Copyright © 2014. F.A. Davis Company Eating Disorders Eating Disorders Chapter 31

Copyright © 2014. F.A. Davis Company

Eating DisordersEating DisordersChapter 31Chapter 31


IntroductionIntroduction

• The hypothalamus contains the appetite regulation center within the brain.

• It regulates the body’s ability to recognize when it is hungry, when it is not hungry, and when it has been sated.


Introduction Introduction (cont.)(cont.)

• Eating behaviors are influenced by:– Society – Culture

• Historically, society and culture also have influenced what is considered desirable in the female body.


Epidemiological Factors Epidemiological Factors

• The prevalence rate of anorexia nervosa among young women in the United States is approximately 1 percent.

• Anorexia nervosa occurs predominantly in girls and women ages 12 to 30 years.


Epidemiological Factors (Epidemiological Factors (contcont.).)

• Bulimia nervosa is more prevalent than anorexia nervosa, with estimates up to 4 percent of young women.

• The onset of bulimia nervosa occurs in late adolescence or early adulthood.

• It occurs primarily in societies that emphasize thinness.


Epidemiological Factors (Epidemiological Factors (contcont.).)

• Obesity has been defined as a body mass index of 30 or greater.

• The number of adult Americans who are overweight is 68.5 percent, and 35 percent of these are in the obese range.


Application of Nursing ProcessApplication of Nursing Process

• Assessment– Anorexia nervosa

• Characterized by a morbid fear of obesity• Symptoms include gross distortion of body image,

preoccupation with food, and refusal to eat.


• Weight loss is extreme, usually more than 15 percent of expected weight.

• Other symptoms include hypothermia, bradycardia, hypotension, edema, lanugo, and a variety of metabolic changes.

Anorexia Nervosa (Anorexia Nervosa (contcont.).)


• Amenorrhea is typical and may even precede significant weight loss.

• There may be an obsession with food.• Feelings of anxiety and depression are common.




1. Which is characteristic of the diagnosis of anorexia nervosa?

A. Obsession with weight gainB. Body image disturbanceC. Disregard for the feelings of othersD. Healthy family relationships



• Correct answer: B– The distortion in body image by a client diagnosed

with anorexia nervosa is manifested by thoughts that they are fat when they are obviously underweight or even emaciated.


• Bulimia Nervosa

– Bulimia nervosa is an episodic, uncontrolled, compulsive, rapid ingestion of large quantities of food over a short period (binging).

– The episode is followed by inappropriate compensatory behaviors to rid the body of the excess calories (self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Nursing Process: Assessment Nursing Process: Assessment (cont.)(cont.)


– Fasting or excessive exercise may also occur.

– Most individuals with bulimia are within a normal weight range, some slightly underweight, some slightly overweight.

– Depression, anxiety, and substance abuse are not uncommon.

Bulimia Nervosa (Bulimia Nervosa (contcont.).)


– Excessive vomiting and laxative or diuretic abuse may lead to problems with dehydration and electrolyte imbalances.




2. Which assessment finding would the nurse expect in clients diagnosed with bulimia?

A. They are below normal weight.B. They binge when they experience hunger.C. They will be highly motivated to seek help.D. They are within their normal weight range.



• Correct answer: D– Clients diagnosed with bulimia nervosa are often

able to maintain a normal weight by purging after binging.


Anorexia Nervosa and Bulimia NervosaAnorexia Nervosa and Bulimia Nervosa

Predisposing Factors

• Biological Influences– Genetics: A hereditary predisposition to eating

disorders has been hypothesized. • Anorexia nervosa is more common among sisters and

mothers of those with the disorder than it is among the general population.

• Possible chromosomal linkage sites have been suggested.


• Biological Influences (cont.)– Neuroendocrine abnormalities: There has been

some speculation about a primary hypothalamic dysfunction in anorexia nervosa.

– Neurochemical influences:• Bulimia nervosa may be associated with the

neurotransmitters serotonin and norepinephrine.• Anorexia nervosa may be associated with high levels

of endogenous opioids.

Predisposing Factors (Predisposing Factors (contcont.).)


