Chapter 21: Eating Disorders PDF

**Chapter 21: Eating disorders** - Eating Disorders - Persistent disturbance in eating behaviors with distressing thoughts & emotions - Can be very serious and cause physical, psychological, and social dysfunction - ​​Eating Disorders - Occur on a continuum...

**Chapter 21: Eating disorders** - Eating Disorders - Persistent disturbance in eating behaviors with distressing thoughts & emotions - Can be very serious and cause physical, psychological, and social dysfunction - ​​Eating Disorders - Occur on a continuum - May be mild, moderate, severe, or extreme - Eating Disorders included in DSM 5: - **Anorexia Nervosa** - **Bulimia Nervosa** - **Binge Eating Disorder** - Avoidant Restrictive Food Intake Disorder - Other Specified Feeding and Eating Disorder - Pica - Rumination Disorder - Eating behaviors are influenced by: - Society and culture - Complex system involving hunger and satiety - Predisposing Factors and Theories - Genetics - Neurobiological & Neuroendocrine - Psychological and Psychosocial - Epidemiology \[pg. 562\] - Eating Disorders - Often start in adolescence -- early adulthood - Usually present with comorbid psychiatric disorders - More frequently seen in females - Male population with anorexia and bulimia is approx. 25%, binge eating is approx. 36% - BED increases risk for obesity - Body mass index - A body mass index (BMI) range for normal weight is 20 to 24.9 - Anorexia nervosa is characterized by a BMI of 17 or lower, or less than 15 in extreme cases - Obesity is defined as a BMI of 30 or greater - **Anorexia nervosa \[pg. 564\]** - Characterized by a morbid fear of obesity - Extreme weight loss, more than 15% of expected weight - **KNOW Characteristics: Perfectionistic tendencies, amenorrhea, underweight, and gross distortion of body image** - **Symptoms include**: - **Emaciated**, preoccupation with food, refusal to eat, hypothermia, bradycardia, hypotension, edema, and a variety of metabolic changes - **Lanugo** (fine, neonatal-like hair growth): type of compensation by body to keep them warm - Amenorrhea is typical and may even precede significant weight loss - No longer a dx factor - Obsession with food - Feelings of anxiety and depression are common - **Bulimia Nervosa** - Bulimia nervosa is characterized by episodes of binge eating followed by purging behaviors - **KNOW Binging:** is an uncontrolled, compulsive, rapid ingestion - **KNOW Purging:** is the inappropriate compensatory behaviors used to rid the body of the excess calories **(self-induced vomiting or the misuse of laxatives, diuretics, enemas, fasting, excessive exercise)** - Most patients with bulimia have a **normal BMI** - Comorbidities are common \[depression, SUD\] - Excessive vomiting, laxative, and/or diuretic abuse may lead to problems with: - **Dehydration** - **Electrolyte imbalances** - **Cardiac arrhythmias, hypotension, hypothermia, suicidal ideation** - **Damaged tooth enamel/poor dentition** due to gastric acid - **Russell's sign**: Some individuals develop calluses on the dorsal surface of their hands, typically on knuckles, secondary to long-term, repeated self-induced vomiting - Tears in gastric or esophagus - **Binge Eating Disorder (BED)** \[pg. 565\] - Characterized by episodes of binge eating large amounts of food **without** compensatory/purging behaviors - BED differs from bulimia nervosa in that the **individual does not engage in behaviors to rid the body of the excess calories leading to obesity or being overweight** - **Medications: fluoxetine, other high dose SSRIs, lisdexamfetamine, topiramate** - **DON'T MEMORIZE Assessment for Bulimia -- SCOFF Questionnaire** - **S**ick: Do you make yourself sick or vomit after a meal because you feel uncomfortable full? - **C**ontrol: Do you fear loss of control over how much you eat? - **O**ne stone: Has the patient lost more than 14 lbs. in a 3-month period? - **F**at: Do you believe you are fat even when others tell you that you are too thin? - **F**ood: Does food dominate your life? - Assessment guidelines for eating disorders - Safety - **Medical & psychiatric stabilization (may need hospitalization)** - **KNOW Reasons for hospitalization for a client with eating disorder: Dehydration, severe electrolyte imbalance, cardiac arrhythmias, hypotension, hypothermia, and suicidal ideation** - Vital signs & fluid balance - Pertinent lab work & EKG \[b/c can affect cardiac function\] - BMI - Medical complications - Co-existing disorders - Insight into disordered eating & feelings regarding weight - Psychosocial assessment - Nursing dx for eating disorders - Examples include \[table 21-1, pg. 569\] - **KNOW Imbalanced nutrition** - **Interventions for this**: **Keep strict record of intake and output, weigh daily (same clothes, scale, after morning void), stay with pt during meals and for 1 hour after, and monitor labs (Mg, Phosphate), VS, and water for refeeding syndrome** - Deficient fluid volume - Risk for injury - Distorted body image - Negative/low self-image - Ineffective coping - Anxiety - Denial - Goals for anorexia - A few of the common outcome criteria for patients with AN include: - The patient will: - Refrain from suicidal behaviors or self-harm. - Normalize eating patterns by eating 75% of 3 meals/day plus 2 snacks. - Achieve 85 - 90% of ideal body weight. - **Be free of physical complications, including refeeding syndrome:** - **Series of negative intracellular shifts associated with aggressive renourishment in a malnourished patient** - **Refeeding syndrome can happen when someone who has been malnourished begins feeding again.