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Eating disorders describe a complex set of behaviors related to eating and share many similarities to anxiety related disorders. Clients with eating disorders describe feeling out of control in other areas of their lives and use food as a coping mechanism. They may also have distorted perceptions of...

Eating disorders describe a complex set of behaviors related to eating and share many similarities to anxiety related disorders. Clients with eating disorders describe feeling out of control in other areas of their lives and use food as a coping mechanism. They may also have distorted perceptions of what they look like, which affects how they feel about themselves. The exact prevalence and incidence of eating disorders existing in a given population during a designated time are most likely underestimated because of the secretiveness of the condition, denying that the illness exists, or avoidance of seeking professional help. The mortality rate for eating disorders is high, and suicide is also a risk. Treatment modalities focus on normalizing eating patterns and beginning to address the issues raised by the illness. Comorbidities include depression, personality disorders, substance use disorder, and anxiety. Various eating disorders are recognized and defined by the DSM-5-TR. Anorexia nervosa Persistent energy intake restriction leading to significantly low body weight in context of age, sex, developmental path, and physical health Fear of gaining weight or becoming overweight Disturbance in self-perceived weight or shape Characteristics Clients are preoccupied with food and the rituals of eating, along with a voluntary refusal to eat. This condition occurs most often in female clients from adolescence to young adulthood. Onset can be associated with a stressful life event, such as college. Compared to clients who have restricting type, those who have binge-eating/purging type have higher rates of impulsivity and are more likely to abuse drugs and alcohol. Types Restricting type: The individual drastically restricts food intake and does not binge or purge. Binge-eating/purging type: The individual engages in binge eating or purging behaviors. Bulimia nervosa  Clients recurrently eat large quantities of food over a short period of time (binge eating), which can be followed by inappropriate compensatory behaviors (self-induced vomiting [purging]), to rid the body of the excess calories. Binge eating and inappropriate compensatory behavior both occur on average of once per week for 3 months. Binge eating is in a discrete period of time (usually less than 2 hours), and an amount of food definitely larger than what most individuals would eat in a similar period of time. Clients have a sense of lack of control over eating. Characteristics Most clients who have bulimia nervosa maintain a weight within a normal range or slightly higher. BMI is 18.5 to 30. The average age of onset in female clients is late adolescence or early adulthood. Bulimia nervosa occurs most commonly in female clients. Between binges, clients typically restrict caloric intake and select low-calorie “diet” foods. Types Purging type: The client uses self-induced vomiting, laxatives, diuretics, and/or enemas to lose or maintain weight. Nonpurging type: The client can compensate for binge eating through other means (excessive exercise and the misuse of laxatives, diuretics, and/or enemas). Binge eating disorder Clients recurrently eat large quantities of food over a short period of time without the use of compensatory behaviors associated with bulimia nervosa. Clients experience distress following the binge-eating episode. An excessive food consumption must be accompanied by a sense of lack of control. At least once per week for 3 months.  Binge eating disorder affects men and women of all ages, but is most common in adults age 46 to 55. The weight gain associated with binge eating disorder increases the client’s risk for other disorders, including type 2 diabetes mellitus, hypertension, and cancer. Severity of the disorder depends on the number of binge-eating episodes each week. Additional eating disorder categories Pica: Eating nonfood items like dirt, soap or paint chips as if they were food. Rumination disorder: Regurgitating food after eating it (behaviors may be referred to as “chewing and spitting”). Avoidant/restrictive food intake disorder: a lack of interest in eating certain types of food which leads to poor growth and nutrition. Prodromal manifestations Increase or decrease in weight that is not related to a medical condition Abnormal eating habits, like severe dieting Ritualized mealtime behaviors, like counting calories Lying about food intake Preoccupation with weight and body image Compulsive and/or excessive exercising Assessment Risk Factors Occupational choices that encourage thinness (fashion modeling) Individual history of being a “picky” eater in childhood Participation in athletics, especially at an