Anorexia nervosa is an illness of starvation, brought on by severe disturbance of body image and a morbid fear of obesity.
Bulimia nervosa is an eating disorder (binge-purge syndrome) characterized by extreme overeating followed by self-induced vomiting. It may include abuse of laxatives and diuretics.
Although these disorders primarily affect women, approximately 5%–10% of those afflicted are men, and both disorders can be present in the same individual.
CARE SETTING
Acute care is provided through inpatient stay on medical or behavioral unit and for correction of severe nutritional deficits/electrolyte imbalances or initial psychiatric stabilization. Long-term care is provided in outpatient/day treatment program (partial hospitalization) or in the community.
RELATED CONCERNS
Dysrhythmias
Fluid and electrolyte imbalances
Metabolic alkalosis (primary base bicarbonate excess)
Total nutritional support: parenteral/enteral feeding
Psychosocial aspects of care
Patient Assessment Database
ACTIVITY/REST
May report: Disturbed sleep patterns, e.g., early morning insomnia; fatigue
Feeling “hyper” and/or anxious
Increased activity/avid exerciser, participation in high-energy sports
Employment in positions/professions that stress/require weight control (e.g., athletics such as gymnasts, swimmers, jockeys; modeling; flight attendants)
May exhibit: Periods of hyperactivity, constant vigorous exercising
CIRCULATION
May report: Feeling cold even when room is warm
May exhibit: Low blood pressure (BP)
Tachycardia, bradycardia, dysrhythmias
EGO INTEGRITY
May report: Powerlessness/helplessness lack of control over eating (e.g., cannot stop eating/control what or how much is eaten [bulimia]); feeling disgusted with self, depressed or very guilty because of overeating Distorted (unrealistic) body image, reports self as fat regardless of weight (denial), and sees thin body as fat; persistent overconcern with body shape and weight (fears gaining weight)
High self-expectations
Stress factors, e.g., family move/divorce, onset of puberty
Suppression of anger
May exhibit: Emotional states of depression, withdrawal, anger, anxiety, pessimistic outlook
ELIMINATION
May report: Diarrhea/constipation
Vague abdominal pain and distress, bloating
Laxative/diuretic abuse
FOOD/FLUID
May report: Constant hunger or denial of hunger; normal or exaggerated appetite that rarely vanishes until late in the disorder (anorexia)
Intense fear of gaining weight (females); may have prior history of being overweight (particularly males)
Preoccupation with food, e.g., calorie counting, gourmet cooking
An unrealistic pleasure in weight loss, while denying self pleasure in other areas
Refusal to maintain body weight over minimal norm for age/height (anorexia)
Recurrent episodes of binge eating; a feeling of lack of control over behavior during eating binges; a minimum average of two binge-eating episodes a week for at least 3
mo
Regularly engages in self-induced vomiting (binge-purge syndrome bulimia) either
independently or as a complication of anorexia; or strict dieting or fasting
May exhibit: Weight loss/maintenance of body weight 15% or more below that expected (anorexia), or
weight may be normal or slightly above or below normal (bulimia)
No medical illness evident to account for weight loss
Cachectic appearance; skin may be dry, yellowish/pale, with poor tugor (anorexia)
Preoccupation with food (e.g., calorie counting, hiding food, cutting food into small pieces,
rearranging food on plate)
Irrational thinking about eating, food, and weight
Peripheral edema
Swollen salivary glands; sore, inflamed buccal cavity; continuous sore throat (bulimia)
Vomiting, bloody vomitus (may indicate esophageal tearing [Mallory-Weiss syndrome])
Excessive gum chewing
HYGIENE
May exhibit: Increased hair growth on body (lanugo), hair loss (axillary/pubic), hair is dull/not shiny
Brittle nails
Signs of erosion of tooth enamel, gums in poor condition, ulcerations of mucosa
NEUROSENSORY
May exhibit: Appropriate affect (except in regard to body and eating), or depressive affect
Mental changes: Apathy, confusion, memory impairment (brought on by malnutrition/ starvation)
Hysterical or obsessive personality style; no other psychiatric illness or evidence of a
psychiatric thought disorder present (although a significant number may show evidence of an affective disorder)
PAIN/DISCOMFORT
May report: Headaches, sore throat/mouth, generalized vague complaints
