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MH: Lecture 12- Nutrition and Eating D/os
Terms in this set (61)
What are factors r/t nutrition across the life spectrum?
-Economic: access = health disparities
-Cultural: traditions, beliefs, symbols
-Religious: rituals, practices
-Societal: media, fam, peer influences
-Age: developmental continuum, physiological needs
-Chronic illness: physiological
What are the diff types of eating d/os?
-Anorexia nervosa (AN)
-Bulimia nervosa (BN)
-Eating disorder NOS (unspecified)
-Binge eating d/o (BED)
-Female athletic triad (FAT) → not official DSM dx
What is an eating d/o overview?
-S/sxs + dxs overlap, on a continuum → dx usually based on weight
-Rare "pure" EDS dx → can jump b/t diff dxs
What are common BWs for diff EDS?
-Bulimic: near normal to overwt
What is the epi r/t EDS?
-All are common, incidence rising
-Prevalence: female 13-35, younger at higher risk (adolescent, young adult), female > male, male athletes/models/gay-identified, underdx in men, geriatric (chronic anorexia)
-Bulimia to anorexia common
What are risk/protective factors to EDS?
-Risk: diet, food focused, social influence (peer pressure)
-Protective: non-western culture, no emphasis on thinness, no dieting
What personal/family hx factors are r/t EDS?
-Sexual abuse hx
-Psych hx: high rates past depression, anxiety, ASPD/BPD/avoidant → self-consciousness others aware of eating habits
Is anorexia nervosa dangerous?
-YES → highest mortality rate of any psych d/o
-Suicide rate → higher than general pop (likely major cause death)
What are nature/nurture etiologies of EDS?
-Environmental: twin studies, trauma, sports emphasizing thinness, dieting, teasing, bullying
cause EDS except r/t
→ multiple genes, 1st degree relative; empowerment models = tx → focus on self-esteem
What is the temperament role in diff EDS?
Harm avoidant, neurotic, obsessional, anxious, low self-esteem =
-AN: low novelty seeking, reward development, perfectionistic
-BN: high novelty seeking, impulsive/multi-impulsive (focus on many things)
What is a summary of AN?
-Females: 15-19 y/o, age onset ~10-20 yrs
-Influences: environmental, psych, socio-cultural, familial/genetic predispo, temperament
What is the DSM-V criteria for AN?
-Low BW: refusal to maintain BW→ at/above minimally normal wt for developmental stage (age/ht) OR wt loss lead to BW <85% expected OR failure make expected wt gain during growth pd; BMI <17.5 in adults
-Intense fear gaining wt or becoming fat and/or persistent behavior interfere w/ wt gain
-Disturbance in body image (self conscious, denial current low BW)
-Ritual w/ food, peculiar food handling
What are DSM-V changes to AN?
-No amenorrhea crit, but still important to assess (absence 3 consec pds OR pd only w/ hormonal assistance estrogen) → deleted to include OCP/HRTs, post-menopausal
-2 types → restricting, binging/purging
What are common psych traits of AN pts?
-Self perception, body image disturbance
-Obsessive thinking r/t food, wt
-Perfectionistic, need be in control
-Phobia being overwt
-Denial/poor insight → refusal accept wt
-Mood → chronically low, low self esteem/self efficacy, swings, depression, hopelessness, helpless
: cog tx → address cog distortion, control issues; neuropsych impairment = v higher doses of meds
What are common behavioral traits of AN pts?
-Compulsive rituals r/t eating, exercise → eat/chew/cut in specific bites, secretive eating, food restriction
-Peers positively reinforce wt loss
: social withdrawal, self-harm, substance abuse, suicide
-Excessive needs please others
-Psychodynamic perspective → girls don't mature → starve off physical development
-Constant weighing, mirror-checking
-Affect → sensitivity abt BW → irritable, aggression
: behavioral tx → contracts, reinforcements
What is the anorexia behavioral pattern?
