Nursing Care Plans for Bulimia Nervosa

Bulimia nervosa the binge and purge syndrome is an eating disorder, the essential features of bulimia nervosa include eating binges followed by feelings of guilt, humiliation, and self deprecation guilt, and anxiety over fear of weight gain. Characterized by extreme overeating, followed by self induced vomiting and abuse of laxatives, diuretics, strict dieting or fasting to overcome the effects of the binges. Unless the patient devotes an excessive amount of time to binging and purging, bulimia nervosa seldom is incapacitating. 

Bulimia nervosa usually begins in adolescence or early adulthood and can occur simultaneously with anorexia nervosa. The disorder occurs predominantly in females and begins in adolescence or early adult life. Between 1% and 3% of adolescent and young females meet the diagnostic criteria for bulimia nervosa; 5% to 15% have some symptoms of the disorder. 

Causes for Bulimia Nervosa 

The exact cause of bulimia is unknown, but bulimia is generally attributed to a combination of psychological, genetic, and physiological causes. Such factors include family disturbance or conflict, sexual abuse, maladaptive learned behavior, struggle for control or self-identity, cultural overemphasis on physical appearance, and parental obesity. Bulimia nervosa is strongly associated with depression. 

Complications for Bulimia Nervosa 

Dental caries result from repetitive vomiting in bulimia nervosa. Erosion of tooth enamel. Parotitis Gum infections. Arrhythmias and even sudden death result from electrolyte imbalances. Ipecac syrup intoxication can cause cardiac failure in patients who rely on this drug to induce vomiting. Esophageal tears and gastric ruptures rare complications. Mucosal damage can occur if patient with bulimia nervosa use laxatives. Potential psychiatric complication of bulimia nervosa is suicide. Bulimia nervosa patients are more prone to psychoactive substance use disorders. 

Nursing Assessment

Patient history of bulimia nervosa is characterized by episodic binge eating that may occur up to several times per day. The patient commonly reports a binge-eating episode during which she continues eating until abdominal pain, sleep, or the presence of another person interrupts it. The preferred food usually is sweet, soft, and high in calories and carbohydrate content. Unlike the anorexic patient bulimic patient usually can keep her eating disorder hidden, because patient’s weight frequently fluctuates, but usually stays within the normal range through the use of diuretics, laxatives, vomiting, and exercise. The patient may complain of abdominal and epigastric, Amenorrhea, Painless swelling of the salivary glands, hoarseness, throat irritation or lacerations, and dental erosion. In addition, the patient may exhibit calluses of the knuckles or abrasions and scars on the dorsum of the hand, resulting from tooth injury during self-induced vomiting. A bulimic patient commonly is perceived by others as a perfect student, mother, or career woman; an adolescent may be distinguished for participation in competitive activities, such as gymnastics, sports, or ballet. However, the patient’s psychosocial history may reveal an exaggerated sense of guilt, symptoms of depression, childhood trauma (especially sexual abuse), parental obesity, or a history of unsatisfactory sexual relationships. 

Symptomatology for Bulimia Nervosa 

Patients with Bulimia Nervosa usually solitary and secret and patients with Bulimia Nervosa able to consume thousands of calories in one episode. Loss of control to stop eating After the binge has begun Following the binge, the individual engages in inappropriate compensatory measures to avoid gaining weight (e.g., self-induced vomiting; excessive use of laxatives, diuretics, or enemas; fasting; and extreme exercising). Eating binges may be viewed as pleasurable but are followed by intense self-criticism and depressed mood. Individuals with bulimia are usually within normal weight range, some a few pounds underweight, some a few pounds overweight. Obsession with body image and appearance is a predominant feature of this disorder. Individuals with bulimia display undue concern with sexual attractiveness and how they will appear to others. Binges usually alternate with periods of normal eating and fasting. Excessive vomiting may lead to problems with dehydration and electrolyte imbalance. Gastric acid in the vomitus may contribute to the erosion of tooth enamel. Treatment Bulimia Nervosa Treatment of bulimia nervosa may continue for several years. Interrelated physical and psychological symptoms must be treated simultaneously. Merely promoting weight gain isn’t sufficient to guarantee long-term recovery. A patient whose physical status is severely compromised by inadequate or chaotic eating patterns is difficult to engage in the psychotherapeutic process. Psychotherapy focuses on breaking the binge-purge cycle and helping the patient regain control over eating behavior. Treatment may occur in either an inpatient or outpatient setting. It includes behavior modification therapy, possibly in highly structured psychoeducational group meetings. Individual psychotherapy and family therapy, which address the eating disorder as a symptom of unresolved conflict, may help the patient understand the basis of her behavior and teach her self-control strategies. Antidepressant drugs, particularly the selective serotonin reuptake inhibitor fluoxetine, may be used to supplement psychotherapy. The patient may also benefit from participation in self-help groups such as Overeaters Anonymous or in a drug rehabilitation program if she has a concurrent substance abuse problem. 

