ANOREXIA NERVOSA/BULIMIA NERVOSA

DSM-IV
307.1 Anoxexia nervosa 307.51 Bulimia nervosa 307.50 Eating disorders NOS Binge-eating disorder (proposed re!uiring "urt#er stud$% Anorexia nervosa is an illness of starvation, brought on by severe disturbance of body image and a morbid fear of obesity. Bulimia nervosa is an eating disorder (binge-purge syndrome) characterized by extreme overeating, followed by self-induced vomiting. t may include abuse of laxatives and diuretics. Binge-eating is defined as recurrent episodes of overeating associated with sub!ective and behavioral indicators of impaired control over and significant distress about the eating behavior but without the use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise).

ETIOLOGICAL THEORIES Psychodynam cs

"he individual reflects a developmental arrest in the very early childhood years. "he tas#s of trust, autonomy, and separation-individuation are unfulfilled, and the individual remains in the dependent position. $go development is retarded. %ymptoms are often associated with a perceived loss of control in some aspect of life and may center on fears of sexual maturity /intimacy. Although these disorders affect women primarily, approximately &' to ()' of those afflicted are men. Additionally, eating disorders are often associated with depression, anxiety, phobias, and cognitive problems.

B o!o" ca!
"hese disorders may be caused by neuroendocrine abnormalities within the hypothalamus. %ymptoms are lin#ed to various chemical disturbances normally regulated by the hypothalamus. *urthermore, a physiological defect may ma#e it difficult for the individual to interpret sensations of hunger and fullness.

#am !y Dynam cs
ssues of control become the overriding factors in the family of the client with an eating disorder. "hese families often consist of a passive father, a domineering mother, and an overly dependent child. "here is a high value placed on perfectionism in this family, and the child believes she or he must please others and satisfy these standards.

CLIENT ASSESSMENT DATA BASE Ac$ % $y/R&s$

+isturbed sleep patterns (e.g., early morning insomnia, fatigue) *eeling -hyper. and/or anxious ncreased activity/avid exerciser, participation in high-energy sports $mployment in positions/professions that re/uire control of weight (athletics, such as gymnasts, swimmers, !oc#eys, wrestlers, modeling, flight attendants)

C 'c(!a$ on
*eeling cold even when room is warm 0ow B1, tachycardia, dysrhythmias

E"o In$&"' $y
1owerlessness/helplessness, lac# of control over eating (e.g., cannot stop eating/control what or how much is eaten 2bulimia3, feeling disgusted with self, depressed, or very guilty after overeating 2bingeeating3) +istorted (unrealistic) body image4reports self as fat regardless of weight (denial), and sees thin body as fat, persistent overconcern with body shape and weight4fears gaining weight (females) 5oncerned with achieving masculine body build (males), rather than actual weight or weight gain %tress factors (e.g., family move/divorce, onset of puberty) 6igh self-expectations %uppression of anger, emotional states of depression, withdrawal, anger, anxiety, pessimistic outloo#

E! m na$ on
+iarrhea/constipation +ecreased fre/uency of voiding/urine output, urine dar# amber (dehydration) 7ague abdominal pain and distress, bloating 0axative/diuretic use

#ood/#!( d
5onstant hunger or denial of hunger, normal or exaggerated appetite that rarely vanishes until late in the disorder (anorexia) ntense fear of gaining weight (female), may have prior history of being overweight (particularly males) nordinate pleasure in weight loss, while denying self pleasure in other areas 8efusal to maintain body weight at or above minimal norm for age/height (anorexia) 8ecurrent episodes of binge-eating, a feeling of lac# of control over behavior during eating binges, minimum average of 9 binge eating episodes a wee# for at least : months (bulimia), ingests large amounts of food when not feeling physically hungry, often consuming as much as 9),))) calories in a 9-hour period, eating much more rapidly than normal in a discrete period of time (e.g., within a 9-hour period), an amount of food that is definitely larger than most people would eat (binge-eating), feels uncomfortably full 8egularly engages in either self-induced vomiting (binge-purge syndrome 2bulimia3) independently or as a complication of anorexia or strict dieting or fasting, excessive gum chewing ;eight loss/maintenance of body weight (&' or more below that expected (anorexia) or weight may be normal or slightly above or below (bulimia) 5achectic appearance, s#in may be dry, yellowish/pale, with poor turgor 1reoccupation with food (e.g., calorie-counting, gourmet coo#ing, hiding food, cutting food into small pieces, rearranging food on plate) 1eripheral edema %wollen salivary glands, sore, inflamed buccal cavity, erosion of tooth enamel, gums in poor condition, continuous sore throat (bulimia) 7omiting, bloody vomitus (may indicate esophageal tearing4<allory-;eiss)

