Transcript Revised-anorexia-unfolding-case-study.1.28.13-final-app

Linda Manfrin-Ledet, DNS, APRN
Amanda Eymard, DNS, RN, CNE
Scott Bellanger, BSN, RN
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Forcano, L. Alvarez, E., Santamaria, J.J.,
Jimenez-Murcia, S., Granero, R. Penelo, E.
…Fernandez-Aranda, F. (2011). Suicide
attempts in anorexia nervosa subtypes.
Comprehensive Psychiatry, 52(4), 352-358.
Quality and Safety Education for Nurses
(QSEN). www.qsen.org
Stuart , G. (2013). Principles and Practice of
Psychiatric Nursing (10th ed.). Chapter 24,
pages 477-497.
Jamie is a 14-year-old female that recently transfer
to a new high school after her family moved across
states. This is her third residence and school
change in the last 5 years. Jamie’s father is in the
military service and recently returned home after a
tour in Iraq for 6 months. Jamie has a two year
history of restricted food intake. Jamie is 5’6” tall
and weighs 98 pounds. She is on the dance team at
school and is an honor roll student.
The school nurse notices that Jamie frequently
eats only an apple during lunch. The nurse is
also concerned that Jamie seems to get easily
fatigued during the dance team practices. Jamie
is very thin and fragile in appearance. She does
not seem as strong, physically, as she did in past
practices during the beginning of the school
year.
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What are the school nurse’s concerns about
Jamie?
Reflect on Jamie’s background and the impact
that her background may have on her present
state.
In general, what are some
predisposing factors for the
development of eating disorders
(ED)?
 Personal Factors?
 Family Factors?
 Sociocultural?
Personal Factors
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Weight
Puberty/maturation
Body image
disturbance
Restricted eating
Perfectionism
Stress
Poor coping skills
Substance abuse
History of abuse
Family Factors
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Parental attitudes
Family functioning
Sociocultural Factors
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Media influences
Social pressure
Peer pressure and
attitudes about weight
Teasing
Activities that have an
emphasis on beauty or
fitness
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Jamie’s dad was not able to be around over the
last several months. It will be important to
work with a family therapist to allow the
patient to discuss her feelings about dad not
being around.
In regards to the living situation, Jamie’s family
moved 3 times in the last 5 years.
Meeting many new people, losing friends, and
not having a solid foundation can create a
tremendous amount of stress which can
antagonize the ED.
Evidence-Based Practice (EBP): “Integrate best
current expertise and patient/family preferences
and values for delivery of optimal care.”
Skills: “Base individualized care plan on patient
values, clinical expertise and evidence.”
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Anorexia nervosa
Bulimia nervous
Binge eating disorder
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Anorexia nervosa
Anorexia nervosa: is a serious, life-threatening, mental
disorder that is characterized by self-imposed starvation,
intense and irrational beliefs about one’s body image, and
excessive weight loss. It’s onset is usually between the
ages of 13-20 years of age, but this illness can occur in any
age group. It occurs mostly in females (94%), but it can
occur in males. For some, this is a chronic illness, but
many recover within 5 years. Vomiting, purging, bulimia,
and obsessive-compulsive personality symptoms are
associated with a least favorable outcome.
Symptomology associated with anorexia
nervosa
 Prolonged loss of appetite
 Refusal to eat
 Morbid fear of obesity
 Preoccupation with food
 Distorted body image
 Perception of being “fat,” when they are
severely underweight or emaciated
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Review Jamie’s health record on file.
Assess record for any health issues which
correlate with weight loss, and fatigue.
Possibly contact Jamie’s parents.
Possibly consult the guidance counselor at
Jamie’s school.
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Talk with Jamie in private setting about
concerns and observations. Therapeutic
relationships are essential in the recovery
process.
Make family contact in the presence of Jamie.
QSEN Highlight
Patient-centered Care - Skills: “Remove barriers
to presence of families and other designated
surrogates based on patient preferences.”
Give examples of therapeutic
communication techniques to
use during communication with
Jamie and her family :
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The development of eating disorders are rarely
about food. It is important for the patient to
gain insight on the causes of the eating
disorder.
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What questions would the nurse ask Jamie and
her parents while assessing Jamie’s history?
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Stressors?
Medical history?
Medication history?
Previous hospitalizations?
Eating habits?
Attitudes toward food?
Perceptions of Jamie’s body image?
Exercise history?
Any previous psych history?
History of suicide attempts?***
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Depressive symptoms, severe anxiety, and
purging in individuals with anorexia nervosa is
a sign of elevated risk for suicide (Forcano et
al., 2011)
Forcano, L. Alvarez, E., Santamaria, J.J., Jimenez-Murcia, S., Granero, R.