** - **s/s electrolyte imbalances \[hypokalemia, hypocalcemia, etc.\]** - Demonstrate improved self-acceptance. - Address maladaptive beliefs, thoughts, and activities. - Goals for bulimia and BED - Measurable outcome criteria for patients with BN & BED include - The patient will: - Obtain/maintain normal electrolyte balance & stable VS - Refrain from binge (BN & BED) and purge (BN) behaviors - Be free of self-harm behaviors and suicide ideation - Demonstrate at least two new skills for managing stress/anxiety/shame in a non-food related way - No longer demonstrate high levels of anxiety related to fear of gaining weight - Demonstrate improved self-esteem by naming two personal strengths - Verbalize desire to participate in ongoing treatment - Interventions for eating disorders - Interventions - Acknowledge emotional and physical difficulty - Assess mood & for any suicidal thoughts/behaviors - Monitor physiological parameters - **Weigh patient consistently/daily \[same clothes & time, before eating & bathing\]** - **Monitor labs, VS, watch for refeeding syndrome** - **Monitor I&Os** - **Monitor/stay with patient during and after meals \[at least 1 hour afterwards\]** - Monitor for purge - Recognize patient's distorted image without minimizing or challenging patient's perceptions - Work with patients to identify strengths - Psychotherapy - Client/family education - Management of the illness \[box 21-4, pg. 579\] - Principles of nutrition - Ways client may feel in control of life - Importance of verbalizing/expressing fears and feelings, rather than holding them inside - Alternative coping strategies - Correct administration of prescribed medications - Indication for, and side effects of, prescribed medications - Relaxation techniques \[visualization, progressive muscle relaxation, deep breathing\] - Problem-solving skills - For the obese client - How to: - Plan a reduced-calorie, nutritious diet - Read food content labels - Establish a realistic weight loss plan - Establish a planned program of physical activity - Support services \[box 21-4, pg. 579\] - National Eating Disorders Association - National Association of Anorexia Nervosa and Associated Disorders - Weight Watchers International - Overeaters Anonymous - Evaluation - Evaluation of the client with an eating disorder requires reassessment of the behaviors for which the client sought treatment - Behavioral change will be required by the client and family members - **KNOW Tx modalities for eating disorders: family therapy, CBT, behavior modification, and psychopharmacology** - Tx Modalities: **Behavior Modification** \[pg. 580\] - **Issues of control** are central to the etiology of these disorders - For the program to be successful, the client must perceive that they are in control of the treatment - Successes have been observed when the client - Is allowed to contract for privileges based on weight gain - Has input into the care plan - Clearly sees what the treatment choices are - The client has control over - Eating - Amount of exercise pursued - Whether to induce vomiting - Staff and client agree about goals and system of rewards - Tx Modalities: **Family Therapy** - ​​The Maudsley approach for - Treatment of adolescents with anorexia nervosa - Usually used for teenager population - Evidence based outpatient tx program - **Phase I** is focused on weight restoration - **Phase II:** ​​When the child accepts parental demands for increased food intake and demonstrates steady weight gain, and when there is a change in the mood of the family (i.e., relief at having taken charge of the eating disorder; both the adolescent and the parents identify reduced anxiety) - **Phase III:** Once the teen demonstrates the ability to maintain above 95% of ideal weight, the shift to phase III focuses on assisting the adolescent to develop a healthy self-identity - The treatment program is conducted - as an intensive outpatient program and involves three different phases of treatment - Tx Modalities: **Individual Therapy** - Helpful when underlying psychological problems are contributing to the maladaptive behaviors - **Tx Modalities: Psychopharmacology** - Medication research has not yet identified a medication that results in a definitive improvement in core symptoms but some have demonstrated effectiveness - **KNOW Pharmacological interventions for eating disorders** - **Anorexia Nervosa** (meds may be tried, mainly for associated symptoms or comorbid depression) - **Fluoxetine (SSRI)** - Olanzapine - **Bulimia Nervosa** - these meds need to be @ higher dose for them to work - Fluoxetine - Amitriptyline or Desipramine (TCA) - Topiramate (anticonvulsant) - **Binge-Eating Disorder** - Fluoxetine - **Topiramate** - **Lisdexamfetamine (vyvanse)** - **SSRI teaching**: take it exactly as prescribed, monitor for suicidal ideation \[esp. young children\]