Hy" &n&
ncreased hair growth on body (lanugo), hair loss (axillary/pubic), hair dull/not shiny Brittle nails %igns of erosion of tooth enamel, gum abscesses, ulcerations of mucosa

N&('os&nso'y
Appropriate affect, except in regard to body and eating, or depressive affect (depression) <ental changes= apathy, confusion, memory impairment (brought on by malnutrition/starvation) 6ysterical or obsessive personality style, no other psychiatric illness or evidence of a psychiatric thought

disorder present (although a significant number may show evidence of an affective disorder)

Pa n/D scom)o'$
6eadaches, sore throat, general vague complaints

Sa)&$y
Body temperature below normal 8ecurrent infectious processes (indicative of depressed immune system) $czema/other s#in problems Abrasions/callouses may be noted on the bac# of hands (stic#ing finger down throat to induce vomiting)

S&*(a! $y
Absence of at least : consecutive menstrual cycles (decreased levels of estrogen in response to malnutrition) 1romiscuity or denial/loss of sexual interest 6istory of sexual abuse Breast atrophy, amenorrhea

Soc a! In$&'ac$ ons

<iddle-class or upper-class family bac#ground 1assive father/dominant mother, family members enmeshed, togetherness prized, personal boundaries not respected 6istory of being a /uiet, cooperative child 1roblems of control issues in relationships, difficult communications with others /authority figures, poor communications within family of origin $ngagement in power struggles Altered relationships or problems with relationships (not married /divorced), withdrawal from friends/social contacts Abusive family relationships %ense of helplessness <ay have history of legal difficulties (e.g., shoplifting)

T&ach n"/L&a'n n"

6igh academic achievement *amily history of higher than normal incidence of depression, other family members with eating disorders (genetic predisposition) >nset of the illness usually between the ages of () and 99 6ealth beliefs/practices (e.g., certain foods have -too many. calories, use of -health. foods) ?o medical illness evident to account for weight loss

DIAGNOSTIC STUDIES
CBC with Differential: +etermines presence of anemia, leu#openia, lymphocytosis. 1latelets show significantly less than normal activity by the enzyme monoamine oxidase (thought to be a mar#er for depression). Electrolytes: mbalances may include decreased potassium, sodium, chloride, and magnesium. Endocrine Studies: Thyroid Function: "hyroxine (" ) levels usually normal, however, circulating triio-dothyronine (" ) @ : levels may be low.

Pituitary Function: "hyroid-stimulating hormone ("%6) response to thyrotropin-releasing factor ("8*) is abnormal in anorexia nervosa. 1ropranolol-glucagon stimulation test (studies the response of human growth hormone) reveals depressed level of A6 in anorexia nervosa. Aonadotropic hypofunction is noted. Cortisol: <etabolism may be elevated. Dexamethasone Suppression Test (DST): $valuates hypothalamic-pituitary function, dexamethasone resistance indicates cortisol suppression, suggesting malnutrition/depression. uteini!in" #ormone Secretions Test: 1attern often resembles those of prepubertal girls. Estro"en: +ecreased. Blood Su"ar and Basal $eta%olic &ate (B$&): <ay be low. 'ther Chemistries: A%" elevated, increased carotene level, decreased protein and cholesterol levels. $#P ( e)els: +ecreased, suggestive of malnutrition/depression. *rinalysis and &enal Function: BB? may be elevated, #etones present reflecting starvation, decreased urinary (C-#etosteroids, increased specific gravity (dehydration). E+,: Abnormal tracing with low voltage, "-wave inversion, dysrhythmias.

NURSING PRIORITIES
(. 9. :. @. &. D. 8eestablish ade/uate/appropriate nutritional inta#e. 5orrect fluid and electrolyte imbalance. Assist client to develop realistic body image/improve self-esteem. 1rovide support/involve %>, if available, in treatment program to client/%>. 5oordinate total treatment program with other disciplines. 1rovide information about disease, prognosis, and treatment.

DISCHARGE GOALS
(. 9. :. @. &. D. Ade/uate nutrition and fluid inta#e maintained. <aladaptive coping behaviors and stressors that precipitate anxiety recognized. Adaptive coping strategies and techni/ues for anxiety reduction and self-control implemented. %elf-esteem increased. +isease process, prognosis, and treatment regimen understood. 1lan in place to meet needs after discharge.