Predisposing Factors (Predisposing Factors (contcont.).)

• Psychodynamic Influences– Psychodynamic influences suggest that eating

disorders result from very early and profound disturbances in mother-infant interactions resulting in:

• Delayed ego development• Unfulfilled sense of separation-individuation


Predisposing Factors Predisposing Factors (cont.)(cont.)

• Family Influences– Conflict avoidance

• Families may promote and maintain psychosomatic symptoms, including anorexia nervosa, in an effort to avoid spousal conflict.

• The sick child becomes the problem, and focus on the conflict is diverted.



• Family Influences (cont.)– Elements of power and control

• Power and control may become the overriding elements within the family.

• Parental criticism promotes an increase in obsessive and perfectionistic behavior on the part of the child who continues to seek love, approval, and recognition.


Predisposing FactorsPredisposing Factors (cont.) (cont.)

• Family Influences (cont.)– Elements of power and control (cont.)

• Ambivalence toward the parents develops, and distorted eating patterns may represent rebellion against the parents.

• Eating disorder is seen as a way to gain control.


Nursing Process: AssessmentNursing Process: Assessment

• Obesity– A body mass index of 30 is considered obese.– Obesity can contribute to increases in morbidity

and mortality.


Obesity (Obesity (contcont.).)

– Obese people are at higher risk for: • Hyperlipidemia • Diabetes mellitus• Osteoarthritis • Angina• Respiratory insufficiency


• The DSM-5 identifies binge eating disorder (BED) as an eating disorder than can lead to obesity.

– The individual binges on large amounts of food, as in bulimia nervosa.

– BED differs from bulimia nervosa in that the individual does not engage in behaviors to rid the body of the excess calories.

Obesity (Obesity (contcont.).)


• Biological Influences– Genetics: 80 percent of children born of two

obese parents will also be obese.– Twin studies have also supported a hereditary

factor.

Predisposing Factors: Obesity (Predisposing Factors: Obesity (contcont.).)



• Biological Influences (cont.)– Physiological factors

• Lesions in the appetite and satiety centers of the hypothalamus

• Hypothyroidism• Decreased insulin production• Increased cortisone production


• Biological Influences (cont.)– Lifestyle factors

• Increased caloric intake• Sedentary lifestyle



• Psychosocial Influences– Unresolved dependency needs– Fixation in the oral stage of psychosexual

development




3. The nurse is teaching a class on obesity prevention. Which statement by a student indicates that learning about obesity has occurred?

A. “Obesity is classified as a psychiatric disorder in the DSM-5.”

B. “Obesity is defined as a body mass index (BMI) of 25.0 to 29.9.”

C. “Eighty percent of offspring of two obese parents are obese.”

D. “Lesions in the appetite center in the thalamus may contribute to obesity.”



• Correct answer: C– Genetics have been implicated in the

development of obesity. Research indicates that 80 percent of offspring of two obese parents are obese.


Nursing ProcessNursing Process

• Nursing Diagnoses

– Imbalanced nutrition: less than body requirements related to refusal to eat

– Deficient fluid volume (risk for or actual) related to decreased fluid intake, self-induced vomiting, and laxative and/or diuretic abuse


• Ineffective denial related to delayed ego development and fear of losing the only aspect of life over which he or she perceives some control (eating)

• Imbalanced nutrition: more than body requirements related to compulsive overeating

Nursing Process Nursing Process (cont.)(cont.)


Nursing Diagnoses Nursing Diagnoses (cont.)(cont.)

• Disturbed body image/low self-esteem related to retarded ego development, dysfunctional family system, or feelings of dissatisfaction with body appearance

• Anxiety (moderate to severe) related to feelings of helplessness and lack of control over life events



4. A client is 5’8’’ tall and weighs 105 pounds. The client has been taking laxatives daily, an self-induces vomiting after eating. Which is the priority nursing diagnosis for this client?

A. Ineffective denialB. Disturbed body imageC. Low self-esteemD. Imbalanced nutrition: less than body

requirements



• Correct answer: D– This client is malnourished and underweight due

to self-induced vomiting and laxative abuse. Nutritional status is compromised and this problem must be prioritized to establish physiological integrity.


