EATING DISORDERS
RNSG 2213
Topics in this Presentation

Covered:
 Anorexia Nervosa
 Bulimia Nervosa

Not Covered:

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Overeating and Binge
Eating Disorders
Obesity and Bariatrics
Anorexia Nervosa
Anorexia Nervosa:
Incidence and Characteristics

Females, 90% (male numbers are
growing)
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Affects 3.7% of women
Less common than bulimia
6 to 20% die as a result of the illness
Higher death rate than any other
psychiatric disorder
Anorexia Nervosa Characteristics,
cont’d
 Onset:
 adolescence
to early adulthood
 age of onset is decreasing
 often insidious
 occurs during important life transitions
 No loss of appetite

Deliberate Weight loss
Cultural Factors and Influences
Weight and Shape
very important in US culture
 Unrealistic ideals:
“culture of thinness”
e.g. computer graphics
make thin models even
thinner

Beauty Queens
1920s
2008
Cultural Factors & Influences,
cont’d
 Epidemic of obesity and
dieting


Preoccupation with fitness
thinness = self-control
DSM IV-TR Criteria
for Anorexia Nervosa
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Refusal to maintain normal weight
Intense fear of gaining weight, even if
underweight
Body image disturbances
In female adults or adolescents, absence
of at least 3 consecutive menstrual cycles
Types are: Restricting and Binge/Purging
Psychosocial and Family Factors
Fears of becoming adult or independent
 Rigid, competitive, perfectionistic
 Anxious, compulsive and obsessive

 the eating disorder is a way to have control

Compliant “people pleasers”
Psychosocial and Family Factors,
cont’d

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Correlates with childhood sexual abuse
Family characteristics that correlate with
anorexia:

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
over-controlling or rigid
emphasis on appearance
may have unusual eating habits
Food-Related Behaviors in
Anorexia Nervosa
Restricting intake, fasting
 Hoarding food
 Highly avoidant of certain foods
 Preoccupation with calories, meals, recipes, etc.
 Preparing/serving elaborate meals for others
 Rituals before and during eating
 become compulsions
Many characteristic behaviors of Anorexia

Nervosa are associated primarily with low
weight/starvation symptoms
How Anorexics Get Rid of the
“Weight”
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Use of laxatives and enemas
Exercise
Purging Behavior in Anorexia

Purgers and vomiters
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Eat normally in a social situations
Amount of food eaten is not excessive
Purge if no success with severe restricting
(Not on the test)
Physical Assessment:
Metabolic Consequences
Anorexia: More Metabolic
Consequences

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GI: slowed peristalsis, delayed gastric emptying
 Feel full much longer
Reproductive: loss of menses, loss of libido
  development of secondary sex
characteristics
Osteopenia or Osteoporosis: bone mass loss
may be irreversible
Other Physical Assessment Data

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Muscle wasting, weakness and fatigue
Dehydration
Pitting edema
Electrolyte imbalance: secondary to
laxative, enema or emetic abuse and from
starvation
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Hypocalcemia, hypokalemia
Anorexia: Complications
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Heart failure, life threatening arrhythmias
Cardiac ventricular dilation
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Decreased thickness of the ventricular wall
Decreased oxygenation of
cardiac muscle
Renal failure
Metabolic alkalosis or acidosis
Complication of Treatment:
Re-feeding Syndrome

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Severe Fluid Shifts from too rapid
re-introduction of food
Cardiovascular, neurological and
hematologic complications
Interventions:


Refeed slowly
Close supervision of physical status
Nursing Diagnosis:
Critical thinking
Write a nursing diagnosis for each of these
consequences of Anorexia Nervosa:
1) Hides food and is dishonest about intake
2) Heart Rate is persistently 48 bpm
3) Uses laxatives several times a week to
achieve wt. loss
Nursing Diagnosis:
Critical thinking
Some possible choices
Ineffective coping or
1b) R/F nutrition less than body
requirements r/t dishonesty about intake
and compensatory behaviors
2) R/F falls r/t hypotension
3a) Fluid volume deficit r/t laxative overuse
3b) Constipation (or Diarrhea) r/t altered
gastric motility
1a)
Mental Health Problems
Associated with Anorexia
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Anxiety

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If perceives loss of control over eating will
lose weight by any means, e.g. exercising,
laxatives, enemas or emetics
Sexual dysfunctions, low sex drive
Feelings of helplessness, inadequacy
Obsessive-compulsive Disorder
Mental Health Disorders Associated
with Anorexia Nervosa, cont’d