NURSING DIAGNOSIS May B& R&!a$&d $o+ Poss -!y E% d&nc&d -y+

NUTRITION+ a!$&'&d, !&ss $han -ody '&.( '&m&n$s &nade!uate "ood inta'e( sel"-indu)ed vomiting *#roni)+ex)essive laxative use Bod$ ,eig#t 15- (or more% .elo, expe)ted (anorexia% or ma$ .e ,it#in normal range (.ulimia .inge-eating% /ale )on0un)tiva and mu)ous mem.ranes( poor s'in turgor+mus)le tone edema Ex)essive loss o" #air( in)reased gro,t# o" .od$ #air (lanugo% Amenorr#ea 1$pot#ermia Brad$)ardia )ardia) irregularities #$potension Ele)trol$te im.alan)es

D&s '&d O($com&s/E%a!(a$ on C' $&' a/ C! &n$ 0 !!+

2er.ali3e understanding o" nutritional needs. Esta.lis# a dietar$ pattern ,it# )alori) inta'e ade!uate to regain+maintain appropriate ,eig#t. 4emonstrate ,eig#t gain to,ard expe)ted goal range.

ACTIONS/INTERVENTIONS Ind&1&nd&n$
$stablish a minimum weight goal and daily nutritional re/uirements.

RATIONALE

<alnutrition is a mood-altering condition leading to depression and agitation and affecting cognitive functioning/decision-ma#ing. mproved nutritional status enhances thin#ing ability, and psychological wor# can begin. 1rovides structured eating stimulation while allowing client some control in choices. Behavior modification may be effective only in mild cases or for short-term weight gain. -ote: 5ombination of cognitive-behavioral approach is preferred for treating bulimia. 5lient detects urgency and reacts to pressure. Any comment that might be seen as coercion provides focus on food. ;hen staff member responds consistently, client can begin to trust her or his responses. "he single area in which client has exercised power and control is food/eating, and she or he may experience guilt or rebellion if forced to eat. %tructuring meals and decreasing discussions about food will decrease power struggles with client and avoid manipulative games. Aastric dilation may occur if refeeding is too rapid following a period of starvation dieting. -ote: 5lient may feel bloated for :ED wee#s while body read!usts to food inta#e. 5lient who gains self-confidence and feels in control of environment is more li#ely to eat preferred foods. 5lient will try to avoid ta#ing in what is viewed as excessive calories and may go to great lengths to avoid eating. 1rovides accurate ongoing record of weight loss/gain. Also diminishes obsessing about changes in weight. Although some programs prefer client to see the results of weighing, this approach can force the issue of trust in client who usually does not trust

nvolve client with team in setting up/carrying out program of behavior modification. 1rovide reward for weight gain as individually determined, ignore loss.

Bse a consistent approach. %it with client while eating, present and remove food without persuasion and/or comment. 1romote pleasant environment and record inta#e.

1rovide smaller meals and supplemental snac#s, as appropriate.

<a#e selective menu available and allow client to control choices, as much as possible. Be alert to choices of low-calorie foods/beverages, hoarding food, disposing of food in various places such as poc#ets or wastebas#ets. <aintain a regular weighing schedule, such as <onday/*riday before brea#fast in same attire, on same scale, and graph results. ;eigh with bac# to scale (depending on program protocols).

others. Avoid room chec#s and other control devices whenever possible. 1rovide (=( supervision and have the client remain in the dayroom area with no bathroom privileges for a specified period (e.g., 9 hours) following eating, if contracting is unsuccessful. <onitor exercise program and set limits on physical activities. 5hart activity/level of wor# (pacing, and so on). <aintain matter-of-fact, non!udgmental attitude if giving enteral feedings, parenteral nutrition, etc. Be alert to possibility of client disconnecting tube and emptying parenteral nutrition, if used. 5hec# fluid measurements and tape tubing snugly. $xternal control reinforces clientFs feelings of powerlessness and are therefore usually not helpful. 1revents vomiting during/after eating. 5lient may desire food and use a binge-purge syndrome to maintain weight. -ote: 1urging may occur for the first time in a client as a response to establishment of weight gain program. <oderate exercise helps maintain muscle tone/ weight and combat depression. 6owever, client may exercise excessively to burn calories. 1erception of punishment is counterproductive to promoting self-confidence and faith in own ability to control destiny. %abotage behavior is common in attempt to prevent weight gain.

