Monday, May 24, 2010

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.

Posted bay Lifenurses. Contact me mail lifenurses


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