Nursing diagnosis

• Anxiety 
• Chronic low self-esteem 
• Constipation 
• Deficient fluid volume 
• Disturbed body image 
• Disturbed sleep pattern 
• Imbalanced nutrition: Less than body requirements 
• Ineffective coping 
• Social isolation 

Nursing Key outcomes

The patient will: State strategies to reduce levels of anxiety. Express positive feelings about self. Have regular bowel elimination patterns. Acknowledge change in body image. Verbalize feeling well rested. Display appropriate eating patterns, including regular, nutritious meals. Participate in decision-making about case. Interact with family or friends. Fluid balance will remain stable, with intake equal to or greater than output. 

Nursing interventions

Supervise the patient during mealtimes and for a specified period after meals, usually 1 hour. Set a time limit for each meal. Provide a pleasant, relaxed environment for eating. Using behavior modification techniques, reward the patient for satisfactory weight gain. Establish a contract with the patient, specifying the amount and type of food to be eaten at each meal. Encourage the patient to recognize and verbalize her feelings about her eating behavior. Provide an accepting and nonjudgmental atmosphere, controlling your reactions to her behavior and feelings. Encourage the patient to talk about stressful issues, such as achievement, independence, socialization, sexuality, family problems, and control. Identify the patient’s elimination patterns. Assess the patient’s suicide potential. Refer the patient and her family to the National Eating Disorders Association and the National Association of Anorexia Nervosa and Associated Disorders as sources of additional information and support. 

Nursing interventions for bulimia nervosa base on its nursing diagnosis: 

Nursing Diagnosis Imbalanced nutrition: Less than body requirements 

If client is unable or unwilling to maintain adequate oral intake, physician may order a liquid diet to be administered via nasogastric tube. Nursing care of the individual receiving tube feedings should be administered. In collaboration with dietitian, to provide realistic (according to body structure and height) weight gain, determine number of calories required to provide adequate nutrition. Explain to patient’s behavior modification program as outlined by physician. Explain benefits of compliance with prandial routine and consequences for noncompliance. Sit with client during mealtimes for support and to observe amount ingested. Give to the patient a time limit for meals. Client should be observed for at least 1 hour following meals. Client may need to be accompanied to bathroom. Weigh client daily; use same scale, if possible. Do not discuss food or eating with client. 

Nursing Diagnosis Deficient fluid volume 

Teach client importance of daily fluid intake of 2000 to 3000 ml. This information is required to promote client safety and plan nursing care. Keep strict record of intake and output. Weigh client daily; use same scale, if possible. Assess and document condition of skin turgor and any changes in skin integrity. Hot water and soap are drying to the skin, .Discourage client from bathing every day if skin is very dry. Monitor laboratory serum values, and notify physician of significant alterations. Client should be observed for at least 1 hour after meals and may need to be accompanied to the bathroom if self-induced vomiting is suspected. Assess and document moistness and color of oral mucous membranes. To minimizing risk of tissue infection. Encourage frequent oral care to moisten mucous membranes, reducing discomfort from dry mouth, and to decrease bacterial count. Help client identify true feelings and fears that contribute to maladaptive eating behaviors. 