Co!!a-o'a$ %&
5onsult with dietitian/nutritional therapy team. 6elpful in determining individual dietary needs and appropriate sources. -ote: nsufficient calorie and protein inta#e can lower resistance to infection and cause constipation, hallucinations, and liver damage. 1eriodontal disease and loss of tooth enamel leading to caries and loose fillings re/uires prompt intervention to improve nutritional inta#e and general well-being. 6aving a variety of foods available will enable the client to have a choice of potentially en!oyable foods. ;hen caloric inta#e is insufficient to sustain metabolic needs, nutritional support can be used to prevent malnutrition while therapy is continuing. 6igh-calorie li/uid feedings may be given as medication, at times separate from meals, as an alternate means of increasing caloric inta#e. $nteral feedings are preferred as they preserve A function and reduce atrophy of the gut. "1? is usually reserved for life-threatening situations. <ay be used as part of behavior modification program to provide total inta#e of needed calories. 0axative use is counterproductive, as it may be used by client to rid body of food/calories. -ote: <etamucil/bran may be used to treat constipation. dentifies therapeutic needs/effectiveness of treatment. $lectrolyte imbalances can cause cardiac dysrhythmias, severe muscle spasms, and even sudden death.

8efer for dental care.

1rovide diet and snac#s with substitutions of preferred foods when available. Administer li/uid diet, tube feedings/parenteral nutrition as appropriate.

Blenderize and tube feed anything left on the tray after a given period of time if indicated. Avoid giving laxatives.

<onitor laboratory values, as appropriate (e.g., prealbumin, transferrin, serum protein levels, electrolytes).

Administer medications as indicated, e.g., 5yproheptadine (1eriactin),

"ricyclic antidepressants, e.g., amitriptyline ($lavil, $ndep), imipramine ("ofranil), desipramine (?orpramin), selective serotonin reupta#e inhibitors, e.g., fluoxetine (1rozac), Antianxiety agents, e.g., alprozolam (Ganax), Antipsychotics, e.g., chlorpromazine ("horazine),

<A> inhibitors, e.g., tranylcypromine sulfate (1arnate). 1repare for/assist with electroconvulsive therapy ($5") if indicated. +iscuss reasons for use and help client understand this therapy is not punishment. "ransfer to acute medical setting for nutritional therapy, when condition is life-threatening.

A serotonin and histamine antagonist used in high doses to stimulate the appetite, decrease preoccupation with food, and combat depression. +oes not appear to have serious side effects, although decreased mental alertness may occur. 0ifts depression and stimulates appetite. %%8 s reduce binge-purge cycles and may also be helpful in treating anorexia. -ote: Bse must be closely monitored owing to potential side effects, although side effects from %%8 s are less significant than those associated with tricyclics. 8educes tension and anxiety/nervousness and may help client to participate in treatment. 1romotes weight gain and cooperation with psychotherapeutic program, however, used only when absolutely necessary because of extrapyramidal side effects. <ay be used to treat depression when other drug therapy is ineffective, decreases urge to binge in clients with bulimia. n rare and difficult cases in which malnutrition is severe/life-threatening, a short-term $5" series may enable the client to begin eating and become accessible to psychotherapy. "he underlying problem cannot be cured without improved nutritional status. 6ospitalization provides a controlled environment in which food inta#e, vomiting/elimination, medications, and activities can be monitored. t also separates the client from %>(s) and provides exposure to others with the same problem, creating an atmosphere for sharing.

NURSING DIAGNOSIS May B& R&!a$&d $o+

#LUID VOLUME d&) c $, ' s2 )o' o' ac$(a! &nade!uate inta'e o" "ood and li!uids *onsistent sel"-indu)ed vomiting *#roni)+ex)essive laxative or diureti) use

Poss -!y E% d&nc&d -y 3Ac$(a!4+

4r$ s'in and mu)ous mem.ranes de)reased s'in turgor &n)reased pulse rate .od$ temperature( #$potension Output greater t#an input (diureti) use%( )on)entrated urine+de)reased urine output (de#$dration% 5ea'ness *#ange in mental state 1emo)on)entration altered ele)trol$te .alan)e

D&s '&d O($com&s/E%a!(a$ on C' $&' a/ C! &n$ 0 !!+

6aintain+demonstrate improved "luid .alan)e as eviden)ed .$ ade!uate urine output sta.le vital signs moist mu)ous mem.ranes good s'in turgor. 2er.ali3e understanding o" )ausative "a)tors and .e#aviors ne)essar$ to )orre)t "luid de"i)it.

ACTIONS/INTERVENTIONS Ind&1&nd&n$
<onitor vital signs, capillary refill, status of mucous membranes, s#in turgor.

RATIONALE

ndicators of ade/uacy of circulating volume. >rthostatic hypotension may occur, with ris# of falls/in!ury following sudden changes in position. 5lient may abstain from all inta#e, resulting in dehydration, or may substitute fluids for caloric inta#e, affecting electrolyte balance. 6elping client deal with feelings that lead to vomiting and/or laxative/diuretic use may prevent continued fluid loss. -ote: "he client with bulimia has learned that vomiting provides a release of anxiety. nvolving client in plan to correct fluid imbalances improves chances for success.