Penelo, E. …Fernandez-Aranda, F. (2011). Suicide attempts in anorexia
nervosa subtypes. Comprehensive Psychiatry, 52(4), 352-358.
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“Safety: Minimizes risk of harm to patients and
providers through both system effectiveness
and individual performance.”
(www.qsen.org/competencies/pre-licensureksas/#safety)
What should the nurse do next?
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Remain with Jamie at all times.
Notify Jamie’s parents.
Notify Jamie’s doctor.
Arrange for transportation to mental health
hospital
What are the signs and symptoms/clinical
presentation that the nurse should assess?
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Physical signs and symptoms?
Psychological signs and symptoms?
Behavioral signs and symptoms?
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Low body mass index
(BMI)
Emaciation, weight loss
Hypotension
Bradycardia
Cardiac arrhythmias
Dehydration
Lethargy
Amenorrhea
Hunger denied
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Constipation
Abdominal pain
Muscle weakness
Cold intolerance
Lanugo
Dental caries
Hand calluses
Knuckle abrasions
Poor skin turgor
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Distorted body image
Depression
Irritability
Anxiety
Socially withdrawn
Self-deprecating
thoughts
Insomnia
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Substance abuse
Impaired
concentration
Decreased libido
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Cutting food into tiny
pieces
Ritualistic behaviors
with food
Regularly eating alone
Preoccupation with
food or weight loss
Binging
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Purging or selfinducted vomiting
Excessive use of
laxatives, diuretics,
enemas, or diet pills
Excessive exercise
Frequently
evaluation/measuring
of self
Jamie is admitted to a mental health
hospital. What are some of the criteria for
hospitalization for individuals with an ED?
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More than 15% below normal body weight
Activity Intolerance
Life threatening lab values such as low
hemoglobin, low hematocrit, potassium,
hypotension, bradycardia
Imbalanced nutrition less than body requires
Electrolyte Imbalance
Disturbed Body Image
Anxiety
 Situation
 Background
 Assessment
 Recommendation
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Imbalanced Nutrition, less than body required
Risk for Electrolyte Imbalance
Fatigue
Risk for Activity Intolerance
Disturbed Body Image
Powerlessness
Chronic or Situational Low Self-Esteem
Risk for Self Mutilation
Patient-centered Care: “Recognize the patient or
designee as the source of control and full partner
in providing compassionate and coordinated care
based on respect for patient’s preferences, values,
and needs.”
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Admit labs to obtain a baseline:
CBC, CMP, TSH, MG, Phosphorus, Prealbumin, Amylase, Direct bilirubin, urine drug
test, Urinalysis, Urine Pregnancy Test,
Estrodial.
Anorexia Nervosa can affect these labs. It is
important to monitor these labs weekly for any
deterioration in the patient’s condition.
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Amylase level needs to be monitored.
Amylase level may increase due to secretions
associated with purging behaviors.
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Education regarding anorexia nervosa, and what to
expect during treatment to reduce patient’s anxiety
Monitor meals for restrictive behaviors
Monitor and document I/O
Supervise patient for 2 hours after each meal and
snack to make sure patient is not purging food
(vomiting, over exercising)
Administer medications as ordered and monitor
the effects and possible side effects
A full physical exam should be performed
A psychiatric exam and history
Monitor for edema, order support hose if needed
Admit and weekly lab tests
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Family sessions, individual sessions, sessions with
their nutritionist and psychiatrist. An interprofessional team approach is best to yield the
highest success rate.
Dental consult if history of purging
Orthostatic vitals daily
Weigh consistently while inpatient
Provide dietary information, education and meal
planning. The nutritionist will create a meal plan so
the patients gains (usually ½ lb. a day)
A balanced diet to improve activity intolerance,
fatigue, electrolyte imbalance and imbalanced
nutrition
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Multivitamins
Fiber supplements (make sure patient takes with full glass of
water)
Calcium supplements due to osteopenia and osteoporosis.
Medications for relief of constipation.
Anti-anxiety medications as needed.
Selective Serotonin Reuptake Inhibitors (SSRIs) are
sometimes prescribed due to the high levels of depression
associated with ED.
Synthroid if hypothyroidism is indicated.
Medications used to treat indigestion are common.
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Restore weight (0.5lbs daily).
Positive self image.
Normal body weight, decrease of ED
behaviors, decease in anxiety r/t food.
Have balanced nutritional intake.
Exhibit lab values within normal ranges.
Increase patient’s energy level.
Correct body image distortions.
Identify social support systems.
Patient-centered Care: Knowledge – “Describe
strategies to empower patients or families in all
aspects of the health care process.”