Nursing Diagnosis Ineffective coping 

Establish a trusting relationship with. When nutritional status has improved, begin to explore with client the feelings associated with his or her extreme fear of gaining weight, Explore family dynamics. Help client to identify his or her role contributions and their appropriateness within the family system Initially, allow client to maintain dependent role. To deprive the individual of this role at this time could cause his or her anxiety to rise to an unmanageable level. Give Positive reinforcement to increases self-esteem and encourages the client to use behaviors that are more acceptable. Explore with client ways in which he or she may feel in control within the environment, without resorting to maladaptive eating behaviors. 

Patient teaching for Bulimia Nervosa 

To monitor the treatment progress Teach the patient how to keep a food journal. Teach about risks abuse of laxative, emetic, and diuretic to the patient. To help the patient gain control over her behavior and achieve a realistic and positive self-image Provide assertiveness training. If the patient is taking a prescribed tricyclic antidepressant, instruct her to take the drug with food. Warn her to avoid consuming alcoholic beverages; exposing herself to sunlight, heat lamps, or tanning beds; and discontinuing the medication unless she has notified the physician.

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Nursing Care Plans For Delusional Disorder

The diagnosis of delusional disorder can be made when a person exhibits non-bizarre delusions of at least 1 month duration that cannot be attributed to other psychiatric disorders. Non-bizarre delusions must be about phenomena that, although not real, are within the realm of being possible. In general, the patient’s delusions are well systematized and have been logically developed. The person’s behavioral and emotional responses to the delusions appear to be appropriate. Usually the person’s functioning and personality are well preserved and show minimal deterioration if at all. 

Characteristics of delusional disorder

• Non-bizarre delusions of at least 1 month’s duration 
• No positive or negative symptoms of schizophrenia present 
• Tactile or olfactory hallucinations may be present and related to the delusional theme 
• Functioning not markedly impaired and behavior not obviously bizarre or odd 
• Only brief mood episodes, if any 
• Not due to direct physiologic effects of a chemical or a general medical condition 

Etiology of delusional disorder 

Etiology of the delusional disorder is unknown. Risk factors associated with the disorder include advanced age, sensory impairment/isolation, family history, social isolation, personality features (e.g. unusual interpersonal sensitivity), and recent immigration. Some have reported higher association of delusional disorder with widowhood, celibacy, and history of substance abuse. Age of onset is later than schizophrenia and earlier in men compared to women. 

Subtypes of delusional disorder 

Persecutory Type 

Here the person affected believes that he or she is being followed, spied on, poisoned or drugged, harassed, or conspired against. The person affected may get preoccupied by small slights that can become incorporated into the delusional system. These individuals may resort to legal actions to remedy perceived injustice. Individuals suffering from these delusions often become resentful and angry with a potential to get violent against those believed to be against them. 

Jealous Type 

Individuals with this subtype have the delusional belief that their spouses/lovers are unfaithful. Jealousy is a powerful emotion and when it occurs in delusional disorder or as part of another condition, it can be potentially dangerous and has been associated with violence including suicidal and homicidal behavior. Delusions of infi delity have also been called conjugal paranoia . The term Othello syndrome has been used to describe morbid jealousy. 

Erotomanic Type 

Persons with delusional disorder of the erotomanic type have delusions of being loved by another. The patient believes that a perceived suitor, usually more socially prominent than herself, is in love with her. Erotomania shares many features with, is derived from, and is often referred to as de Clerambault’s syndrome. 

Somatic Type 

Delusional disorder with somatic delusions has been called monosymptomatic hypochondriacal psychosis . This disorder differs from other conditions with hypochondriacal symptoms in degree of reality impairment. Munro ( 1991 ) has described the largest series of cases and has used content of delusions to defi ne three main types: 

Delusions of Infestations (Including Parasitosis). 

Delusional parasitosis has been described in association with many physical illnesses such as vitamin B 12 defi ciency, pellagra, neurosyphilis, multiple sclerosis, thalamic dysfunction, hypophyseal tumors, diabetes mellitus, severe renal disease, hepatitis, hypothyroidism, mediastinal lymphoma, and leprosy. Use of cocaine and presence of dementia has also been reported. Psychogenic parasitosis was also known as Ekbom’s syndrome before being referred to as delusional parasitosis . 