<onitor amount and types of fluid inta#e. <easure urine output accurately as indicated. +iscuss strategies to stop vomiting and laxative/ diuretic use.

dentify actions necessary to regain/maintain optimal fluid balance (e.g., specific schedule for fluid inta#e).

Co!!a-o'a$ %&
8eview results of electrolyte/renal function test results. Administer/monitor 7, "1?, potassium supplements, as indicated. *luid/electrolyte shifts, decreased renal function can adversely affect clientFs recovery/prognosis and may re/uire additional intervention. Bsed as an emergency measure to correct fluid/electrolyte imbalance. <ay be re/uired to prevent cardiac dysrhythmias.

NURSING DIAGNOSIS May B& R&!a$&d $o+

THOUGHT PROCESSES, a!$&'&d Severe malnutrition+ele)trol$te im.alan)e /s$)#ologi)al )on"li)ts (e.g. sense o" lo, sel"-,ort# per)eived la)' o" )ontrol%

Poss -!y E% d&nc&d -y+

&mpaired a.ilit$ to ma'e de)isions pro.lem-solve Non7realit$-.ased ver.ali3ations &deas o" re"eren)e Altered sleep patterns e.g. ma$ go to .ed late (sta$ up to

.inge+purge% and get up earl$ Altered attention span+distra)ti.ilit$ /er)eptual distur.an)es ,it# "ailure to re)ogni3e #unger "atigue anxiet$ and depression D&s '&d O($com&s/E%a!(a$ on C' $&' a/ C! &n$ 0 !!+ 2er.ali3e understanding o" )ausative "a)tors and a,areness o" impairment. 4emonstrate .e#aviors to )#ange+prevent malnutrition. 4ispla$ improved a.ilit$ to ma'e de)isions pro.lem-solve.

ACTIONS/INTERVENTIONS Ind&1&nd&n$
Be aware of clientFs distorted thin#ing ability.

RATIONALE

Allows the caregiver to have more realistic expectations of the client and provide appropriate information and support. t is not possible to respond logically when thin#ing ability is physiologically impaired. "he client needs to hear reality, but challenging the client leads to distrust and frustration. mproved nutrition is essential to improved brain functioning. (8efer to ?+= ?utrition= altered, less than body re/uirements.) mbalances negatively affect cerebral functioning and may re/uire correction before therapeutic interventions can begin.

0isten to/avoid challenging irrational, illogical thin#ing. 1resent reality concisely and briefly.

Adhere strictly to nutritional regimen.

Co!!a-o'a$ %&
8eview electrolyte/renal function tests.

NURSING DIAGNOSIS May B& R&!a$&d $o+

BOD5 IMAGE d s$('-anc&/SEL# ESTEEM, ch'on c !o6 6or.id "ear o" o.esit$( per)eived loss o" )ontrol in some aspe)t o" li"e 8nmet dependen)$ needs personal vulnera.ilit$ *ontinued negative evaluation o" sel" 4$s"un)tional "amil$ s$stem

Poss -!y E% d&nc&d -y+

4istorted .od$ image (vie,s sel" as "at even in t#e presen)e o" normal .od$ ,eig#t or severe eman)iation% Expresses little )on)ern uses denial as a de"ense me)#anism and "eels po,erless to prevent+ma'e )#anges Expresses s#ame+guilt Overl$ )on"orming dependent on ot#ers9 opinions

D&s '&d O($com&s/E%a!(a$ on C' $&' a/

Esta.lis# a more realisti) .od$ image.

C! &n$ 0 !!+

A)'no,ledge sel" as an individual. A))ept responsi.ilit$ "or o,n a)tions.

ACTIONS/INTERVENTIONS Ind&1&nd&n$
$stablish a therapeutic nurse/client relationship. 1romote self-concept without moral !udgment.