Fear getting fat → striving lose wt → diet/physical exertion → wt loss → hormonal/physiological changes (amenorrhea) → depression, cog d/os → fear getting fat
What are neuro findings in AN?
-Structural/functional brain change
-Reduced blood flow to temporal lobe
What are metabolic findings in AN?
-Increased muscle/fat metabolism → fatty liver → non-alc fatty liver disease, elevated LFTs
-Constipation r/t reduced BMR
-Endocrine dysfx → amenorrhea, slow breast development
-Refeeding syndrome → low phos, liver failure
-Sexual → decreased libido, impotence, fertility issues
What are VS changes in AN?
-Inappropriate sinus tach
-Hypothermia, cold intolerance
What are CV findings in AN?
-Poor circulation (pallor)
-Blue/purple extremities, bruising
What are orthopedic findings in AN?
-Low CA intake/absorption, reduced estrogen secretion
-Pain, difficulty moving extremities
What are derm findings in AN?
-Lanugo (fine, soft hair)
-Head hair thinning
-Dry, chapped lips
-Carotenemia (orange hue) r/t hypercholesterolemia → defect in conversion carotene to Vit A → hypothyroidism
What are HEENT findings in AN?
What is refeeding syndrome?
-Potentially fatal shifts in F&E in malnourished pts receiving artificial refeeding (enterally, parenterally)
-Starts 1-4 days of re-starting foods after starvation
-F&E imbalances → hypo-phosphatemia; neuro, pulm, CV, NM, hematologic, liver complications
After starvation, what are effects upon refeeding?
-Sudden shift fat → carb metabolism (increase BMR) → increase insulin level → increase cell uptake of phos (low serum phos)
-Decrease serum electrolytes (Ph, K, Mg, glucose, thiamine)
-Increase cardiac workload/HR → acute CHF
-Increase O2 consumption → strain resp system → resp failure + difficulty weaning off vents
: all these can result in confusion, coma, convulsions, death
What are the lab abnormalities in AN?
-Reduction in WBC → reduced immune system
What is the priority tx of AN?
-Safety → focus on immediate wt gain, use target wt goals (90% avg for ht/wt), balance RN use of scales w/ over-focus on pt weighing self → nourishes brain, NT normalcy = med efficacy
-De-emphasis on scales/wts
-Discuss health risks
What is included in pharm management of AN?
-Meds = lesser role
: many studies discourage for most part
-SSRIs: fluoxetine (Prozac) for relapse prevention
-Antipsychotics: olanzapine, risperidone, quetiapine
-Zinc supplementation → increase appetite = wt gain, increase NT effectiveness
What is included in psychotherapy of AN?
-No specific individual psychotherapy
-DBT/CBT all used w/ some benefit
-Referral to family-based tx (FBT) → Maudslev approach
What health risks need to be discussed w/ AN pts?
-Physical, emotional, hormone, NT changes
-Pt/fam education r/t health, nutrition, ideal BW for age/ht, adequate eating
-Serious cases → involuntary hospital committal, tx needed
-Majority of AN pts are in outpt → specialty referral
: multi-disciplinary care team → MD, RN, endo, orthopedic, MH specialist
What are effects of hypophosphatemia?
What are effects of hypokalemia?
What are effects of hypomagnesemia?
What groups are at risk for refeeding syndrome?
-Elderly (comorbid, decreased physiological reserve)
-LT antacid/diuretic users → electrolyte imbalances
-Chronic malnutrition → prolonged fasting, low energy diet, morbid obese w/ profound wt loss, high stress, malabsorptive syndrome (IBD, chronic pancreatitis, CF, short bowel syndrome)
How do you ID high risk people for refeeding probs?