SAFETY
May exhibit: Body temperature below normal
Recurrent infectious processes (indicative of depressed immune system)
Eczema/other skin problems, abrasions/calluses may be noted on back of hands from sticking finger down throat to induce vomiting
SEXUALITY
May report: Absence of at least three consecutive menstrual cycles (decreased levels of estrogen in response to malnutrition)
Promiscuity or denial/loss of sexual interest
History of sexual abuse
Homosexual/bisexual orientation (higher percentage in male patients than in general population)
May exhibit: Breast atrophy, amenorrhea
SOCIAL INTERACTION
May report: Middle-class or upper-class family background
History of being a quiet, cooperative child
Problems of control issues in relationships, difficult communications with others/authority
figures, poor communication within family of origin
Engagement in power struggles
An emotional crisis of some sort, such as the onset of puberty or a family move
Altered relationships or problems with relationships (not married/divorced), withdrawal from friends/social contacts
Abusive family relationships
Sense of helplessness
History of legal difficulties (e.g., shoplifting)
May exhibit: Passive father/dominant mother, family members closely fused, togetherness prized, personal boundaries not respected
TEACHING/LEARNING
May report: Family history of higher than normal incidence of depression, other family members with eating disorders (genetic predisposition)
Onset of the illness usually between the ages of 10 and 22
Health beliefs/practice (e.g., certain foods have “too many” calories, use of “health” foods)
High academic achievement
Substance abuse
Discharge plan
DRG projected mean length of inpatient stay: 6.4 days
Assistance with maintenance of treatment plan
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Complete blood count (CBC) with differential: Determines presence of anemia, leukopenia, lymphocytosis. Platelets show significantly less than normal activity by the enzyme monoamine oxidase (thought to be a marker for depression).
Electrolytes: Imbalances may include decreased potassium, sodium, chloride, and magnesium.
Endocrine studies:
Thyroid function: Thyroxine (T4) levels usually normal; however, circulating triiodothyronine (T3) levels may be low.
Pituitary function: Thyroid-stimulating hormone (TSH) response to thyrotropin-releasing hormone (TRH) is abnormal in anorexia nervosa. Propranolol-glucagon stimulation test studies the response of human growth hormone (GH), which is depressed in anorexia. Gonadotropic hypofunction is noted.
Cortisol metabolism: May be elevated.
Dexamethasone suppression test (DST): Evaluates hypothalamic-pituitary function. Dexamethasone resistance indicates cortisol suppression, suggesting malnutrition and/or depression.
Luteinizing hormone (LH) secretions test: Pattern often resembles those of prepubertal girls.
Estrogen: Decreased.
MHP 6 levels: Decreased, suggestive of malnutrition/depression.
Serum glucose and basal metabolic rate (BMR): May be low.
Other chemistries: AST elevated. Hypercarotenemia, hypoproteinemia, hypocholesterolemia.
Urinalysis and renal function: Blood urea nitrogen (BUN) may be elevated; ketones present reflecting starvation; decreased urinary 17-ketosteroids; increased specific gravity/dehydration.
Electrocardiogram (ECG): Abnormal tracing with low voltage, T-wave inversion, dysrhythmias.
NURSING PRIORITIES
1. Reestablish adequate/appropriate nutritional intake.
2. Correct fluid and electrolyte imbalance.
3. Assist patient to develop realistic body image/improve self-esteem.
4. Provide support/involve significant other (SO), if available, in treatment program.
5. Coordinate total treatment program with other disciplines.
6. Provide information about disease, prognosis, and treatment to patient/SO.
DISCHARGE GOALS
1. Adequate nutrition and fluid intake maintained.
2. Maladaptive coping behaviors and stressors that precipitate anxiety recognized.
3. Adaptive coping strategies and techniques for anxiety reduction and self-control implemented.
4. Self-esteem increased.
5. Disease process, prognosis, and treatment regimen understood.
6. Plan in place to meet needs after discharge.
Bulimia nervosa is an eating disorder (binge-purge syndrome) characterized by extreme overeating followed by self-induced vomiting. It may include abuse of laxatives and diuretics.