Major Depression

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(Dx and tx only after weight gain is
established)
Substance abuse: laxatives and enemas
rather than alcohol or illegal drugs
Personality disorders
Neurobiology of Anorexia

High levels of serotonin
SSRIs are not effective
 If used should not be started until weight
restoration is established

Bulimia Nervosa
Bulimia Nervosa




Age of onset: adolescence to young
adulthood
Primarily in women
4% of young adults
Symptoms overlap with Anorexia, making
diagnosis difficult
Bulimia Characteristics



Often develops after period of dieting
Weight loss NOT a characteristic sign of
bulimia
Purging develops as a way to compensate for
massive amounts of food eaten
Restrictive eating...bingeing…purging
cycle
Binge Eating Episode

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Precipitated by feelings of
lack of control or anxiety
Often done in secret
High calorie-High
carbohydrate intake
Consumed in less than 2
hours
Become addicted to the
“high” experienced when
eating
Purging = Compensatory
Behavior for Binge Eating


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May use manual stimulation, laxatives,
and/or emetics
Over time, self-induced vomiting occurs
with minimal stimulation
Post-purging: sense of relief, calm
Consequences and
Complications of Purging

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Electrolyte imbalances
Metabolic Acidosis
Metabolic Alkalosis
Cardiomyopathy
Enlarged salivary glands
Erosion of dental enamel
Russell’s sign
Pancreatitis
Etiology: Psychosocial and
Family Factors in Bulimia

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Depression, low self-esteem
Shame: will hide the excessive eating
Associated family characteristics:
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Mood disorders
Lack of nurturing
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food is a form of self-nurturing
Substance abuse
Family conflict or disorganization

evidence Bulimia is a response to chaos
Etiology: Neurobiology of
Bulimia

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Lowered serotonin activity
Binge eating raises levels of serotonin
Treat with SSRI, particularly fluoxetine
(Prozac)
Management of
Eating Disorders

Goals for client with
Anorexia Nervosa
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Increase weight to
90% of average body
weight for height
Increase self-esteem
Decrease need for
perfection (provided
by thinness)

Goals for client with
Bulimia

Stabilize weight
without purging
Management of Eating
Disorders, cont’d

Both Anorexia and Bulimia:


Inpatient treatment for medical stabilization
and dietary management
Long-term outpatient tx. addresses
psychosocial issues
Interventions: Starvation
Phase of Anorexia

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Assess labs:
Monitor intake/output
Assess for cardiovascular, neurological
complications
Refeed slowly; careful dietary supervision
Intravenous lines and feeding tubes
if client refuses food
Nurse Patient Relationship

Anorexia Nervosa
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Usually forced into tx.
Tx means loss of
control over eating
Nurse is the enemy

Bulimia Nervosa
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More likely to want help:
break the cycle
More likely to enter
treatment of their own
volition
Tendency to manipulate
Hide the degree of the
problem
Critical Thinking: Nursing
Interventions
Give rationales for interventions listed on
next slide 
Some Interventions for Eating
Disorders

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Do not confront denial,
but encourage feelings
identification
Honesty
Collaborate
TEACH patient about
their disorder
Assist to identify positive
qualities
Eat with the client

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Set appropriate limits
Encourage decision making concerning issues
other than food
Behavior modification:
 Patient input
 Rewards for weight
gain
Psychopharmacology


Anxiolytics when re-feeding is occurring
SSRI for Bulimia

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Equally effective for depressed and nondepressed patients
Psychotherapy for Anorexia

Use antidepressant for co-morbid severe
depression
Milieu Management

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Orient to program and goals of treatment
Warm nurturing environment

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Convey an understanding of their fears
Close observation during and after meals
Do we let these patient go to the rest room alone?
Should we let them go to their room right after a meal?
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Nonjudgmental confrontation of eating disordered
behavior
CONSISTENCY
Encourage the patient to talk to staff when they
feel the need to purge
Milieu Management, cont’d

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Dietitian: individual planning and
consultation
Weighing protocols
Group Therapy
Which groups would be best for clients with
eating disorders?
Art Therapy &
Expressive Arts
Meditation &
Relaxation
Movement
Therapy
Other Interventions

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Family Involvement:
teaching and family therapy
Follow-up therapy
(outpatient)