RATIONALE

;ithin a helping relationship, client can begin to trust and try out new thin#ing and behaviors. 5lient sees self as wea#-willed, even though part of person may feel a sense of power and control (e.g., dieting/weight loss). 1rovides opportunity to discuss clientFs perception of self/body image and realities of individual situation. 5onsistency is important in establishing trust. As part of the behavior-modification program, client #nows ris#s involved in not following established rules (e.g., decrease in privileges). *ailure to follow rules is viewed as the clientFs choice and accepted by the staff in matter-of-fact manner so as not to provide reinforcement for the undesirable behavior. 5lient may be denying the psychological aspects of own situation and is often expressing a sense of inade/uacy and depression. *eelings of disgust, hostility, and infuriation are not uncommon when caring for these clients. 1rognosis often remains poor even with weight gain because other problems may remain. <any clients continue to see themselves as fat, and there is also a high incidence of affective disorders, social phobias, obsessive-compulsive symptoms, drug abuse, and psychosexual dysfunction. ?urse needs to deal with own response/feelings so they do not interfere with care of the client. *eelings of personal ineffectiveness, low selfconcept, and perfectionism are often part of the problem. 5lient feels helpless to change and re/uires assistance to problem-solve methods of control in life situations. 6elps direct energy away from eating/body image to other life-enhancing and personally satisfying activities. 5lient needs to recognize ability to control other areas in life and may need to learn problemsolving s#ills in order to achieve this control. %etting realistic goals fosters success. Aiving up an illness that has helped form the

6ave client draw picture of self.

%tate rules clearly regarding weighing schedule, remaining in sight during medication and eating times, and conse/uences of not following the rules. ;ithout undue comment, be consistent in carrying out rules.

8espond (confront) with reality when client ma#es unrealistic statements such as - Fm gaining weight, so thereFs nothing really wrong with me.. Be aware of own reaction to clientFs behavior. Avoid arguing.

Assist client to assume control in areas other than dieting/weight loss (e.g., management of own daily activities, wor#/leisure choices).

6elp client formulate goals for self (not related to eating) and create a manageable plan to reach those goals, a single goal at a time, progressing from simple to more complex. +iscuss the meaning of illness and effect of these

behaviors.

individualFs personal identity, the unconscious benefit of the -sic# role,. and the overvalued beliefs about an ideal body and the benefits of thinness must be addressed before the client can confront the full role the illness has played in the clientFs life. <a!or physical/psychological changes in adolescence can contribute to development of eating disorders. *eelings of powerlessness and loss of control of feelings (particularly sexual) and sensations lead to an unconscious desire to desexualize themselves. 5lients often believe that these fears can be overcome by ta#ing control of bodily appearance/development/function. -ote: %ome clients with anorexia believe staying small and emaciated will help #eep them childli#e (and therefore sexually unappealing), whereas clients with binge-eating disorders wish to remain obese, believing excess body fat will lessen sexual attraction. 5lient may use eating as a means of gaining control in life when sexual abuse has been experienced. <ay indicate feelings of isolation and fear of re!ection/!udgment by others. Avoidance of social situations and contact with others can compound feelings of worthlessness. 5lient often does not #now what she or he may want for self. 1arents (usually mother) often ma#e decisions for client. 5lient may also believe she or he has to be the best in everything and holds self responsible for being perfect. +eveloping a sense of identity as separate from family and maintaining sense of control in other ways, besides dieting and weight loss, is a desirable goal of therapy/program. 0earning about methods of enhancing personal appearance may be helpful to long-range sense of self-concept/image. *eedbac# from others can promote feelings of self-worth. 1rovides incentive to at least maintain and not lose weight. 8emoves visual reminder of thinner self. 1ositive image enhances sense of self-esteem. nteraction between persons is more helpful for the client to discover feelings/impulses/needs from within own self. 5lient has not learned this internal control as a child and may not be able to interpret or attach meaning to behavior. -ote: 5ognitive therapy is usually more effective for

Assist client to confront sexual fears. 1rovide sex education as necessary.

+etermine history of sexual abuse and institute appropriate therapy. ?ote clientFs withdrawal from and/or discomfort in social settings.

$ncourage client to ta#e charge of own life in a more healthful way by ma#ing own decisions and accepting self as is at this moment (including inade/uacies and strengths). 0et client #now that it is acceptable to be different from family, particularly mother.

nvolve in personal development program, preferably in a group setting. 1rovide information about proper application of ma#eup and grooming. %uggest disposing of -thin. clothes as weight gain occurs. 8ecommend consultation with an image consultant. Bse interpersonal psychotherapy approach rather than interpretive therapy.

clients diagnosed as bulimic or binge-eaters but may not be useful for anorectic clients during the period of acute hospitalization. $ncourage client to express anger and ac#nowledge when it is verbalized. mportant to #now that anger is part of self and as such is acceptable. $xpressing anger may need to be taught to client, because anger is often considered unacceptable in the family, and therefore client does not express it. *eelings are the underlying issue, and clients often use food instead of dealing with feelings appropriately. "herapeutic writing helps client recognize feelings and how to express them clearly and directly. 0ac# of control is a common/underlying problem for this client and may be accompanied by more serious emotional disorders. -ote: &@' of clients with anorexia have a history of ma!or affective disorder, and ::' have a history of minor affective disorder. ntensity of anxiety/panic about weight gain, depression, hopeless feelings may lead to suicidal attempts, particularly if client is impulsive.