Delusions of Dysmorphophobia 

This condition includes delusions such as of misshapenness, personal ugliness, or exaggerated size of body parts. 

Delusions of Foul Body Odors or Halitosis. 

This is also called olfactory reference syndrome. 

Grandiose Type 

This is also referred to as megalomania . In this subtype, the central theme of the delusion is the grandiosity of having made some important discovery or having great talent. Sometimes there may be a religious theme to the delusional thinking such that the person believes that he or she has a special message from god. 

Mixed Type 

This subtype is reserved for those with two or more delusional themes. However, it should be used only where it is difficult to clearly discern one theme of delusion. This subtype is used for cases in which the predominant delusion cannot be subtyped within the above mentioned categories. A possible example is certain delusions of misidentification, for example, Capgras’s syndrome , named after the French psychiatrist who described the ‘illusions of doubles.’ The delusion here is the belief that a familiar person has been replaced by an imposter. A variant of this is Fregoli’s syndrome where the delusion is that the persecutors or familiar persons can assume the guise of strangers and the very rare delusion that familiar persons could change themselves into other persons at will (intermetamorphosis). 

COMPLICATIONS of delusional disorder If left undiagnosed, untreated, or ineffectively treated, schizophrenia can lead to profound inability to function and contribute to the problem of homelessness in our society. Neglect of other medical conditions; therefore, complications due to untreated medical illness are common. Depression and suicide. Substance use, abuse, or dependency. 

Nursing Diagnosis Delusional Disorder 

Nursing Diagnosis for Delusional Disorder determine from what we found in Nursing Assessment Nursing Care Plans for Delusional Disorder. 

Nursing assessment nursing care Plans for Delusional Disorders Assess for positive symptoms of schizophrenia. These symptoms reflect aberrant mental activity and are usually present early in the first phase of the schizophrenic illness. 

Alterations in Thinking 

• Delusion: false, fixed belief that is not amenable to change by reasoning. The most frequent elicited delusions include: Ideas of reference. Delusions of grandeur. Delusions of jealousy. Delusions of persecution. Somatic delusions. 
• Loose associations: the thought process becomes illogical and confused. 
• Neologisms: made-up words that have a special meaning to the delusional person. 
• Concrete thinking: an overemphasis on small or specific details and an impaired ability to abstract. 
• Echolalia: pathologic repeating of another’s words. 
• Clang associations: the meaningless rhyming of a word in a forceful way. 
• Word salad: a mixture of words that is meaningless to the listener. 

Alterations in Behavioral Responses 

• Bizarre behavioral patterns Motor agitation and restlessness Automatic obedience or robotlike movement Autonomic obedience or robotlike movement Negativism Stereotyped behaviors Stupor Waxy flexibility (allowing another person to reposition extremities) 
• Agitated or impulsive behavior 
• Assess for negative symptoms of schizophrenia that reflect a deficiency of mental functioning Alogia (lack of speech) Anergia ( inability to react) Anhedonia ( inability to experience pleasure) Avolition (lack of motivation or initiation) Poor social functioning Poverty of speech Social withdrawal Thought blocking 
• Assess for associated symptoms of schizophrenia Substance use, abuse, or dependence Depression Fantasy Violent or aggressive behavior Water intoxication Withdrawal 

Common nursing diagnosis found in Nursing Care Plans for Delusional Disorder 

• Disturbed Thought Processes related to perceptual and cognitive distortions, as demonstrated by suspiciousness, defensive behavior, and disruptions in thought
• Social Isolation related to an inability to trust 
• Activity Intolerance related to adverse reactions to psychopharmacologic drugs 
• Ineffective Coping related to misinterpretation of environment and impaired communication ability 
• Risk for Self-directed or Other-directed Violence related to delusional thinking and hallucinatory experiences 

Nursing Care Plans for Delusional Disorder 

Nursing Care Plans For Delusional Disorder, delusional disorder diagnosis can be made when a person exhibits nonbizarre delusions of at least 1 month duration that cannot be attributed to other psychiatric disorders. Nonbizarre delusions must be about phenomena that, although not real, are within the realm of being possible. In general, the patient’s delusions are well systematized and have been logically developed. The person’s behavioral and emotional responses to the delusions appear to be appropriate. Usually the person’s functioning and personality are well preserved and show minimal deterioration if at all. 

