Eating Disorders - Comprehensive Notes

Eating Disorders

Objectives

Define eating disorders
Identify different types of eating disorders
Identify different forms of eating disorders
Apply nursing assessment and history taking of clients with eating disorders.
Apply nursing care plans for clients with eating disorders

DSM-V Classifications

Neurodevelopmental disorders
Schizophrenia spectrum & other psychotic disorders
Bipolar & related disorders
Depressive disorders
Anxiety disorders
Obsessive-compulsive & related disorders
Trauma- & stressor-related disorders
Dissociative disorders
Somatic symptom & related disorders
Feeding & eating disorders
Sleep–wake disorders
Sexual dysfunctions
Gender dysphoria
Disruptive, impulse-control, & conduct disorders
Substance-related & addictive disorders
Neurocognitive disorders
Paraphilic disorders
Personality disorders

Pica

Diagnostic Criteria:

A. Persistent eating of nonnutritive, nonfood substances over a period of at least 1 month.
B. The eating of nonnutritive, nonfood substances is inappropriate to the developmental level of the individual.
C. The eating behavior is not part of a culturally supported or socially normative practice.
D. If the eating behavior occurs in the context of another mental disorder (e.g., intellectual Disability [intellectual developmental disorder], autism spectrum disorder, schizophrenia) or medical condition (including pregnancy), it is sufficiently severe to warrant additional clinical attention.

What Causes Pica?

Deficiency in iron, zinc, or another nutrient may lead to pica.
The body will try to replace the low levels of nutrients through “food”.
Mental health conditions, such as obsessive- compulsive disorder (OCD) and schizophrenia can develop pica to cope.
People with eating disorders such as Anorexia Nervosa may attempt to ease hunger by eating nonfood substances to get a feeling of fullness.
Cultural factors — in families, religions, or groups in which eating nonfood substances is a learned practice.
Parental neglect, lack of supervision, or food deprivation — often seen in children living in poverty.
Developmental problems, such as mental retardation, autism, other developmental disabilities, or brain abnormalities.
Pregnancy due to the increase in iron demand by the developing baby.

Diagnostic Markers

Abdominal flat plate radiography, ultrasound, and other scanning methods may reveal obstructions related to pica.
Blood tests and other laboratory tests can be used to ascertain levels of poisoning or the nature of infection.

Treatment for Pica

Counseling or behavior
This may include Iron supplementation for Anemia
If occurring in child, pay close attention

Rumination Disorder

A client brings back up and re-chews partially digested food that has already been swallowed.

The repeated regurgitation is not due to a medication condition (e.g., gastrointestinal condition).
The behavior does not occur exclusively in the course of anorexia nervosa, bulimia nervosa, BED, or avoidant/restrictive food intake disorder.
If occurring in the presence of another mental disorder (e.g., intellectual developmental disorder), it is severe enough to warrant independent clinical attention.

Avoidant/Restrictive Food Intake Disorder

Anorexia Nervosa

Is a life-threatening eating disorder characterized by the client’s 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, and steadfast inability or refusal to acknowledge the seriousness of the problem or even that one exists (APA, 2000).

Symptoms of Anorexia Nervosa

Fear of gaining weight or becoming fat even when severely underweight
Body image disturbance
Amenorrhea
Depressive symptoms such as depressed mood, social withdrawal, irritability, and insomnia
Preoccupation with thoughts of food
Feelings of ineffectiveness Inflexible thinking Strong need to control environment
Limited spontaneity and overly restrained emotional expression
Complaints of constipation and abdominal pain
Cold intolerance
Lethargy
Emaciation
Hypotension, hypothermia, and bradycardia
Hypertrophy of salivary glands
Elevated BUN (blood urea nitrogen)
Electrolyte imbalances Leukopenia and mild anemia
Elevated liver function studies

Subgroups of Anorexia Nervosa

Binge eating means consuming a large amount of food (far greater than most people eat at one time) in a discrete period of usually 2 hours or less.
Purging means the compensatory behaviors designed to eliminate food by means of self -induced vomiting or misuse of laxatives, enemas, and diuretics.

Bulimia Nervosa

Often simply called bulimia, is an eating disorder characterized by recurrent episodes (at least twice a week for 3 months) of binge eating followed by inappropriate compensatory behaviors to avoid weight gain such as purging (self-induced vomiting or use of laxatives, diuretics, enemas, or emetics), fasting, or excessively exercising (APA, 2000).