Assist client to learn strategies other than eating for dealing with feelings. 6ave client #eep a diary of feelings, particularly when thin#ing about food.

Assess feelings of helplessness/hopelessness.

Be alert to suicidal ideation/behavior.

Co!!a-o'a$ %&
nvolve in group therapy. 8efer to occupational/recreational therapy. 1rovides an opportunity to tal# about feelings and try out new behaviors. 5an develop interests and s#ills to fill time that has been occupied by obsession with eating. nvolvement in recreational activities encourages social interactions with others and promotes fun and relaxation. Although exercise is often used negatively by these clients (i.e., for weight loss/control), directed activities provide an opportunity to learn self-reliance, enhance self-esteem, and realize that food is the fuel re/uired by the body to do its wor#. <ay need professional assistance to accept self as a sexual adult.

$ncourage participation in directed activities (e.g., bicycle tours, wilderness adventures, such as >utward Bound 1rogram).

8efer to therapist trained in dealing with sexuality.

NURSING DIAGNOSIS May B& R&!a$&d $o+

#AMIL5 PROCESSES, a!$&'&d &ssues o" )ontrol in "amil$ Situational+maturational )rises 1istor$ o" inade!uate )oping met#ods

Poss -!y E% d&nc&d -y+

4issonan)e among "amil$ mem.ers( "amil$ needs not .eing met :amil$ developmental tas's not .eing met &ll-de"ined "amil$ rules "un)tions and roles :o)us on ;identi"ied patient< (&/%( "amil$ mem.er(s% a)ting as ena.lers "or &/

D&s '&d O($com&s/E%a!(a$ on C' $&' a/ #am !y 0 !!+

4emonstrate individual involvement in pro.lemsolving pro)esses dire)ted at en)ouraging )lient to,ard independen)e. Express "eelings "reel$ and appropriatel$. 4emonstrate more autonomous )oping .e#aviors ,it# individual "amil$ .oundaries more )learl$ de"ined. =e)ogni3e and resolve )on"li)t appropriatel$ ,it# t#e individuals involved.

ACTIONS/INTERVENTIONS Ind&1&nd&n$
dentify patterns of interaction. $ncourage each family member to spea# for self. +o not allow 9 members to discuss a third without that memberFs participation. +iscourage members from as#ing for approval from each other. Be alert to verbal or nonverbal chec#ing with others for approval. Ac#nowledge competent actions of client. 0isten with regard when the client spea#s.

RATIONALE

6elpful information for planning interventions. "he enmeshed, overinvolved family members often spea# for each other and need to learn to be responsible for their own words and actions. $ach individual needs to develop own internal sense of self-worth. ndividual often is living up to othersF (familyFs) expectations rather than ma#ing own choices. Ac#nowledgment provides recognition of self in positive ways. %ets an example and provides a sense of competence and self-worth in that the client has been heard and attended to. 8einforces individualization and return to privacy. ndividuation needs reinforcement. %uch a message confronts rigidity and opens options for different behaviors. >ften these families have not allowed free expression of feelings and will need help and permission to learn and accept this. nappropriate interventions in family subsystems prevent individuals from wor#ing out problems successfully. "he focus on the child with an eating disorder is very intense and often is the only area through

$ncourage individuals not to answer to everything. 5ommunicate message of separation, that it is acceptable for family members to be different from each other. $ncourage and allow expression of feelings (e.g., crying, anger) by individuals. 1revent intrusion in dyads by other members of family. 8einforce importance of parents as a couple who have rights of their own.

which the couple interact. "he couple needs to explore their own relationship and restore the balance within it to prevent its disintegration. 1revent client from intervening in conflicts between parents. 6elp parents identify and solve their marital differences. "riangulation occurs in which a parent-child coalition exists. %ometimes the child is openly pressed to align with ( parent against the other. "he symptom or behavior (eating disorder) is the regulator in the family system, and the parents deny their own conflicts. *eelings of blame, shame, and helplessness may lead to unconscious behavior designed to maintain the status /uo. <ay help reduce overprotectiveness, support/ facilitate the process of dealing with unresolved conflicts and change.

Be aware of and confront sabotage behavior on the part of family members.

Co!!a-o'a$ %&
8efer to community resources, such as family group therapy, parentsF groups, as indicated, and 1arent $ffectiveness classes.