Nursing Care Plans Delusional Disorder with nursing diagnosis; Disturbed Thought Processes, Social Isolation, Activity Intolerance, Ineffective Coping, Risk for Self-directed or Other-directed Violence.

NURSING DIAGNOSE	NURSING OUTCOME	INTERVENTION	EVALUATION
Disturbed Thought Processes related to perceptual and cognitive distortions, as demonstrated by suspiciousness, defensive behavior, and disruptions in thought	Patient showed the Differentiation Between Delusions and Reality	Provide patient with honest and consistent feedback in a nonthreatening manner. Avoid challenging the content of patient's behaviors. Focus interactions on patient's behaviors. Administer drugs as prescribed while monitoring and documenting patient's response to the drug regimen. Use simple and clear language when speaking with patient. Explain all procedures, tests, and activities to patient before starting them, and provide written or video material for learning purposes.	Exhibits improved reality orientation, concentration, and attention span as demonstrated through speech and behavior
Social Isolation related to an inability to trust	Patient showed the Promoting Socialization	Encourage patient to talk about feelings in the context of a trusting, supportive relationship. Allow patient time to reveal delusions to you without engaging in a power struggle over the content or the reality of the delusions. Use a supportive, empathic approach to focus on patient's feelings about troubling events or conflicts. Provide opportunities for socialization and encourage participation in group activities. Be aware of patient's personal space and use touch judiciously. Help patient to identify behaviors that alienate significant others and family members.	Communicates with family and staff in a clear manner without evidence of loose, dissociated thinking
Activity Intolerance related to adverse reactions to psychopharmacologic drugs	Patient showed the Improving Activity Tolerance	Assess patient's response to prescribed antipsychotic drug. Collaborate with patient and occupational and physical therapy specialists to assess patient's ability to perform ADLs. Collaborate with patient to establish a daily, achievable routine within physical limitations. Teach strategies to manage adverse effects of antipsychotic drug that affect patient's functional status, including: Change positions slowly Gradually increase physical activities Limit overdoing it in hot, sunny weather Use sun precautions Use caution in activities if extrapyramidal symptoms develop.	Independently maintains personal hygiene without fatigue
Ineffective Coping related to misinterpretation of environment and impaired communication ability	Patient showed the Improving Coping with Thoughts and Feelings	Encourage patient to express feelings. Focus on patient's feelings and behavior. Provide honest perceptions of reality and feedback about symptoms and behaviors. Encourage patient to explore adaptive behaviors that increase abilities and success in socializing and accomplishing ADLs. Decrease environmental stimuli.	Attends group activities
Risk for Self-directed or Other-directed Violence related to delusional thinking and hallucinatory experiences	Safety appears	Monitor patient for behaviors that indicate increased anxiety and agitation. Collaborate with patient to identify anxious behaviors as well as the causes. Tell patient that you will help with maintaining behavioral control. Establish consistent limits on patient's behaviors and clearly communicate these limits to patient, family members, and health care providers. Secure all potential weapons and articles from patient's room and the unit environment that could be used to inflict an injury. To prepare for possible continued escalation, form a psychiatric emergency assist team and designate a leader to facilitate an effective and safe aggression-management process. Determine the need for external control, including seclusion or restraints. Communicate the decision to patient and put plan into action. Frequently monitor patient within the guidelines of facility's policy on restrictive devices and assess the patient's level of agitation. When patient's level of agitation begins to decrease and self-control is regained, establish a behavioral agreement that identifies specific behaviors that indicate self-control against a reescalation of agitation.	Remains free from harm or violent acts

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Nursing care Plans for Bipolar disorder

Bipolar disorder

Nursing care Plans for Bipolar disorder. Bipolar disorder these disorders are characterized by mood swings from profound depression to extreme euphoria (manic), with intervening periods of normalcy. Some patients suffer from acute attacks of mania only. 

