NCP Bulimia

Bulimia

Eating Disorder; Bulimia Nervosa; Normal Weight Bulimia

Bulimia is a syndrome characterized by episodes of binge eating. Binge eating is the rapid consumption of massive quantities of food within a limited time. Intense feelings of guilt and shame follow binge eating. These negative feelings trigger purging and dieting as attempts to relieve negative feelings and restore a sense of control. The term normal weight bulimia refers to those individuals whose weight remains in the normal range or above; the term bulimia nervosa refers to the subgroup who have experienced a previous episode but who no longer meet the criteria for anorexia nervosa. Unlike anorexia nervosa in which the primary symptom is starvation, in bulimia the primary symptom is bingeing followed by purging. This disease commonly affects adolescent females and young adults. Bulimia onset rarely is diagnosed after 25 years of age. Patients with bulimia often have other psychiatric disorders, including mood disorders and substance disorders that complicate treatment. When purging has not resulted in medical complications, bulimia may be managed in clinics or in day treatment programs.

Nursing Diagnosis

Imbalanced Nutrition: More Than Body Requirements

Common Related Factor	Defining Characteristics
Intake exceeds nutritional and caloric needs (wide fluctuations in weight within a discrete period of time in response to binging and purging)	Unhealthy eating pattern Episodic binge eating Eating in response to cues (i.e., conflict, social situation) Eating in response to emotions (i.e., anxiety, depression) Wide weight fluctuations within a short period of time
Common Expected Outcomes Patient is able to stabilize weight without bingeing and purging. Patient is able to stabilize eating behavior.	NOC Outcome Nutritional Status: Nutrient Intake NIC Interventions Eating Disorders Management; Nutritional Counseling

Ongoing Assessment

Actions/Interventions	Rationale
Obtain accurate history of weight changes.	Many patients with bulimia have histories of struggles with the balance of food consumed and nutritional needs.

Obtain accurate food history, including daily intake and number and types of weight loss diets used in the past.	Many patients have experienced unsuccessful attempts at severely restrictive dieting followed by secret consumption of large amounts of food.
Determine type and frequency of binge-purge behavior with associated feeling states.	Purging (vomiting, laxatives, diuretics, or exercise) may result in weight fluctuations greater than 10 pounds within 1 to 2 days. It is critical that the therapist obtain a clear picture of maladaptive behaviors so that therapeutic measures can be integrated into the individual treatment plan.
Weigh the patient routinely, without comment and using a matter-of-fact manner, no more than twice per week.	Weighing too often reinforces the patient’s preoccupation with weight. A standardized method of weighing the patient will improve the value of recording patient weights.

Therapeutic Interventions

Actions/Interventions	Rationale
Devise a food plan that specifies total daily calories (³1600 kcal/day) and includes all food groups, with three meals plus a light evening snack.	Adequate intake alleviates effects of starvation (e.g., sleeplessness or waking during the night) and decreases preoccupation with thoughts of food and relapse.
Provide accurate information about nutrition, metabolic functioning, and role of deprivation in triggering binges.	Knowledge serves to correct faulty ideas.
Provide healthy interactions immediately before, during, and after meals.	Healthy social interactions encourage normal eating and interfere with the potential impulse to vomit. Interactions can be provided by a friend or family member or by staff if the patient is hospitalized.
Encourage healthy physical activity. Discourage excessive exercise as a method of coping with binge eating.	Balanced activity promotes feelings of well-being and self-control.
Continually assess potential for purging behavior, particularly in response to weight changes. If bingeing is suspected, address it directly. Use observation and supervision only as necessary.	Early assessment helps interrupt compulsive bingeing and purging behaviors.

Nursing Diagnosis

Ineffective Coping

Common Related Factors	Defining Characteristics
Deficit in self-awareness (i.e., difficulty identifying, articulating, and modulating internal states such as hunger, satiety, and their effects) Unrealistic self-perceptions	Difficulty coping and problem solving Potentially destructive behavior toward self Reliance on ineffective, immature defense mechanisms Overeating habits
Common Expected Outcomes Patient describes or initiates healthy coping strategies. Patient decreases or stops bingeing and purging behaviors.	NOC Outcomes Coping; Social Support NIC Interventions Coping Enhancement; Self-Awareness Enhancement; Therapy Group

