behavioral Patterns:
  • Clients with anorexia nervosa typically avoid conflict and struggle to express negative emotions, particularly anger.
  • Key characteristics include perfectionism and an intense drive for thinness.
  • Behaviors often become highly organized around food-related activities, such as preparing food, meticulous calorie counting, and reading cookbooks.
• Psychosocial Factors and Comorbidity:
  • Body dissatisfaction is a central feature, strongly linked to low self-esteem.
  • Individuals with AN often experience feelings of ineffectiveness and inadequacy, which are significant risk factors for the disorder.
  • Depression is a common comorbid condition, and individuals with AN are at a heightened risk for suicide.
  • Paranoia and primary insomnia are generally not associated comorbid conditions.
  • Aggression is unlikely due to the difficulty in expressing anger.
• Family Dynamics:
  • Families of individuals with anorexia nervosa are frequently characterized by being overprotective, enmeshed, and having difficulty with conflict resolution and rigid boundaries.
  • A close, undifferentiated relationship with parents or siblings would not typically support an AN diagnosis, contrary to the often enmeshed dynamics observed.
• Nursing Care and Interventions:
  • Priority Assessment: For a teenager with AN and a Body Mass Index (BMI) of 15.2 ext{ kg/m}^2, the absolute priority is to assess for self-harm (e.g., asking, "Do you ever think about hurting yourself?"). Suicide and cardiopulmonary arrest are the leading causes of death for individuals with anorexia nervosa, who often use highly lethal means to attempt suicide.
  • Nursing Diagnosis: A behavioral plan for increasing weight is a core intervention for the nursing diagnosis of "Imbalanced nutrition: less than body requirements," as part of a refeeding program.
  • Therapeutic Relationship: A nonjudgmental, accepting approach is crucial. Nurses should avoid power struggles, especially concerning control issues. Responding to expressions of irritation (e.g., "You sound irritated; tell me about what is bothering you") acknowledges feelings, provides feedback, and conveys interest without being judgmental.
  • Discharge Planning: Education should focus on helping the client set realistic and attainable goals, recognizing their inherent perfectionist tendencies. Other vital topics include weight monitoring, resource identification, and the physiological effects of restrictive eating.
• Indicators for Hospitalization:
  • Heart rate near 40 ext{ beats/min}.
  • Blood pressure less than 80/50 ext{ mm Hg}.
  • Decreased serum potassium concentrations (hypokalemia).
  • Decreased serum magnesium concentrations (hypomagnesemia).
  • Hypophosphatemia.
  • Acute weight loss (less than 85% below ideal body weight).
  • Body temperature less than 36.1^ ext{o}C.
  • Severe depression and significant risk for suicide.
  • Poor motivation to recover.
  • Failure to comply with outpatient treatment.
  • Inadequate response to treatment at a lower level of care.

Bulimia Nervosa (BN)

• Behavioral Traits:
  • Clients with bulimia often exhibit impulsivity.
  • Binge eating episodes are frequently precipitated by feelings of being overwhelmed and powerless.
  • Underlying issues that need to be explored include the client’s ability to set boundaries, control impulsivity, and maintain quality relationships.
  • Panic, hyperactivity, and delusions are not typically associated with bulimia nervosa.
• Family Dynamics:
  • Families of individuals with bulimia nervosa are often described as chaotic, with few established rules and unclear boundaries.
  • An overly close or enmeshed relationship between the daughter and mother is common, where the mother may act as a confidante (e.g., "My mother is my confidante for everything").
  • Daughters may feel responsible for their mother’s happiness and emotional well-being (e.g., "My mother’s happiness depends on me"), and experience guilt about separation.
  • Blurred boundaries hinder the separation-individuation process.
  • A statement like "My mother and I are close but not joined at the hip" would be least likely associated with bulimia, as it suggests healthier boundaries.
• Medication Interventions:
  • Selective Serotonin Reuptake Inhibitors (SSRIs) are commonly prescribed.
  • Client Teaching for SSRIs: Nurses should emphasize reporting any significant weight changes, particularly decreased appetite and weight loss, during the first few weeks of administration.
  • It is crucial to monitor medication intake for possible purging after administration to ensure absorption.
  • Monitoring fluid intake and menstrual irregularities are not directly associated side effects of SSRIs for bulimia nervosa.
• Therapeutic Approaches:
  • The combination of Cognitive Behavioral Therapy (CBT) and pharmacologic interventions is considered most effective for producing an initial decrease in symptoms.
  • Other therapies, such as behavioral therapy, interpersonal therapy, and family therapy, may also be employed.
• Cognitive and Behavioral Interventions (Self-Monitoring):
  • Self-monitoring, often through keeping a diary, involves recording binges, purges, precipitating emotions, and environmental cues.
  • This technique helps identify emotional and environmental triggers for dysfunctional behaviors, allowing for the substitution and reinforcement of alternative, healthier responses.
• Specific Characteristics (Compared to AN):
  • Boundary problems are particularly specific to bulimia nervosa as a distinguishing characteristic.

Binge Eating Disorder (BED)

• Distinguishing Characteristics from Bulimia Nervosa:
  • Individuals with BED typically do not engage in purging behaviors or compensatory actions like overexercising after binges.
  • Most individuals with BED are currently or were historically obese, differing from other eating disorders.
  • They tend to exhibit less dietary restraint and have a higher body weight compared to those with bulimia nervosa.
  • Binge-eating episodes in BED are not necessarily shorter than those in bulimia nervosa.
  • Feelings of guilt do occur after binging in BED, similar to bulimia nervosa.

Common Characteristics of Anorexia Nervosa and Bulimia Nervosa

• Body dissatisfaction
• Feelings of powerlessness (a perceived lack of control)
• Obsessiveness
• Low self-esteem
• Perfectionism
• Cognitive distortions

Prevention and General Nursing Considerations

• Community Education (for teachers, parents, and adolescents):
  • Emphasize strategies to counteract the influence of media that encourages unrealistic body ideals, recognizing that both boys and girls are at risk for developing eating disorders.
  • Focus on improving self-esteem.
  • Highlight the significant influence of peer pressure on eating habits and weight concerns.
  • It is essential not to focus prevention efforts solely on female students, as males are also affected.
  • It is not appropriate to suggest allowing students to eat without attention or supervision to prevent inadvertently influencing eating patterns; rather, mindful and healthy eating discussions are beneficial.
  • Clarification should be made that peer pressure is typically problematic in children in the fifth and sixth grades and beyond.
• Guidance for Friends and Family Supporting Someone with an Eating Disorder:
  • Express concern directly and offer assistance.
  • Suggest seeking help from a professional.
  • If the individual refuses help, reach out to a trusted adult.
  • Avoid discussing the person's weight or the number of calories they are consuming.
  • Shift conversations to topics other than food.
  • Avoid power struggles, and do not attempt to force the person to eat.