-1+ s/sx: BMI <16, unintentional wt loss >15% past 3-6 mo, little/no nutritional intake >10 days, low levels K/Ph/Mg before feeding
-2+ s/sx: BMI <18.5, unintentional wt loss >10% past 3-6 mo, little/no nutritional intake >5 days; hx SUDs, insulin, chemo, antacids, diuretics
What are the nursing interventions for refeeding syndrome?
-ID pts at risk → communicate findings early
-Ensure serial labs ordered (K, Ca, Ph, Mg), monitor
-Follow protocols, order for slow refeeding regimen + Vit supplementation
-Recommended: thiamine, Vit B complex, MVI, mineral supplementation (PO/IM); labs regularly until stable
What is the typical regimen for refeeding?
-Incr 200 kcal PO qday every 2-3 days (slow)
-Initial diet restriction, nutrition consult → modest protein/kcal increases
-Monitor VS, labs, daily wts, PA for fluid/flood overload (avoiding CV/liver damage)
What is a summary of BN?
-Age of onset: 14-18
-Typically normal wt, overweight
-Etiologies similar to AN → detached family environment, behavioral prob
What is the BN DSM-V criteria?
-Recurrent "binge" episodes → eating amt food during discrete pd time large than most people would eat, lack control over eating
-Recurrent "purge" episodes → inappropriate compensatory behavior occur w/ binge at least 1x week for 3 mo → vomiting, laxatives, diuretics, enemas, exercise, fasting
-Persistent concern over BW
What is the cyclical behavioral pattern of bulimia?
Begins w/ skipping meals sporadically → over-restrict, dieting, fasting → purge (vomit, laxatives, excess exercise) + guilt, shame, depression, anxiety → repeat
What are physical findings in bulimia?
-Loss dental enamel
-Russel's sign → abrasions on knuckles b/c fingers down throat, hydrochloric acid
-Parotid enlargement (chipmunk cheeks)
-Esophagitis, mallory-weiss tears (decrease esophageal lining d/t increased gastric acid)
-Barret's syndrome, esophageal cancer
-Ipecac sequelae → stay in muscle fibers for long time → low K+, renal/cardiac dysfx → saggy, baggy heart risks
What is the tx for BN?
-Meds: Topiramate (Topamax) = anti-convulsant → block cravings for opiates, cocaine, ETOH, food; careful b/c can cause wt loss, dumbs down
-Max autonomy w/ choices
-CBT tools → contracts, cog reframing
-Maintain advocacy, support
-Refferal to psychotherapy, support groups, family tx, individual DBT
: SSRI's, but Wellbutrin (Buproprion) → be careful w/ increased seizure risk
What are AN/BN med complications?
-Dental erosion of enamel
-CV risks, sudden death
What is a summary of BED?
-New DSM-V category
-Occurs esp in women, do well in controlled diet programs, but regain wt after stop diet
-Often obese, overwt
-Distinguishing factor → no behavior to prevent wt gain
What is the BED DSM-V criteria?
On avg 1 day/wk x 3 mos w/ 3+ s/sxs
-Recurrent binge-eating episodes → same as bulimia
-S/sxs: eat v rapidly, eat until feel uncomfortably full, eat large amts when not hungry, eat alone b/c embarrassed by large amt eating, feel disgusted w/ self/depressed/guilty after overeat
-Marked distress, impairment in fxing
What are secondary/tertiary interventions for BED?
-Similar to BN
-Support groups → overeaters anon (OA)
-Psychotherapy → CBT, MI tools/stages of change
-Avg wt loss = 2-4 lbs/week
What are meds used for BED?
-Topamax (Topiramate) → anticonvulsant, mood stabilizer; SE is wt loss, dumbs down
-Belvig (Lorcaserin) → 5HT2c blocker, acts as appetite suppressant (anorectic)
-Vyvanse (lisdexamfetamine dimesylate) → ADD drug, stimulant, schedule 2 risks
What is the female athlete triad?