Although these disorders primarily affect women, approximately 5%–10% of those afflicted are men, and both disorders can be present in the same individual.
CARE SETTING
Acute care is provided through inpatient stay on medical or behavioral unit and for correction of severe nutritional deficits/electrolyte imbalances or initial psychiatric stabilization. Long-term care is provided in outpatient/day treatment program (partial hospitalization) or in the community.
RELATED CONCERNS
Dysrhythmias
Fluid and electrolyte imbalances
Metabolic alkalosis (primary base bicarbonate excess)
Total nutritional support: parenteral/enteral feeding
Psychosocial aspects of care
Patient Assessment Database
ACTIVITY/REST
May report: Disturbed sleep patterns, e.g., early morning insomnia; fatigue
Feeling “hyper” and/or anxious
Increased activity/avid exerciser, participation in high-energy sports
Employment in positions/professions that stress/require weight control (e.g., athletics such as gymnasts, swimmers, jockeys; modeling; flight attendants)
May exhibit: Periods of hyperactivity, constant vigorous exercising
CIRCULATION
May report: Feeling cold even when room is warm
May exhibit: Low blood pressure (BP)
Tachycardia, bradycardia, dysrhythmias
EGO INTEGRITY
May report: Powerlessness/helplessness lack of control over eating (e.g., cannot stop eating/control what or how much is eaten [bulimia]); feeling disgusted with self, depressed or very guilty because of overeating Distorted (unrealistic) body image, reports self as fat regardless of weight (denial), and sees thin body as fat; persistent overconcern with body shape and weight (fears gaining weight)
High self-expectations
Stress factors, e.g., family move/divorce, onset of puberty
Suppression of anger
May exhibit: Emotional states of depression, withdrawal, anger, anxiety, pessimistic outlook
ELIMINATION
May report: Diarrhea/constipation
Vague abdominal pain and distress, bloating
Laxative/diuretic abuse
FOOD/FLUID
May report: Constant hunger or denial of hunger; normal or exaggerated appetite that rarely vanishes until late in the disorder (anorexia)
Intense fear of gaining weight (females); may have prior history of being overweight (particularly males)
Preoccupation with food, e.g., calorie counting, gourmet cooking
An unrealistic pleasure in weight loss, while denying self pleasure in other areas
Refusal to maintain body weight over minimal norm for age/height (anorexia)
Recurrent episodes of binge eating; a feeling of lack of control over behavior during eating binges; a minimum average of two binge-eating episodes a week for at least 3
mo
Regularly engages in self-induced vomiting (binge-purge syndrome bulimia) either
independently or as a complication of anorexia; or strict dieting or fasting
May exhibit: Weight loss/maintenance of body weight 15% or more below that expected (anorexia), or
weight may be normal or slightly above or below normal (bulimia)
No medical illness evident to account for weight loss
Cachectic appearance; skin may be dry, yellowish/pale, with poor tugor (anorexia)
Preoccupation with food (e.g., calorie counting, hiding food, cutting food into small pieces,
rearranging food on plate)
Irrational thinking about eating, food, and weight
Peripheral edema
Swollen salivary glands; sore, inflamed buccal cavity; continuous sore throat (bulimia)
Vomiting, bloody vomitus (may indicate esophageal tearing [Mallory-Weiss syndrome])
Excessive gum chewing
HYGIENE
May exhibit: Increased hair growth on body (lanugo), hair loss (axillary/pubic), hair is dull/not shiny
Brittle nails
Signs of erosion of tooth enamel, gums in poor condition, ulcerations of mucosa
NEUROSENSORY
May exhibit: Appropriate affect (except in regard to body and eating), or depressive affect
Mental changes: Apathy, confusion, memory impairment (brought on by malnutrition/ starvation)
Hysterical or obsessive personality style; no other psychiatric illness or evidence of a
psychiatric thought disorder present (although a significant number may show evidence of an affective disorder)
PAIN/DISCOMFORT
May report: Headaches, sore throat/mouth, generalized vague complaints
SAFETY
May exhibit: Body temperature below normal
