Videbeck Outlines by jakebiles

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									                                     Chapter 18

                                 Eating Disorders


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.


ANOREXIA NERVOSA
Life-threatening eating disorder characterized by:
   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
   Steadfast refusal by client to acknowledge that the problem is severe or that there is
    even a problem at all
   85% of expected body weight or less
   Amenorrhea
   Total absorption in quest for thinness and weight loss
     Even though it is called anorexia, the client has hunger but doesn’t eat.
Preoccupation with food-related activities is common (ritualistic food behaviors).
Excessive exercise may occupy several hours a day.
    Two subgroups of anorexia: restricting (losing weight primarily through dieting or
fasting and excessive exercise) or binge eating and purging (consuming large amounts of
food, then purging by use of vomiting or misuse of laxatives, enemas, and diuretics).


ONSET AND CLINICAL COURSE
   Begins between 14 and 18 years of age
   Ability to control weight gives pleasure to client.
   Client may feel empty emotionally and be unable to identify or express feelings.
   As illness progresses, depression and labile moods are common.
   Client is socially isolated, mistrustful of others; may believe that others are trying to
    make him or 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.


BULIMIA NERVOSA
Characterized by recurrent episodes of binge eating, 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.
    Dentists may be the first to discover bulimia due to loss of tooth enamel, caries, and
chipped or ragged teeth.


ONSET AND CLINICAL COURSE
   Begins at 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.
   About 50% of clients recover completely, 20% continue to meet all criteria for
    bulimia, and 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%.


RELATED DISORDERS
With bulimia, major depression, substance abuse, and personality disorders are common,
and eating disorders are often linked to a past history of sexual abuse.
    Binge eating disorder—recurrent episodes of binge eating; no compensatory
behaviors; feelings of guilt, shame, and disgust; marked psychological distress
    Night eating syndrome—morning anorexia; night hyperphagia; nighttime awakening
to consume snacks; associated with life stress, low self-esteem, anxiety, and depression


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


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 whether these changes cause the
    disorders or are a result of eating disorders.


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


DEVELOPMENTAL FACTORS: BULIMIA NERVOSA
   Separation-individuation difficulties (excessive anxiety over growing up, leaving
    home, and becoming independent)
   Body image dissatisfaction
FAMILY INFLUENCES
   Families of anorexic clients are often rigid and overprotective; avoid interpersonal
    conflict by ignoring it; and stifle the client’s 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, and to maintain
    harmony.


SOCIOCULTURAL FACTORS
   Image of ideal woman as thin and perfectly toned in United States and westernized
    countries
   Books, magazines, and TV promote this thin image, as do numerous ―beauty‖
    industries (weight loss, plastic surgery, body building, etc.).
   Being overweight is often equated with being lazy, lacking will power, and being
    ―bad‖ or unsuccessful.
   Pressure from peers, parents, and coaches may also contribute to the development of
    eating disorders.


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.


TREATMENT: ANOREXIA NERVOSA
   Clients are very treatment-resistant, due to denial of problems.
   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, and correction of electrolyte imbalances.
   Severely malnourished clients may require total parenteral nutrition or tube feedings;
    nutritionally balanced meals and snacks are introduced, gradually increasing calories.
   Generally, client is supervised during meals to ensure eating and after meals while
    using the bathroom to prevent purging.
   Weight gain and adequate intake are often criteria for judging treatment effectiveness.
   Many drugs have been studied and tried, but few show success. Amitriptyline (Elavil)
    and cyproheptadine (Periactin) can promote weight gain. Fluoxetine (Prozac) may
    help prevent relapse but only when weight has been gained, because it can cause
    weight loss.
   Family therapy is beneficial if client is under 18 and living at home to provide role
    clarification, negotiate conflicts, and improve communication.
   Individual therapy is effective for clients not as closely involved in their nuclear
    families.


TREATMENT: BULIMIA NERVOSA
   Most clients are treated on outpatient basis; inpatient basis is required only if
    bingeing and purging behavior is out of control or medical status is compromised.
   Cognitive-behavioral therapy has been effective; it is designed to change client’s
    thinking and actions about food, eating, weight, body image, and self-concept.
   Medications are marginally effective; antidepressants do improve mood, reduce
    preoccupation with shape and weight, and reduce bingeing and purging behaviors.
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, causing no
    trouble, and dependable before onset of anorexia. Clients with bulimia are eager to
    please and conform and avoid conflict, but may have a history of impulsive behavior.
   General appearance and motor behavior: Clients with anorexia are slow, lethargic,
    even emaciated; are slow to respond to questions; have difficulty deciding what to
    say; are reluctant to answer questions fully; often wear baggy clothes or layers to hide
    weight or keep warm; have limited eye contact; and are unwilling to discuss problems
    or enter treatment. Clients with bulimia generally have a normal appearance and are
    open and talkative.
   Mood and affect: Moods are labile, corresponding to eating or dieting behavior.
    Clients with anorexia may look sad and anxious, and they 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.
   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, and food-related issues. Body image disturbance can be almost delusional.
    Clients with anorexia may have paranoid ideas about their families and health care
    professionals being the ―enemy,‖ trying to make them fat.
   Sensorium and intellectual processes: Clients are generally alert, oriented, intact; the
    exception is the severely malnourished client with anorexia, who may have mild
    confusion, slowed mental processes, and difficulty with concentration and attention.
   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.
   Self-concept: Low self-esteem is prominent in clients with eating disorders; they see
    themselves only in terms of their ability to control food intake and weight, 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.
   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. He or she withdraws
    from 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.
   Physiologic and self-care considerations: Client’s 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. Thorough medical evaluation is essential.


DATA ANALYSIS
Nursing diagnoses may include:
       Imbalanced Nutrition: Less Than/More Than Body Requirements
       Ineffective Coping
       Disturbed Body Image
Other diagnoses, such as Deficient Fluid Volume, Constipation, Fatigue, and Activity
Intolerance, may be indicated.


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


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


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


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, and coping strategies for
    dealing with emotions and life issues.
   Routine screening for eating disorders in high school and at colleges and universities
    might prove useful.


MENTAL HEALTH PROMOTION
   Decrease focus on ―thin-is-beautiful‖ ideal.
   Emphasize healthy eating and exercise, not body size.
SELF-AWARENESS ISSUES
   Feelings of frustration when client rejects help
   Being seen as ―the enemy‖ if you must ensure that the client eats
   Dealing with own issues about body image and dieting

								
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