-Epi: female, sports, college athletes
amenorrhea, aberrant/altered eating habits, osteoporosis
-Interventions: similar to AN, HRT doesn't replace/reverse effects, Fosamax may help + Vit D supplements
What is a summary of EDS interventions?
-Primary: family ed, childhood eating practices, exercise, lifestyle mod, temperament, values on weight/body/self-image/self efficacy
-Secondary: ID high risk groups, assess all pts, early intervention in childhood/adolesc, referrals
-Tertiary: nurse-pt contract, CBT/DBT, educate consequences, relapse prevention, group therapy, EDS support groups, family therapy
What is a summary of nursing dx's for EDS?
-Nutrition, imbalanced: less than body requirements
-Nutrition, readiness for enhanced
-Self care deficit, feeding
-Fluid volume, risk for deficient/imbalanced
-Coping, readiness for enhanced family
-Coping, compromised family
-Knowledge, readiness for enhanced
-Body image, disturbed
What is a summary of EDS outcomes?
-ST: target wts, improved physiological fxn, labs
-LT: wts, psychosocial
What is a summary of nursing interventions for EDS?
-Physiological, basic nutritional pt/fam edu
-Monitor refeeding, manage nutritional requirements
-Monitor I&Os, VS, F&E, daily wts
-Observe behavior during/after meals, bathrooms
-Avoid discuss food, restaurants
-Limit setting, behavioral contracts
-Mandatory tube feedings (low wt, high risk abnormal labs)
-Scale + target wts
-Pharmacotherapy if needed → Topamax, SSRI, zinc
What is a summary of psychosocial/support interventions for EDS?
-Cog tools → positive reframe
-Motivational tools at bedside → stages of change (pre-contemplative = risk/cons, contemplative = benefits/pros, planning, maintenance = strengths, support, removal barriers); OARS (open ended, affirm, reflect, summarize)
-Behavioral → s/sx management, relapse prevention → coping tools, ID triggers, role-play, progressive relaxation, contracts
-Referrals → fam therapy (Maudsley tx), individual (CBT/DBT/IPT), groups (recovery model), residential, PHP, outpt programs
What is DBT?
-Structured cognitive behavioral therapy w/ workbooks, homework
-Balances acceptance of maladaptive behaviors w/ ongoing work to change
-Integrates wide range strategies, multi-disciplinary team
What 4 problem solving tools does DBT introduce?
-Mindfulness (attention to experience, improve moment)
-Interpersonal effectiveness (accept reality)
-Emotional regulation (reduce vulnerability to negative emotions, steps increasing positive emotions)
-Distress tolerance (distraction)
What is a summary of motivational interviewing?
-Based on model (stages) of change
-Understand resistance as attempt to preserve ego-syntonic nature EDS → don't label as resistant tho
-External locus control often strongest predictor relapse → pt doing tx to appease parents, partners, but not self = try to shift to internal locus of control (responsibility on pt)
-Create cog dissonance (pt own conflict in thinking) ambivalence
What is the acronym OARS?
pen ended questions
What is the acronym READS?
oll w/ resistance
What are the goals/interventions for a pt in pre-contemplation for EDS?
-Goals: move towards next stage, pt begin thinking about change
-Interventions: present cons of behaviors/recovery process, trust, TC, limit-setting, explore priorities/values understand what motivates behavior, don't try convince to change
What are the goals/interventions for a pt in contemplation for EDS?
-Goals: move towards next stage, self-efficacy, hope that change possible
-Interventions: present pros of behavior change, explore barrier to recovery, foster relationships, experiment w/ small behavior change, instill hope, avoid lecturing, avoid underestimate ambivalence (roll w/ resistance)
What are the interventions/special txs for a pt in action for EDS?
-Interventions: validate difficulty of change, ID triggers/barriers, offer support/structure, provide opportunities see what helps/hinders change, list supports/resources/skills/relapse prevention tools, ID who help keep accountable
-Specialty: ropes challenge, equine therapy symbolic of struggle
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