Symptoms of Bulimia Nervosa

Recurrent episodes of binge eating
Compensatory behavior such as self- induced vomiting, misuse of laxatives, diuretics, enema or other medications, or excessive exercise
Self-evaluation overly influenced by body shape and weight Usually within normal weight range, possible underweight or overweight
Restriction of total calorie consumption between binges, selecting low-calorie foods while avoiding foods perceived to be fattening or likely to trigger a binge
Depressive and anxiety symptoms
Possible substance use involving alcohol or stimulants
Loss of dental enamel Chipped, ragged, or moth-eaten appearance of teeth Increased dental caries
Menstrual irregularities
Dependence on laxatives Esophageal tears Fluid and electrolyte abnormalities
Metabolic alkalosis (from vomiting) or metabolic acidosis (from diarrhea) Mildly elevated serum amylase levels

Treatment Modalities

Behavior Modification:
- Issues of control are central to the etiology of these disorders.
- For the program to be successful, the client must perceive that he or she is in control of the treatment.
- Successes have been observed when the client:
  - Is allowed to contract for privileges based on weight gain
  - Has input into the care plan
  - Clearly sees what the treatment choices are
The client has control over:
- Eating
- Amount of exercise pursued
- Whether to induce vomiting
Staff and client agree about:
- Goals
- System of rewards
The client has a choice whether to:
- Abide by the contract
- Gain weight
- Earn the desired privilege

Psychopharmacology

For anorexia nervosa
- Fluoxetine (Prozac)
- Clomipramine (Anafranil)
- Cyproheptadine (Periactin)
- Chlorpromazine (Thorazine)
- Olanzapine (Zyprexa)
For bulimia nervosa
- Fluoxetine (Prozac)
- Imipramine (Tofranil)
- Desipramine (Norpramine)
- Amitriptyline (Elavil)
- Nortriptyline (Aventyl)
- Phenelzine (Nardil)
For binge-eating disorder with obesity:
- Topiramate (Topamax)
For obesity:
- Fluoxetine (Prozac)
- Sibutramine (Meridia)
- Various anorexiants (CNS stimulants)

Nursing Care Plan for Eating Disorders

Assessment:

Identifying data
Reliability of informant/s
Present complaints and problems
History of present illness
Past history of illness
Personal history
Family history (genogram)
Description of premorbid personality
Functional history
Social history

Nursing Assessment

Include at least three to five subjective and/or objective data that lead to the nursing diagnosis)
Subjective data: (What did patient or family or police say- use direct quotations)?
Objective Data: (what did you see, hear, smell, feel – first finding) and measure?
Client lab values, test results:
Medications:
Doctor’s diagnosis:
From this data, the reader must be able to tell that he/she really has a problem

Nursing Diagnosis

Risk for Imbalanced Nutrition: less than body requirements
Low self concept
Self-care deficit
Impaired communication
Sleep disturbance
Ineffective coping related to inability to meet basic needs.
Disturbed body image related to being excessively underweight.

Nursing Care Planning and Goals

The client will establish adequate nutritional eating patterns.
The client will eliminate use of compensatory behaviors such as excessive exercise and use of laxatives and diuretics.
The client will demonstrate coping mechanisms not related to food.
The client will verbalize feelings of guilt, anger, anxiety, or an excessive need for control.
The client will verbalize acceptance of body image with stable body weight.

Nursing Interventions

Establishing nutritional eating patterns. When clients can eat, a diet of 1200 to 1500 calories per day is ordered, with gradual increases in calories until clients are ingesting adequate amounts for height, activity level, and growth needs; the nurse is responsible for monitoring meals and snacks and often initially will sit with a client during eating at a table away from other clients; after each meal or snack, clients may be required to remain in view of staff for 1 to 2 hours to ensure that they do not empty the stomach by vomiting.
Identifying emotions and developing coping strategies. The nurse can help clients begin to recognize emotions such as anxiety or guilt by asking them to describe how they are feeling and allowing adequate time for response.
Dealing with body image issues. The nurse can help clients to accept a more normal body image; this may involve clients agreeing to weigh more than they would like, to be healthy, and to stay out of the hospital; helping clients to identify areas of personal strength that are not food related broaden’s client’s perceptions of themselves.

Evaluation

Goals are met as evidenced by:
- The client was able to establish adequate nutritional eating patterns.
- The client was able to eliminate use of compensatory behaviors such as excessive exercise and use of laxatives and diuretics.
- The client was able to demonstrate coping mechanisms not related to food.
- The client was able to verbalize feelings of guilt, anger, anxiety, or an excessive need for control.
- The client was able to verbalize acceptance of body image with stable body weight.