OutcomesOutcomes

• The Client:– Has achieved and maintained at least 80 percent of expected body weight– Has vital signs, blood pressure, and laboratory serum studies within normal limits– Verbalizes importance of adequate nutrition


Outcomes (Outcomes (contcont.) .)

• The Client:– Verbalizes knowledge regarding consequences

of fluid loss caused by self-induced vomiting (or laxative/diuretic abuse) and importance of adequate fluid intake

– Verbalizes events that precipitate anxiety and demonstrates techniques for its reduction


Outcomes (Outcomes (contcont.).)

• The Client:

– Verbalizes ways in which he or she may gain more control of the environment and thereby reduce feelings of powerlessness

– Expresses interest in welfare of others and less preoccupation with own appearance



• The Client:

– Verbalizes that image of body as “fat” was misperception and demonstrates ability to take control of own life without resorting to maladaptive eating behaviors (anorexia nervosa).



• The Client (with obesity):

– Has established a healthy pattern of eating for weight control, and weight loss toward a desired goal is progressing

– Verbalizes plans for future maintenance of weight control


Planning and ImplementationPlanning and Implementation

• Nursing care of the client with an eating disorder is aimed at restoring nutritional balance.

• Emphasis is also placed on helping the client gain control over life situations in ways other than inappropriate eating behaviors.

• Self-esteem and positive self-image are promoted in ways that relate to aspects other than appearance.


Client/Family EducationClient/Family Education

• Nature of the Illness– Symptoms of anorexia nervosa and bulimia

nervosa– What constitutes obesity?– Causes of eating disorders– Effects of the illness or condition on the body


Client/Family Education (Client/Family Education (contcont.).)

• Management of the Illness

– Principles of nutrition– Ways client may feel in control of life– Importance of expressing fears and feelings,

rather than holding them inside– Alternative coping strategies



• Management of the Illness (cont.)

– Correct administration of prescribed medications– Indication for and side effects of prescribed

medications– Relaxation techniques– 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– Weight Watchers International– Overeaters Anonymous– National Association of Anorexia Nervosa

and Associated Disorders– National Eating Disorders Association


EvaluationEvaluation

• 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 client and family members.


Treatment ModalitiesTreatment Modalities

• Behavior Modification– Issues of control are central to the etiology of

these disorders.

– For the program to be successful, the client must perceive that he or she is in control of the treatment.


Treatment Modalities (Treatment Modalities (contcont.).)

• Behavior Modification (cont.)– 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



• Behavior Modification (cont.)– The client has control over:

• Eating• Amount of exercise pursued• Whether to induce vomiting

– Staff and client agree about:• Goals• System of rewards



• Behavior Modification (cont.)– The client has a choice whether to:

• Abide by the contract• Gain weight• Earn the desired privilege



• Individual Therapy– Helpful when underlying psychological

problems are contributing to the maladaptive behaviors.



• Family Therapy– Involves educating the family about the disorder– Assesses the family’s impact on maintaining the

disorder– Assists in methods to promote adaptive functioning by the client



• Psychopharmacology– No medications are specifically indicated for eating

disorders.– Various medications have been prescribed for

associated symptoms such as: • Anxiety • Depression


• Psychopharmacology (cont.)• Medications that have been tried with some

success include:– Anorexia nervosa

• Fluoxetine (Prozac)• Clomipramine (Anafranil)• Cyproheptadine (Periactin)• Chlorpromazine (Thorazine)• Olanzapine (Zyprexa)




success include:– Bulimia nervosa

• Fluoxetine (Prozac)• Imipramine (Tofranil)• Desipramine (Norpramine)• Amitriptyline (Elavil)• Nortriptyline (Aventyl)• Phenelzine (Nardil)




success include:

– Binge eating disorder with obesity• Topiramate (Topamax)




success include:

– Obesity• Fluoxetine (Prozac)• Various anorexiants (CNS stimulants)• Lorcaserin (Belviq)• Phentermine/topiramate (Qsymia)


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Copyright © 2014. F.A. Davis Company Eating Disorders Eating Disorders Chapter 31