NURSING DIAGNOSIS May B& R&!a$&d $o+ Poss -!y E% d&nc&d -y+

S7IN INTEGRIT5, m1a '&d, ' s2 )o' o' ac$(a! Altered nutritional state( edema 4e#$dration+)a)#e)ti) )#anges (s'eletal prominen)e% 4r$+s)al$ s'in ,it# poor s'in turgor( tissue "ragilit$ Brittle+dr$ #air 4r$ ras# reports o" it)#ing dermal a.rasions ("rom s)rat)#ing%

D&s '&d O($com&s/E%a!(a$ on C' $&' a/ C! &n$ 0 !!+

2er.ali3e understanding o" )ausative "a)tors and relie" o" dis)om"ort. &denti"$ and demonstrate .e#aviors to maintain so"t supple inta)t s'in.

ACTIONS/INTERVENTIONS Ind&1&nd&n$
>bserve for reddened, blanched, excoriated areas. $ncourage bathing every other day instead of daily. Bse s#in cream twice a day and always after bathing. <assage s#in gently, especially over bony prominences. +iscuss importance of fre/uent change of position, need for remaining active.

RATIONALE

ndicators of increased ris# of brea#down re/uiring more intense treatment. *re/uent baths contribute to s#in dryness. 0ubricates s#in and decreases itching. mproves s#in circulation, enhances s#in tone. $nhances circulation and perfusion to s#in by preventing prolonged pressure on tissues.

$mphasize importance of ade/uate nutrition/fluid inta#e. (8efer to ?+= ?utrition= altered, less than body re/uirements.)

mproved nutrition and hydration will improve s#in condition.

NURSING DIAGNOSIS May B& R&!a$&d $o+

7NO0LEDGE d&) c $ 3LEARNING NEED4 '&"a'd n" cond $ on, 1'o"nos s, s&!) ca'& and $'&a$m&n$ n&&ds >a)' o" exposure to+un"amiliarit$ ,it# in"ormation resour)es( misinterpretation >a)' o" interest in learning >earned maladaptive )oping s'ills

Poss -!y E% d&nc&d -y+

2er.ali3ation o" mis)on)eption /reo))upation ,it# extreme "ear o" o.esit$ and distortion o" o,n .od$ image =e"usal to eat .inging+purging A.use o" laxatives+diureti)s( ex)essive exer)ising Expression o" desire to learn more adaptive ,a$s o" )oping ,it# stress or o" relations#ip o" )urrent situation and .e#aviors &nappropriate .e#aviors (e.g. apat#$%

D&s '&d O($com&s/E%a!(a$ on C' $&' a/ C! &n$ 0 !!+

2er.ali3e a,areness o" and plan "or li"est$le )#anges to maintain desired ,eig#t. &denti"$ relations#ip o" signs+s$mptoms (e.g. ,eig#t loss toot# de)a$% to .e#aviors o" not eating+.inge-purging. Assume responsi.ilit$ "or o,n learning. See' out sour)es+resour)es to assist ,it# ma'ing identi"ied )#anges. :ormulate plan to meet individual goals "or ,ellness.

ACTIONS/INTERVENTIONS Ind&1&nd&n$
+etermine level of #nowledge and readiness to learn. ?ote bloc#s to learning (e.g., physical/intellectual/ emotional).

RATIONALE

0earning is easier when it begins where the learner is. <alnutrition, family problems, drug abuse, affective disorders, obsessive-compulsive symptoms can interfere with learning, re/uiring resolution before effective learning can occur. 5lient/family may need assistance with planning for new way of eating. As constipation may occur when laxative use is curtailed, dietary considerations may prevent need for more aggressive therapy.

8eview dietary needs, answering /uestions as indicated. $ncourage inclusion of high-fiber foods and ade/uate fluid inta#e.

+iscuss conse/uences of behavior.

%udden death may occur owing to electrolyte imbalances, suppression of the immune system and liver damage may result from protein deficiency, or gastric rupture may follow bingeeating/vomiting. ?ew ways of coping with feelings of anxiety and fear will help client manage these feelings more effectively, assisting in giving up maladaptive behaviors of not eating/binging-purging. $xercise can help develop a positive body image and combats depression (release of endorphins in the brain enhances sense of well-being). 5lient may use excessive exercise as a way of controlling weight. 6elpful as reminder of and reinforcement for learning. Because avoidance of own sexuality is an issue for this client, realistic information can be helpful in beginning to deal with self as a sexual being. <ay be a helpful source of support and information for client and %>(s).

$ncourage the use of relaxation and other stressmanagement techni/ues (e.g., visualization, guided imagery, biofeedbac#). Assist with establishing a sensible exercise program. 5aution regarding overexercise.

1rovide written information for client/%>(s). +iscuss need for information about sex and sexuality.

8efer to ?ational Association of Anorexia ?ervosa and Associated +isorders, >vereaters Anonymous, and other local resources.