Eating Disorders: Anorexia and Bulimia Nervosa

• Eating disorders include anorexia nervosa and bulimia nervosa

Etiology

• Societal factors: Popular media promotes unrealistic levels of thinness.
• Family dynamics: Self-worth based on appearance, unhealthy attitudes about food modeled by parents, and family tensions contribute to eating disorder development.
• Psychological factors: Positive reinforcement for weight loss and cognitive distortions, such as all-or-nothing thinking and perfectionism, are common
• Biological factors: Brain structure (e.g., hypothalamus) and neurotransmitter (e.g., serotonin) changes, as well as genetic factors, may be involved in eating disorders.

Relevant Nursing Diagnoses

• Examples: Activity intolerance, anxiety, chronic low self-esteem, defensive coping, deficient fluid volume, diarrhea, disturbed body image, fear, imbalanced nutrition.

Anorexia Nervosa

• Characterized by excessive worry about being overweight, even when severely underweight.
• Strategies to keep weight off include caloric restriction, over-exercising, or purging.
• Individuals with anorexia nervosa spend much time focusing on their body and avoiding things that might make them "fatter."
• Individuals are hungry and preoccupied with food, despite the misnomer of "lack of appetite".

Assessment Findings

• BMI of 17 or lower signifies being underweight.
• Physical signs include emaciation, arrested growth and development, low bone mineral density, and amenorrhea.
• Common vital sign abnormalities are bradycardia, hypotension, and hypothermia.
• Newborn-like hair (lanugo) may cover the skin to help retain heat.
• Hypercarotenemia, a yellowish skin pigmentation, might result from a vegetable-only diet.
• Peripheral edema can be caused by laxative and diuretic abuse.

Laboratory Findings

• Food restrictions and purging can cause electrolyte deficiencies such as hypokalemia and hypomagnesemia
• Anemia, leukopenia, and thrombocytopenia may also be present.

Epidemiology

• Lifetime prevalence in the United States is 0.6%, with women being three times more likely to be affected.
• The average age of onset is 18 years

Effective Treatments

• Psychotherapy such as CBT, psychoanalysis, motivational interviewing, and the Maudsley method of family therapy can be effective.
• Pharmacotherapy may include second-generation antipsychotics (e.g., olanzapine) to help with weight gain and SSRIs (e.g., fluoxetine) for comorbid anxiety and depressive disorders.
• Standard treatment: nutritional rehabilitation plus psychotherapy.

Nursing Interventions

• Create a therapeutic alliance by conveying unconditional positive regard and monitoring personal feelings.
• Hospitalization may be necessary for medically unstable clients (e.g., unstable vital signs, cardiac dysrhythmias, body weight less than 70% of ideal).
• Encourage fluid intake (e.g., 125 mL per hour) and closely monitor vital signs, fluid volume status, and lab values.
• Ensure clients are weighed accurately, and that they are not hiding heavy objects.
• To encourage compliance, administer small, frequent meals and implement behavioral limits consistently and avoid arguing.
• Meals usually have a 30-minute time limit, and clients should be observed for one hour afterward.
• Bathroom trips must be monitored.
• Monitor exercise, and calories not consumed may be given via a nasogastric tube.
• Two to three pounds of weight gain weekly is medically safe.
• Refeeding syndrome, indicated by hypophosphatemia can result from rapid weight gain is and potentially deadly, so monitor electrolyte levels.
• Focus conversations on emotions and feelings.

Bulimia Nervosa

• Characterized by recurrent episodes (at least once a week) of rapid, uncontrolled eating followed by compensatory behaviors to prevent weight gain.
• Compensatory behaviors include inducing vomiting, misusing laxatives or diuretics, fasting, or extreme exercise.
• Clients are preoccupied with their weight and body shape but are typically at a healthy weight, unlike those with anorexia nervosa.
• Binge eating disorder: recurrent eating binges without compensatory behaviors

Assessment Findings

• Physical signs of excessive vomiting include parotid gland enlargement, erosion of tooth enamel, and Russell’s sign (scarring on the knuckles).
• Tachycardia is common

Laboratory Findings

• Metabolic alkalosis and electrolyte abnormalities can result from purging behaviors.
• Hypokalemia can cause cardiac dysrhythmias.

Epidemiology

• The lifetime prevalence of bulimia nervosa is about 1% in the United States and is three times more common in women.
• The average age of onset is 18 years.

Effective Treatments

• CBT helps clients reevaluate and change dysfunctional thoughts and beliefs and behavioral reactions to these thoughts and beliefs.
• Antidepressants (e.g., an SSRI) can be added if clients don’t respond well to psychotherapy.

Nursing Interventions

• Create a therapeutic alliance by conveying unconditional positive regard.
• Closely monitor clients during and after meals, and bathroom trips may need to be monitored.
• The client’s exercise needs to be monitored,
• Monitor fluid volume status and laboratory values.