elite level of competition or in a sport where lean body build is prized (bicycling) or where a specific weight is necessary (wrestling) A history of obesity Family genetics: more commonly seen in families who have a history of eating disorders Biological: hypothalamic, neurotransmitter, hormonal, or biochemical imbalance, with disturbances of the serotonin neurotransmitter pathways seeming to be implicated Interpersonal relationships: influenced by parental pressure and the need to succeed Psychological influences: rigidity, ritualism; separation and individuation conflicts; feelings of ineffectiveness, helplessness, and depression; distorted body image; internal or external locus of control or self-identity; and potential history of physical abuse Environmental factors: media influence and pressure from society to have the “perfect body” Temperamental: anxiety or obsessional traits in childhood Expected findings Nursing history should include the following. QPCC The client’s perception of the issue Eating habits History of dieting Methods of weight control (restricting, purging, exercising) Value attached to a specific shape and weight Interpersonal and social functioning Difficulty with impulsivity, as well as compulsivity Family and interpersonal relationships (frequently troublesome and chaotic, reflecting a lack of nurturing) Mental status Cognitive distortions include the following. o Overgeneralizations: “Other people don’t like me because I’m fat.” o “All-or-nothing” thinking: “If I eat any dessert, I’ll gain 50 pounds.” o Catastrophizing: “My life is over if I gain weight.” o Personalization: “When I walk through the hospital hallway, I know everyone is looking at me.” o Emotional reasoning: “I know I look bad because I feel bloated.” Client demonstrates high interest in preparing food, but not eating. Client is terrified of gaining weight.  Client perception is that they are severely overweight and sees this image reflected in the mirror. Client can exhibit low self-esteem, impulsivity, and difficulty with interpersonal relationships. Client can exhibit the need for an intense physical regimen. Client can experience guilt or shame due to binge eating behavior. Obsessive-compulsive features can be related and unrelated to food (collecting recipes, hoarding food, concerns about eating in public). Vital signs Low blood pressure with possible orthostatic hypotension. Decreased pulse and body temperature. Hypertension can be present in clients who have binge eating disorder. Weight: Clients who have anorexia nervosa have a body weight that is less than 85% of expected normal weight. Most clients who have bulimia nervosa maintain a weight within the normal range or slightly higher. Clients who have binge eating disorder are typically overweight or obese. Integumentary: Skin, hair, and nails Clients who have anorexia nervosa can have fine, downy hair (lanugo) on the face and back; yellowed skin; pale, cool extremities; and poor skin turgor. Clients who self-induce vomiting can have calluses or scars on hand (Russell’s sign). Head, neck, mouth, and throat Clients who engage in purging behaviors can have enlargement of the parotid glands. Dental erosion and caries (if the client is purging) Cardiovascular system  Irregular heart rate (dysrhythmias noted on cardiac monitor), heart failure, cardiomyopathy Peripheral edema Acrocyanosis Fluid/Electrolyte Acidosis or alkalosis Dehydration Electrolyte imbalances Musculoskeletal system Muscle weakness Decreased energy Loss of bone density Gastrointestinal system Constipation (dehydration) Diarrhea (laxative use) Abdominal pain Self-induced vomiting Excessive use of diuretics or laxatives Esophageal tears, gastric rupture (bulimia) Reproductive status Amenorrhea can be seen in clients who have anorexia nervosa. Menstrual irregularities Psychosocial  Client can exhibit low self-esteem, impulsivity, and difficulty with interpersonal relationships Depressed mood Social withdrawal Irritability Insomnia Criteria for acute care treatment Weight loss of 20% of ideal body weight or less than 10% body fat Unsuccessful weight gain in outpatient treatment, failure to adhere to treatment contract Vital signs demonstrating heart rate less than 50/min, systolic blood pressure less than 90 mm Hg, body temperature less than 36˚ C (96.8˚ F) ECG changes Electrolyte disturbances Psychiatric criteria: severe depression, suicidal behavior, family crisis, or psychosis Laboratory and diagnostic tests Common laboratory abnormalities associated with anorexia and bulimia Hypokalemia, especially for those who have bulimia nervosa o There is a direct loss of potassium due to purging (vomiting). o Dehydration stimulates increased aldosterone production, which leads to sodium and water retention and potassium excretion. Anemia and leukopenia with lymphocytosis; thrombocytopenia Possible impaired liver function, evidenced by increased enzyme levels Hypoalbuminemia Possible elevated cholesterol Elevated blood urea nitrogen (dehydration) Abnormal thyroid function tests  Elevated carotene levels, which cause skin to appear yellow Decreased bone density (possible osteoporosis) Abnormal blood glucose level ECG changes (prolonged QT interval) Possible increase blood bicarbonate (metabolic alkalosis) related to self-induced vomiting Possible decrease blood bicarbonate (metabolic acidosis) related to laxative use Electrolyte imbalances can depend on the client’s method of purging (laxatives, diuretics, vomiting). Hypokalemia Hyponatremia Hypochloremia Hypomagnesemia (occurs due to malnutrition) Hypophosphatemia (occurs due to malnutrition) Decreased estrogen (females who have anorexia) Decreased testosterone (males who have anorexia) Standardized screening tools QEBP Eating Disorder Inventory Eating Disorder Examination Eating Attitudes Test Patient-Centered Care Nursing Care Perform self-assessment regarding possible feelings of frustration regarding the client’s eating behaviors, the belief that the disorder is self-imposed, or the need to nurture rather than care for the client. Provide a highly structured milieu in an acute care unit for the client requiring intensive therapy.  Develop and maintain a trusting nurse/client relationship through consistency and therapeutic communication. Use a positive approach and support to promote client self-esteem and positive self- image. Encourage client decision making and participation in the plan of care to allow for a sense of control. Establish realistic goals for weight loss or gain. Promote cognitive-behavioral therapies. EBP o Cognitive reframing o Relaxation techniques o Journal writing o Desensitization exercises Monitor the client’s vital signs, intake and output, and weight (2 to 3 lb/week is medically acceptable). Use behavioral contracts to modify client behaviors. Reward the client for positive behaviors (completing meals or consuming a set number of calories). Closely monitor the client during and after meals to prevent purging, which can necessitate accompanying the client to the bathroom. Monitor the client for maintenance of appropriate exercise. Teach and encourage self-care activities. Incorporate the family when appropriate in client education and discharge planning. Work with a dietitian to provide nutrition education to include correcting misinformation regarding food, meal planning, and food selection. QTC o Consider the client’s preferences and ability to consume food when developing the initial eating plan.  o A structured and inflexible eating schedule at the start of therapy, only permitting food during scheduled times, promotes new eating habits and discourages binge or binge-purge behavior. o Provide small, frequent meals, which are better tolerated and will help prevent the client from feeling overwhelmed. o Provide liquid supplement as prescribed. o Provide a diet high in fiber to prevent constipation. o Provide a diet low in sodium to prevent fluid retention. o Limit high-fat and gassy foods during the start of treatment. o Administer a multivitamin and mineral supplement. o Instruct the client to avoid caffeine to reduce the risk for increased energy, resulting in difficulty controlling eating disorder behaviors. Caffeine also can be used by clients as a substitute for healthy eating. Make arrangements for the client to attend individual, group, and family therapy to assist in resolving personal issues contributing to the eating disorder. Medications Selective serotonin reuptake inhibitors Fluoxetine Nursing actions Instruct the client that medication can take 1 to 3 weeks for initial response, with up to 2 months for maximal response. Instruct the client to avoid hazardous activities (driving, operating heavy equipment/machinery) until individual adverse effects are known. Instruct the client to notify the provider if sexual dysfunction occurs and is intolerable. Interprofessional care A registered dietitian should be involved to provide the client with nutritional and dietary guidance. QTC  Consistency of care among all staff is important. Client education Care After Discharge Assist the client to develop and implement a maintenance plan related to weight management. Encourage follow-up treatment in an outpatient setting. Encourage client participation in a support group. Continue individual and family therapy as indicated. Complications Refeeding syndrome Refeeding syndrome is the potentially fatal complication that can occur when fluids, electrolytes, and carbohydrates are introduced to a severely malnourished client. Nursing actions Care for the client in a hospital setting. Consult with the provider and dietitian to develop a controlled rate of nutritional support during initial treatment. QTC Monitor blood electrolytes, and administer fluid replacement as prescribed. Cardiac dysrhythmias, severe bradycardia, and hypotension Nursing actions Place the client on continuous cardiac monitoring. Monitor vital signs frequently. Report changes in the client’s status to the provider.