Ongoing Assessment

Actions/Interventions	Rationale
Assess the patient’s ability to recognize and name mood states.	Binge or purge behaviors may be activated to alleviate negative mood states. The patient proceeds from activation of mood state to the immediate need to stop unpleasant feelings without consideration.
Obtain detailed history of type, duration, and intensity of all impulsive behaviors.	Multiple impulse disorders (e.g., alcohol or drug abuse, sexual promiscuity, stealing, and self-harm) can develop in response to psychosocial stressors (e.g., depression, stress, and anxiety).
Teach the patient to keep a health journal; include before, during, and after binge or purge activities.	Self-monitoring helps patients begin to associate their mood with their binge-purge behaviors.
Provide accurate information on weight loss and the role of deprivation and overeating in triggering binge eating.	This information helps the person develop a more realistic understanding of their food choices and weight management.
Help the patient assess family perceptions about food and weight and the family influence on individual struggles with food.	This helps the patient see how struggles with food are culturally and biologically influenced. If eating was used as a method of soothing tensions or rewarding positive behavior in childhood, then the patient may have continued this behavior as an adult.
Help the patient identify and use alternatives to impulsive behavior (e.g., talking to someone, going for a walk).	By teaching techniques of impulse delay, impulses can be lessened in strength; use of alternative strategies can increase feelings of mastery.
Encourage the patient’s disclosure of negative feelings without judgment.	Nonjudgmental interaction aids in defusing excessive feelings of guilt, shame, and helplessness.
Assess for cognitive distortions:
·     Magical thinking	This is thinking that one can control events or people by wishing or hoping for something.
·     Dichotomous thinking	This is all-or-nothing thinking.
·     Control fallacy	This is thinking that one really does have the ability to control events and persons by superimposing one’s wishes on others.
·     Externalizing	This is viewing oneself as externally controlled.
·     Magnification	This is exaggeration of intensity and importance.
·     Overgeneralization	This is using a single event to explain many experiences.
Refer for psychological counseling and treatment as indicated.	Eating disorders are relapsing disorders that require specialized intervention.
Refer to a community support group.	Groups that come together for mutual support are beneficial for long-term recovery.

Nursing Diagnosis

Disturbed Body Image

Common Related Factors	Defining Characteristics
Feelings of inadequacy, worthlessness Shame and guilt caused by discrepancy between “real” self and “ideal” self.	Self-hate Negative feelings about body Distorted perception of weight and body shape Persistent dissatisfaction with body
Common Expected Outcomes Patient develops respect for self and body. Patient identifies positive methods of coping with personal problems. Self-imposed isolation is reduced.	NOC Outcome Body Image NIC Interventions Self-Awareness Enhancement; Body Image Enhancement; Therapy Group

Ongoing Assessment

Actions/Interventions	Rationale
Assess real body image as compared to ideal body image.	Patients may hold themselves to unhealthy and unrealistic ideals.
Assess the degree of impairment in life (i.e., work, interpersonal relationships) resulting from symptomatic behaviors.	The patient’s self-hate may impair multiple areas of functioning.

Therapeutic Interventions

Actions/Interventions	Rationale
Explore alternatives and teach the patient to use self-satisfying activities (e.g., exercising, artistic endeavor, scholastic accomplishment).	These decrease social isolation and withdrawal and support self-esteem.
Encourage the patient to use family and friends as sources of support and feedback.	This reduces anxiety and fear of rejection from others.
Encourage the patient to learn and use healthy problem-solving skills.	These aid in confronting perfectionistic self-expectations. Grappling with these issues can present the means to separate real goals from goals that are unrealistic and not achievable. Success in this area is vital.
Focus on healthy aspects of personality. Give examples of how distorted thinking can magnify weight-related concerns and minimize or invalidate real personal assets.	Building a patient’s perspective provides an opportunity to de-emphasize negative self-concept.
Listen to the patient’s concerns without minimizing them.	Maintaining positive regard and fundamental respect can allow the patient to experience self and others in a more accepting way.
Encourage the patient to identify and work with community support groups as an adjunct to other treatment interventions.	Groups that come together for mutual support ensure interactions and provide additional structure that is helpful to recovery.

Nursing Diagnosis

Risk for Deficient Fluid Volume

Common Risk Factor
Fluid shifts caused by excess reliance on vomiting, laxatives, diuretics, severely restrictive dieting
Common Expected Outcome Patient maintains optimal body fluid volume, as evidenced by normal blood pressure, normal heart rate, absence of dysrhythmia, good skin turgor, and electrolytes within normal limits.	NOC Outcomes Electrolyte and Acid-Base Balance; Fluid Balance NIC Intervention Fluid/Electrolyte Management

Ongoing Assessment

Actions/Interventions	Rationale
Assess for signs of dehydration.	Purging behaviors, such as vomiting and laxative abuse, may contribute to fluid deficit. Dry skin and hair, decreased skin turgor, brittle nails, and erosion of enamel from teeth may be indications that the patient is vomiting after meals.
Monitor vital signs.	Patients who are fluid depleted may be prone to hypotension and tachycardia.
Review laboratory results for electrolyte imbalance.	Calcium, potassium, and sodium abnormalities are common complications.
Observe for signs of unexplained diarrhea or persistent hypokalemia.	This may indicate continued purging.
Observe or monitor for dysrhythmia.	Cardiac dysrhythmias may result from severe electrolyte imbalance.

Therapeutic Interventions

Actions/Interventions	Rationale
Provide adequate and appropriate fluid. Parenteral replacement may be required if derangements are severe or if the patient is symptomatic.	Replacements treat fluid and electrolyte imbalances.
Provide nutritional sources rich in needed electrolytes (e.g., Gatorade).	Correcting electrolyte imbalances is important in preventing complications.