Bipolar I Disorder 

Bipolar I disorder is the diagnosis given to an individual who is experiencing, or has experienced, a full syndrome of manic or mixed symptoms. The client may also have experienced episodes of depression. 

Bipolar II Disorder

Bipolar II disorder is characterized by recurrent bouts of major depression with the episodic occurrence of hypomania. This individual has never experienced a full syndrome of manic or mixed symptoms. 

Cyclothymia Disorder 

A variant of bipolar disorder, numerous episodes of hypomania and depressive symptoms are too mild to meet the criteria for major depression or bipolar illness. The essential feature is a chronic mood disturbance of at least 2 years’ duration, involving numerous periods of depression and hypomania 

Treatment for Bipolar disorder 

Lithium proves highly effective in relieving and preventing manic episodes. But has a narrow therapeutic range, so treatment must be initiated cautiously and the dosage adjusted slowly. The drug curbs the accelerated thought processes and hyperactive behavior without the sedating effect of antipsychotic drugs. In addition, it may prevent the recurrence of depressive episodes; however, it’s ineffective in treating acute depression. 

Valproic acid is an alternative to lithium. Antidepressants occasionally are used to treat depressive symptoms. However, these drugs may trigger a manic episode. 

Nursing diagnosis nursing care Plans for Bipolar disorder 

Common nursing diagnosis found in Nursing care Plans for Bipolar disorder: 

• Risk for suicide 
• Chronic low self-esteem 
• Disturbed personal identity 
• Disturbed thought processes 
• Impaired social interaction 
• Ineffective coping 
• Ineffective health maintenance 
• Ineffective role performance 

Nursing interventions nursing care Plans for Bipolar disorder 

Nursing interventions for Bipolar disorder With nursing diagnosis Risk for suicide 

Nursing Diagnosis	Outcomes	Interventions	Evaluation
Risk for suicide	·     Client will seek out staff when feeling urge to harm self ·     Client will make short-term verbal (or written) contract with nurse not to harm self. ·     Client will not harm self. ·     Client verbalizes no thoughts of suicide. ·     Client commits no acts of self-harm. ·     Client is able to verbalize names of resources outside the hospital from whom he or she may request help if feeling suicidal.	·     Ask client directly: about how when where you will harming yourself? If so, what do you plan to do? Do you have the means to carry out this plan?” ·     Create a safe environment for the client. ·     Remove harmful objects e.g (glass, belts, rope, bobby pins). ·     Supervise his medications. ·     Institute suicide precautions as dictated by facility policy. ·     Formulate a short-term verbal or written contract with the client that he or she will not harm self. ·     Secure promise from client that he or she will seek out a staff member or support person if any thoughts of suicide. ·     Maintain close observation of client. Place in room close to nurse’s station; do not assign to private room ·     Make rounds at, irregular intervals. ·     Encourage verbalizations of honest feelings.  Through exploration and discussion, help client to identify symbols of hope in his or her life. ·     Encourage client to express angry feelings within appropriate limits. Provide safe method of hostility release. Help client to identify true source of anger and to work on adaptive coping skills for use outside the treatment setting. ·     Identify community resources that client may use as support system and from whom he or she may request help if feeling suicidal. ·     Orient client to reality. ·     Spend time with client.	Client will not harm self.

Patient teaching nursing care Plans for Bipolar disorder 

• Drugs may cause adverse reactions If the patient is taking lithium, teach him and his family to discontinue the drug and notify the physician if signs of toxicity occur, including diarrhea, abdominal cramps, vomiting, unsteadiness, drowsiness, muscle weakness, polyuria, and tremors. 
• Lithium may impair mental and physical function; caution against driving or operating dangerous equipment while taking the drug. 
• Teach the patient the importance of continuing his medication regimen even when he doesn’t feel a need for it. 
• Advise the patient to discontinue medications only with the physician’s approval because abrupt withdrawal could cause severe symptoms.

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