Recurrent infectious processes (indicative of depressed immune system)
Eczema/other skin problems, abrasions/calluses may be noted on back of hands from sticking finger down throat to induce vomiting
SEXUALITY
May report: Absence of at least three consecutive menstrual cycles (decreased levels of estrogen in response to malnutrition)
Promiscuity or denial/loss of sexual interest
History of sexual abuse
Homosexual/bisexual orientation (higher percentage in male patients than in general population)
May exhibit: Breast atrophy, amenorrhea
SOCIAL INTERACTION
May report: Middle-class or upper-class family background
History of being a quiet, cooperative child
Problems of control issues in relationships, difficult communications with others/authority
figures, poor communication within family of origin
Engagement in power struggles
An emotional crisis of some sort, such as the onset of puberty or a family move
Altered relationships or problems with relationships (not married/divorced), withdrawal from friends/social contacts
Abusive family relationships
Sense of helplessness
History of legal difficulties (e.g., shoplifting)
May exhibit: Passive father/dominant mother, family members closely fused, togetherness prized, personal boundaries not respected
TEACHING/LEARNING
May report: Family history of higher than normal incidence of depression, other family members with eating disorders (genetic predisposition)
Onset of the illness usually between the ages of 10 and 22
Health beliefs/practice (e.g., certain foods have “too many” calories, use of “health” foods)
High academic achievement
Substance abuse
Discharge plan
DRG projected mean length of inpatient stay: 6.4 days
Assistance with maintenance of treatment plan
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Complete blood count (CBC) with differential: Determines presence of anemia, leukopenia, lymphocytosis. Platelets show significantly less than normal activity by the enzyme monoamine oxidase (thought to be a marker for depression).
Electrolytes: Imbalances may include decreased potassium, sodium, chloride, and magnesium.
Endocrine studies:
Thyroid function: Thyroxine (T4) levels usually normal; however, circulating triiodothyronine (T3) levels may be low.
Pituitary function: Thyroid-stimulating hormone (TSH) response to thyrotropin-releasing hormone (TRH) is abnormal in anorexia nervosa. Propranolol-glucagon stimulation test studies the response of human growth hormone (GH), which is depressed in anorexia. Gonadotropic hypofunction is noted.
Cortisol metabolism: May be elevated.
Dexamethasone suppression test (DST): Evaluates hypothalamic-pituitary function. Dexamethasone resistance indicates cortisol suppression, suggesting malnutrition and/or depression.
Luteinizing hormone (LH) secretions test: Pattern often resembles those of prepubertal girls.
Estrogen: Decreased.
MHP 6 levels: Decreased, suggestive of malnutrition/depression.
Serum glucose and basal metabolic rate (BMR): May be low.
Other chemistries: AST elevated. Hypercarotenemia, hypoproteinemia, hypocholesterolemia.
Urinalysis and renal function: Blood urea nitrogen (BUN) may be elevated; ketones present reflecting starvation; decreased urinary 17-ketosteroids; increased specific gravity/dehydration.
Electrocardiogram (ECG): Abnormal tracing with low voltage, T-wave inversion, dysrhythmias.
NURSING PRIORITIES
1. Reestablish adequate/appropriate nutritional intake.
2. Correct fluid and electrolyte imbalance.
3. Assist patient to develop realistic body image/improve self-esteem.
4. Provide support/involve significant other (SO), if available, in treatment program.
5. Coordinate total treatment program with other disciplines.
6. Provide information about disease, prognosis, and treatment to patient/SO.
DISCHARGE GOALS
1. Adequate nutrition and fluid intake maintained.
2. Maladaptive coping behaviors and stressors that precipitate anxiety recognized.
3. Adaptive coping strategies and techniques for anxiety reduction and self-control implemented.
4. Self-esteem increased.
5. Disease process, prognosis, and treatment regimen understood.
6. Plan in place to meet needs after discharge.
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