Nursing Care Plan – Anorexia Nervosa / Bulimia Nervosa

Anorexia nervosa is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. It is often coupled with a distorted self image which may be maintained by various cognitive biases that alter how the affected individual evaluates and thinks about her or his body, food and eating. Persons with anorexia nervosa continue to feel hunger, but deny themselves all but very small quantities of food. The average caloric intake of a person with anorexia nervosa is 600-800 calories per day, but there are extreme cases of complete self-starvation. It is a serious mental illness with a high incidence of comorbidity and the highest mortality rate of any psychiatric disorde

Pathophysiology

Anorexia nervosa is the result of a complex interplay between biological, psychological, and social factors, which tend to affect women more than men, and adolescents more than older women. Some evidence suggests a higher rate of the disorder in monozygotic twins than in dizygotic twins, which may indicate a biologic predisposition.
Psychologically, prepubescent patients who subsequently develop anorexia nervosa have a high incidence of premorbid anxiety disorders. The onset of the disorder during puberty has led to the theory that, by exerting control over food intake and body weight, adolescents are attempting to compensate for a lack of autonomy and selfhood.

Individuals with anorexia nervosa maintain a lifelong increased incidence of anxiety, depressive disorders, and obsessive-compulsive disorder. Neurobiologists hypothesize that disruption of serotonergic pathways in the brain mediate the development of anorexia nervosa and may account for the frequent coexistence of other psychological disturbances.
The patient's altered body image results in a perception of fatness despite being normal or underweight. Attempts to correct this flaw through food restriction or purging lead to progressive malnutrition and eventually starvation. Modern preoccupation with slenderness and beauty in the Western world may contribute to the mindset of thinness as a valued quality in adolescents; however, this link has not been proven. A subset of adolescents who are temperamentally incapable of dealing with age-appropriate challenges without extreme reward-seeking behavior (thinness) may be susceptible to anorexia nervosa.
Malnutrition subsequent to self-starvation leads to protein deficiency and disruption of multiple organ systems. In addition to hypoglycemia and vitamin deficiencies, starvation results in release of endogenous opioids, hypercortisolemia, and thyroid function suppression.

Neuroendocrine disturbances result in delayed puberty, amenorrhea, anovulation, low estrogen states, increased growth hormone, decreased antidiuretic hormone, hypercarotenemia, and hypothermia. Decreased gonadotropin levels and hypogonadism may occur among males who are affected.

Cardiovascular effects include mitral valve prolapse, supraventricular and ventricular dysrhythmias, long QT syndrome, bradycardia, orthostatic hypotension, and shock due to congestive heart failure.
Renal disturbances include decreased glomerular filtration rate (GFR), elevated blood urea nitrogen (BUN), edema, acidosis with dehydration, hypokalemia, hypochloremic alkalosis with vomiting, and hyperaldosteronism.

Gastrointestinal findings include constipation, delayed gastric emptying, and gastric dilation and rupture when binge eating. Patients who induce vomiting develop dental enamel erosion, palatal trauma, enlarged parotids, esophagitis, Mallory-Weiss lesions, and elevated transaminase levels. Cases of superior mesenteric artery (SMA) syndrome from loss of intraperitoneal fat in AN as well as gastric rupture from bingeing and purging, leading to pneumothorax and pneumoperitoneum, have been reported

CARE SETTING

Acute care is provided through inpatient stay on medical or behavioral unit and for correction of severe nutritional deficits/electrolyte imbalances or initial psychiatric stabilization. Long-term care is provided in outpatient/day treatment program (partial hospitalization) or in the community.

RELATED CONCERNS

1. Dysrhythmias
2. Fluid and electrolyte imbalances
3. Metabolic alkalosis (primary base bicarbonate excess)
4. Total nutritional support: parenteral/enteral feeding
5. Psychosocial aspects of care
6. Patient Assessment Database

ACTIVITY/REST

May report: 

1. Disturbed sleep patterns, e.g., early morning insomnia; fatigue
2. Feeling “hyper” and/or anxious
3. Increased activity/avid exerciser, participation in high-energy sports
4. Employment in positions/professions that stress/require weight control (e.g., athletics such as gymnasts, swimmers, jockeys; modeling; flight attendants)

May exhibit: 
Periods of hyperactivity, constant vigorous exercising

CIRCULATION

May report: 
Feeling cold even when room is warm

May exhibit: 
Low blood pressure (BP)
Tachycardia, bradycardia, dysrhythmias

EGO INTEGRITY

May report: 

1. Powerlessness/helplessness lack of control over eating (e.g., cannot stop eating/control what or how much is eaten [bulimia]); feeling disgusted with self, depressed or very guilty because of overeating Distorted (unrealistic) body image, reports self as fat regardless of weight (denial), and sees thin body as fat; persistent overconcern with body shape and weight (fears gaining weight)
2. High self-expectations
3. Stress factors, e.g., family move/divorce, onset of puberty
4. Suppression of anger

May exhibit: 
Emotional states of depression, withdrawal, anger, anxiety, pessimistic outlook

ELIMINATION

May report: 

1. Diarrhea/constipation
2. Vague abdominal pain and distress, bloating
3. Laxative/diuretic abuse

FOOD/FLUID

May report: 

1. Constant hunger or denial of hunger; normal or exaggerated appetite that rarely vanishes until late in the disorder (anorexia)
2. Intense fear of gaining weight (females); may have prior history of being overweight (particularly males)
3. Preoccupation with food, e.g., calorie counting, gourmet cooking
4. An unrealistic pleasure in weight loss, while denying self pleasure in other areas
5. Refusal to maintain body weight over minimal norm for age/height (anorexia)
6. Recurrent episodes of binge eating; a feeling of lack of control over behavior during eating binges; a minimum average of two binge-eating episodes a week for at least 3
7. Regularly engages in self-induced vomiting (binge-purge syndrome bulimia) either
8. independently or as a complication of anorexia; or strict dieting or fasting

