Eating disorders

The distinguishing factor of anorexia includes an earlier age of onset and below-normal
body weight; the person fails to recognize the eating behavior as a problem. Clients with
bulimia have a latter age at onset and a near-normal body weight. They usually are
ashamed and embarrassed by the eating disorder.

Eating disorders appear to be equally common among Hispanic and white women and
less common among African American and Asian women.

Anorexia Nervosa
A life-threatening eating disorder characterized by the clients refusal or inability to
maintain a minimally normal body weight, intense fear of gaining weight or
becoming fat, significantly disturbed perception of the shape or size of the body,
and steadfast inability or refusal to acknowledge the seriousness of the problem
or even that one exists.
Has experienced amenorrhea for at least 3 consecutive cycles
Complaints of constipations and abdominal pain
Cold intolerance
Hypotension, hypothermia, bradycardia
o Intravascular volume is decreased; less blood to pump through heart, also
due to excessive exercise
Elevated BUN
o Normal levels: 10-20 mg/dl
o Urea is formed in the liver and is the end product of protein metabolism.

o In anorexia, the body has already used fat for energy; it is now breaking
down muscles for energythe reason for the elevated BUN
Decreased albumin
o Normal levels: 3.5-5 g/dl
o Measures amount of protein in the body; albumin is a protein formed in the
liver.
o Albumin tests are a great indicator of nutritional status
Leukopenia and mild anemia
o Not enough food and nutrients to replenish cells
Has a preoccupation with food and food-related activities
Can be divided into 2 subgroups:
o Restricting subtype: lose weight primarily through dieting, fasting, or
excessively exercising.
o Binge eating and purging subtype: engage regularly in binge eating
followed by purging.
Engage in unusual or ritualistic food behaviors
o Refusing to eat around others
o Cutting food into minute pieces
o Not allowing the food they eat to touch their lips
Excessive exercise is common
Diagnosed between 14 and 18 years of age
Pleased with their ability to control their weight and may express this.
As the illness progresses, depression and lability in mood become more apparent

 Isolate themselves
Believe peers are jealous of their weight loss and believe family and health care
professionals are trying to make them fat and ugly.
Clients who use laxatives are at a greater risk for medical complications.
Autonomy may be difficult in families that are overprotective or in with
enmeshment (lack of clear boundaries) exists. By losing weight, these clients
have some control in their lives.
Have body image disturbance (page 409)
Can be very difficult to treat because they are often resistant, appear
uninterested, and deny their problems.
Treatment:
o Focusing on weight restoration
o Nutritional rehabilitation
o Rehydration
o Correction of electrolyte imbalances
o Severely malnourished individuals may require TPN, tube feedings, or
hyperalimentation to receive adequate nutritional intake.
o Access to the bathroom is supervised to prevent purging as clients begin
to eat more food.
o Weight gain and adequate food intake are most often the criteria for
determining the effectiveness of treatment.
o Amitriptyline (Elavil) and the antihistamine cyproheptadine (Periactin) in
high doses (up to 28mg/d) can promote weight gain in inpatients.
o Olanzapine (Zyprexa) has been used with success because of both its
antipsychotic effect (on bizarre body image distortions) and associated
weight gain.

o Fluoxetine (Prozac) has shown some effectiveness in preventing relapse

in clients whose weight has been partially or completely restored; close
monitoring is needed because weight loss can be a side effect.
Family members often describe clients with anorexia as perfectionists with above
average intelligence, dependable, eager to please, and seeking approval before
their condition began.
Clients with anorexia appear slow, lethargic, and fatigued; they may appear
emaciated, depending on the amount of weight loss. May be slow to respond and
have difficulty deciding what to say.
Reluctant to answer questions fully because they do not want to acknowledge
any problem.
Often wear loose clothing in layers
Seldom smile, laugh, or enjoy any attempts at humor

Bulimia Nervosa
Characterized by recurrent episodes (at least twice a week for 3 months) of binge
eating followed by inappropriate measures to avoid weight gain such as purging
(vomiting, laxatives, diuretics, enemas, or emetics), fasting, or excessively
exercising.
Engaging in binge eating secretly
Binging or purging episodes are often precipitated by strong emotions and
followed by guilt, remorse, shame, or self-contempt.
Recurrent vomiting destroys tooth enamel, has dental caries and ragged or
chipped teeth. Dentists are often the first health care professionals to recognize
this.
Bulimia is typically diagnosed at 18 or 19.
Clients with bulimia are aware that their eating behavior is pathologic and go
great lengths to hide it from others.

 Clients with a co-morbid personality disorder tend to have poorer outcomes than
those without.
Most are treated on an outpatient basis
Antidepressants are more effective than the placebos in reducing binge eating
Clients are often focused on pleasing others and have a history of impulsive
behavior such as substance abuse and shoplifting as well as anxiety, depression,
and personality disorders.
May be underweight, overweight, but are generally close to expected body weight
for age and size
Appear open and willing to talk; initially pleasant and cheerful as though nothing
is wrong

Nursing outcomes/interventions

Imbalanced Nutrition: Less than/More than body requirements

The client will establish adequate nutritional eating patterns
o Implement and supervise the regimen for nutritional rehabilitation
o A diet of 1200-1500 calories is ordered, with gradual increases in calories
until clients are ingesting adequate amounts for height, activity level, and
growth needs.
Start slowlywill have massive diarrhea
o The client with anorexia may be critically malnourished.
TPN through central line
Electrolyte balance
Tube feeds

o A liquid protein supplement is given to replace any food not eaten to

ensure consumption to ensure total number of calories prescribed
o Must monitor meals and snacks and will sit at the table during eating away
from the other clients
A major goal is to first get them to the table
o Diet beverages and food substitutions may be prohibited
o Specified time may be set for consuming each meal and snack
o Discourage clients from performing food rituals such as cutting food into
tiny pieces or mixing foods in unusual combinations
o Be alert for any attempts by client to hide or discard food
o Must remain in view of staff for 1-2 hours to ensure they do not vomit;
access to bathrooms is supervised.
o Client is weighed daily on awakening and after they have emptied their
bladder. Have the client wear a hospital gown each time they are weighed;
they may attempt to place objects in their clothing to give the appearance
of weight gain.
o In bulimia, the clients should sit at a table in a kitchen or dining room.
o Write out a grocery list, it is easier to follow a nutritious eating plan

Ineffective coping
The client will eliminate use of compensatory behaviors such as excessive
exercise and use of laxatives and diuretics
The client will demonstrate coping mechanisms not related to food
The client will verbalize feelings of guilt, anger, anxiety, or an excessive need for
control

o Help the client recognize emotions such as anxiety or guilt by asking them
to describe what they are feeling; allow adequate time for response. Do
not ask are you anxious? Sad? because the client may quickly agree
rather than struggle for an answer
o Encourage self-monitoring (page 414); a behavior-cognitive approach

Disturbed body image

The client will verbalize acceptance of body image with stable body weight
o Help clients identify areas of personal strength that are not food-related
broadens clients perceptions of themselves.