NCP Anorexia Nervosa Bulimia Nervosa

DSM-IV

307.1 Anoxexia nervosa

307.51 Bulimia nervosa

307.50 Eating disorders NOS

Binge-eating disorder (proposed, requiring further study)

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.

Binge-eating is defined as recurrent episodes of overeating associated with subjective and behavioral indicators of impaired control over and significant distress about the eating behavior but without the use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise).

ETIOLOGICAL THEORIES

Psychodynamics

The individual reflects a developmental arrest in the very early childhood years. The tasks of trust, autonomy, and separation-individuation are unfulfilled, and the individual remains in the dependent position. Ego development is retarded. Symptoms are often associated with a perceived loss of control in some aspect of life and may center on fears of sexual maturity/intimacy. Although these disorders affect women primarily, approximately 5% to 10% of those afflicted are men. Additionally, eating disorders are often associated with depression, anxiety, phobias, and cognitive problems.

Biological

These disorders may be caused by neuroendocrine abnormalities within the hypothalamus. Symptoms are linked to various chemical disturbances normally regulated by the hypothalamus. Furthermore, a physiological defect may make it difficult for the individual to interpret sensations of hunger and fullness.

Family Dynamics

Issues of control become the overriding factors in the family of the client with an eating disorder. These families often consist of a passive father, a domineering mother, and an overly dependent child. There is a high value placed on perfectionism in this family, and the child believes she or he must please others and satisfy these standards.

CLIENT ASSESSMENT DATA BASE

Activity/Rest

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 require control of weight (athletics, such as gymnasts, swimmers, jockeys, wrestlers; modeling, flight attendants)

Circulation

Feeling cold even when room is warm

Low BP; tachycardia, dysrhythmias

Ego Integrity

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 after overeating [binge-eating])

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 (females)

Concerned with achieving masculine body build (males), rather than actual weight or weight gain

Stress factors (e.g., family move/divorce, onset of puberty)

High self-expectations

Suppression of anger; emotional states of depression, withdrawal, anger, anxiety, pessimistic outlook

Elimination

Diarrhea/constipation

Decreased frequency of voiding/urine output, urine dark amber (dehydration)

Vague abdominal pain and distress, bloating

Laxative/diuretic use

Food/Fluid

Constant hunger or denial of hunger; normal or exaggerated appetite that rarely vanishes until late in the disorder (anorexia)

Intense fear of gaining weight (female); may have prior history of being overweight (particularly males)

Inordinate pleasure in weight loss, while denying self pleasure in other areas

Refusal to maintain body weight at or above minimal norm for age/height (anorexia)

Recurrent episodes of binge-eating; a feeling of lack of control over behavior during eating binges; minimum average of 2 binge eating episodes a week for at least 3 months (bulimia); ingests large amounts of food when not feeling physically hungry, often consuming as much as 20,000 calories in a 2-hour period; eating much more rapidly than normal in a discrete period of time (e.g., within a 2-hour period), an amount of food that is definitely larger than most people would eat (binge-eating); feels uncomfortably full

Regularly engages in either self-induced vomiting (binge-purge syndrome [bulimia]) independently or as a complication of anorexia or strict dieting or fasting; excessive gum chewing

Weight loss/maintenance of body weight 15% or more below that expected (anorexia) or weight may be normal or slightly above or below (bulimia)

Cachectic appearance; skin may be dry, yellowish/pale, with poor turgor

Preoccupation with food (e.g., calorie-counting, gourmet cooking; hiding food, cutting food into small pieces, rearranging food on plate)

Peripheral edema

Swollen salivary glands; sore, inflamed buccal cavity, erosion of tooth enamel; gums in poor condition; continuous sore throat (bulimia)

Vomiting; bloody vomitus (may indicate esophageal tearing—Mallory-Weiss)

Hygiene

Increased hair growth on body (lanugo); hair loss (axillary/pubic); hair dull/not shiny

Brittle nails

Signs of erosion of tooth enamel; gum abscesses, ulcerations of mucosa

Neurosensory

Appropriate affect, except in regard to body and eating; or depressive affect (depression)

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

Headaches, sore throat, general vague complaints

Safety

Body temperature below normal

Recurrent infectious processes (indicative of depressed immune system)

Eczema/other skin problems

Abrasions/callouses may be noted on the back of hands (sticking finger down throat to induce vomiting)

Sexuality

Absence of at least 3 consecutive menstrual cycles (decreased levels of estrogen in response to malnutrition)

Promiscuity or denial/loss of sexual interest

History of sexual abuse

Breast atrophy, amenorrhea

Social Interactions

Middle-class or upper-class family background

Passive father/dominant mother, family members enmeshed, togetherness prized, personal boundaries not respected

History of being a quiet, cooperative child

Problems of control issues in relationships, difficult communications with others/authority figures; poor communications within family of origin

Engagement in power struggles

Altered relationships or problems with relationships (not married/divorced), withdrawal from friends/social contacts

Abusive family relationships

Sense of helplessness

May have history of legal difficulties (e.g., shoplifting)

Teaching/Learning

High academic achievement

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/practices (e.g., certain foods have “too many” calories, use of “health” foods)

No medical illness evident to account for weight loss

DIAGNOSTIC STUDIES

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 triio-dothyronine (T3) levels may be low.

Pituitary Function: Thyroid-stimulating hormone (TSH) response to thyrotropin-releasing factor (TRF) is abnormal in anorexia nervosa. Propranolol-glucagon stimulation test (studies the response of human growth hormone) reveals depressed level of GH in anorexia nervosa. Gonadotropic hypofunction is noted.

Cortisol: Metabolism may be elevated.

Dexamethasone Suppression Test (DST): Evaluates hypothalamic-pituitary function, dexamethasone resistance indicates cortisol suppression, suggesting malnutrition/depression.

Luteinizing Hormone Secretions Test: Pattern often resembles those of prepubertal girls.

Estrogen: Decreased.

Blood Sugar and Basal Metabolic Rate (BMR): May be low.

Other Chemistries: AST elevated, increased carotene level; decreased protein and cholesterol levels.

MHP 6 Levels: Decreased, suggestive of malnutrition/depression.

Urinalysis and Renal Function: BUN may be elevated; ketones present reflecting starvation; decreased urinary 17-ketosteroids; increased specific gravity (dehydration).

EKG: 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 client to develop realistic body image/improve self-esteem.

4. Provide support/involve SO, if available, in treatment program to client/SO.

5. Coordinate total treatment program with other disciplines.

6. Provide information about disease, prognosis, and treatment.

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.