May exhibit: 

1. Weight loss/maintenance of body weight 15% or more below that expected (anorexia), or
2. weight may be normal or slightly above or below normal (bulimia)
3. No medical illness evident to account for weight loss
4. Cachectic appearance; skin may be dry, yellowish/pale, with poor tugor (anorexia)
5. Preoccupation with food (e.g., calorie counting, hiding food, cutting food into small pieces,rearranging food on plate)
6. Irrational thinking about eating, food, and weight
7. Peripheral edema
8. Swollen salivary glands; sore, inflamed buccal cavity; continuous sore throat (bulimia)
9. Vomiting, bloody vomitus (may indicate esophageal tearing [Mallory-Weiss syndrome])
10. Excessive gum chewing

HYGIENE

May exhibit: 

1. Increased hair growth on body (lanugo), hair loss (axillary/pubic), hair is dull/not shiny
2. Brittle nails
3. Signs of erosion of tooth enamel, gums in poor condition, ulcerations of mucosa

NEUROSENSORY

May exhibit: 

1. Appropriate affect (except in regard to body and eating), or depressive affect
2. Mental changes: Apathy, confusion, memory impairment (brought on by malnutrition/ starvation)
3. Hysterical or obsessive personality style; no other psychiatric illness or evidence of a
4. psychiatric thought disorder present (although a significant number may show evidence of an affective disorder)

PAIN/DISCOMFORT

May report: 
Headaches, sore throat/mouth, generalized vague complaints

SAFETY

May exhibit: 

1. Body temperature below normal
2. Recurrent infectious processes (indicative of depressed immune system)
3. Eczema/other skin problems, abrasions/calluses may be noted on back of hands from sticking finger down throat to induce vomiting

SEXUALITY

May report: 

1. Absence of at least three consecutive menstrual cycles (decreased levels of estrogen in response to malnutrition)
2. Promiscuity or denial/loss of sexual interest
3. History of sexual abuse
4. Homosexual/bisexual orientation (higher percentage in male patients than in general population)

May exhibit: 
Breast atrophy, amenorrhea

SOCIAL INTERACTION

May report: 

1. Middle-class or upper-class family background
2. History of being a quiet, cooperative child
3. Problems of control issues in relationships, difficult communications with others/authority
4. figures, poor communication within family of origin
5. Engagement in power struggles
6. An emotional crisis of some sort, such as the onset of puberty or a family move
7. Altered relationships or problems with relationships (not married/divorced), withdrawal from friends/social contacts
8. Abusive family relationships
9. Sense of helplessness
10. History of legal difficulties (e.g., shoplifting)

May exhibit: 
Passive father/dominant mother, family members closely fused, togetherness prized, personal boundaries not respected

TEACHING/LEARNING

May report: 

1. Family history of higher than normal incidence of depression, other family members with eating disorders (genetic predisposition)
2. Onset of the illness usually between the ages of 10 and 22
3. Health beliefs/practice (e.g., certain foods have “too many” calories, use of “health” foods)
4. High academic achievement
5. Substance abuse
6. Discharge plan
7. DRG projected mean length of inpatient stay: 6.4 days
8. Assistance with maintenance of treatment plan
9. Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES

1. Complete blood count (CBC) with differential: Determines presence of anemia, leukopenia, lymphocytosis. Platelets show significantly less than normal activity by the enzyme monoamine oxidase (thought to be a marker for depression).
2. Electrolytes: Imbalances may include decreased potassium, sodium, chloride, and magnesium.
3. Endocrine studies:
4. Thyroid function: Thyroxine (T4) levels usually normal; however, circulating triiodothyronine (T3) levels may be low.
5. Pituitary function: Thyroid-stimulating hormone (TSH) response to thyrotropin-releasing hormone (TRH) is abnormal in anorexia nervosa. Propranolol-glucagon stimulation test studies the response of human growth hormone (GH), which is depressed in anorexia. Gonadotropic hypofunction is noted.
6. Cortisol metabolism: May be elevated.
7. Dexamethasone suppression test (DST): Evaluates hypothalamic-pituitary function. Dexamethasone resistance indicates cortisol suppression, suggesting malnutrition and/or depression.
8. Luteinizing hormone (LH) secretions test: Pattern often resembles those of prepubertal girls.
9. Estrogen: Decreased.
10. MHP 6 levels: Decreased, suggestive of malnutrition/depression.
11. Serum glucose and basal metabolic rate (BMR): May be low.
12. Other chemistries: AST elevated. Hypercarotenemia, hypoproteinemia, hypocholesterolemia.
13. Urinalysis and renal function: Blood urea nitrogen (BUN) may be elevated; ketones present reflecting starvation; decreased urinary 17-ketosteroids; increased specific gravity/dehydration.
14. Electrocardiogram (ECG): Abnormal tracing with low voltage, T-wave inversion, dysrhythmias.

NURSING PRIORITIES

1. Reestablish adequate/appropriate nutritional intake.
2. Correct fluid and electrolyte imbalance.
3. Assist patient to develop realistic body image/improve self-esteem.
4. Provide support/involve significant other (SO), if available, in treatment program.
5. Coordinate total treatment program with other disciplines.
6. Provide information about disease, prognosis, and treatment to patient/SO.

DISCHARGE GOALS

1. Adequate nutrition and fluid intake maintained.
2. Maladaptive coping behaviors and stressors that precipitate anxiety recognized.
3. Adaptive coping strategies and techniques for anxiety reduction and self-control implemented.
4. Self-esteem increased.
5. Disease process, prognosis, and treatment regimen understood.
6. Plan in place to meet needs after discharge.