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Introduction
The hypothalamus contains the appetite
regulation center within the brain.
It regulates the body’s ability to recognize
when it is hungry and when it has been
sated.
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Epidemiological implication
Anorexia nervosa: Prolonged loss of
appetite.
Anorexia nervosa occurs predominantly in
females aged 12 to 30 years.
Less than 10 percent of the cases are
males
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Epidemiological implication Bulimia nervosa is more prevalent than
anorexia nervosa with estimates up to 4 percent of young women
Onset of bulimia nervosa occurs in late adolescence or early adulthood.
Crosscultural research suggests that bulimia nervosa occurs primarily in societies that place emphasis on thinness as the model of attractiveness for women and where an abundance of food is available
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Epidemiological implication Obesity has been defined as a body mass index
(BMI) (weight/height2) of 30 or greater. In the United States
statistics indicate that, among adults 20 years of age or older, 61 percent are overweight, with 27 percent of these in the obese
Obesity is more common in black women than in white women and more common in white men than in black men.
The prevalence among lower socioeconomic classes is six times that in upper socioeconomic classes, and there is an inverse relationship between obesity and level of education
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Nursing process
Assessment Anorexia nervosa is characterized by a morbid fear of obesity. Symptoms
include gross distortion of body image, preoccupation with food, and refusal to eat.
Intake of less than 200 calories.
The distortion in body image is manifested by the individual’s perception of being “fat” when he or she is obviously underweight or even emaciated.
Self-induced vomiting and the abuse of laxatives or diuretics
Weight loss is marked.
hypothermia, bradycardia, hypotension, edema, lanugo, and a variety of metabolic changes.
Amenorrhea
Compulsive behaviors, such as hand washing, may also be present.
Age at onset is usually early to late adolescence.
It is estimated to occur in approximately 1 percent of adolescent females, and is 10 times more common in females than in males
Psychosexual development is generally delayed.
Feelings of depression and anxiety often accompany this disorder beside affect disorder.
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ASSESSMENT Bulimia nervosa is an episodic, uncontrolled, compulsive, rapid ingestion of large quantities of
food over a short period of time (binging), followed by inappropriate compensatory behaviors to
rid the body of the excess calories.
The food consumed during a binge often has a high caloric content, a sweet taste, and a soft or
smooth texture that can be eaten rapidly, sometimes even without being chewed
The binging episodes often occur in secret and are usually terminated only by abdominal
discomfort, sleep, social interruption, or self-induced vomiting.
Although the eating binges may bring pleasure while they are occurring, self-degradation and
depressed mood commonly follow.
the individual may engage in purging behaviors (self-induced vomiting, or the misuse of
laxatives, diuretics, or enemas) or other inappropriate compensatory behaviors, such as fasting
or excessive exercise.
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There is a persistent overconcern with personal appearance, particularly regarding how they believe others perceive them.
Weight fluctuations are common because of the alternating binges and fasts.
most individuals with bulimia are within a normal weight range, some slightly underweight, some slightly overweight.
Excessive vomiting and laxative/diuretic abuse may lead to problems with dehydration and electrolyte imbalance. Gastric acid in the vomitus also contributes to the erosion of tooth enamel. In rare instances, the individual may experience tears in the gastric or esophageal mucosa.
Some people with this disorder are subject to mood disorders, anxiety disorders, substance abuse or dependence, most frequently involving amphetamines or alcohol
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Etiological Implications for
Anorexia Nervosa and Bulimia Nervosa
Biological Influences
Genetics: more common among sisters
and daughters of mothers with AN.
mood disorders among first-degree
biological relatives of people with anorexia
nervosa and bulimia nervosa and of
substance abuse and dependence in
relatives of individuals with bulimia nervosa
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Neuroendocrine Abnormalities
Hypothalamic dysfunction in anorexia
nervosa.
elevated cerebrospinal fluid cortisol levels
and a possible impairment of
dopaminergic regulation in individuals
with anorexia.
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Neurochemical Influences
in bulimia may be associated with the neurotransmitters serotonin and norepinephrine.
Some studies have found high levels of endogenous opioids in the spinal fluid of clients with anorexia, promoting the speculation that these chemicals may contribute to denial of hunger
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Psychodynamic Influences: mother-infant
relationship: disturbances lead to
retarded ego…
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Family Influences
Conflict Avoidance
Elements of Power and Control
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Background Assessment Data (Obesity)
Obesity is a factor in BED (Binge eating
disorder) because the individual binges on
large amounts of food (as in bulimia nervosa)
but does not engage in behaviors to rid the
body of the excess calories.
The BMI range for normal weight is 20 to 24.9
overweight is defined as a BMI of 25.0 to 29.9
Obesity BMI of 30.0 or greater.
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Obese people often present with hyperlipidemia, particularly elevated triglyceride and cholesterol levels.
They commonly have hyperglycemia and are at risk for developing diabetes mellitus.
Osteoarthritis may be evident owing to trauma to weight-bearing joints.
Work load on the heart and lungs is increased, often leading to symptoms of angina or respiratory insufficiency
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Etiological Implications
Genetics
Physiological Factors
Lesions in the appetite and satiety centers
in the hypothalamus
Hypothyroidism
Decreased insulin production of diabetes
mellitus and the increased cortisone
production of Cushing’s disease.
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Lifestyle Factors
Psychosocial influences
obese individuals have unresolved
dependency needs
fixed in the oral stage of psychosexual
development
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Nursing diagnosis Imbalanced nutrition: Less than body requirements related
to refusal to eat
Deficient fluid volume (risk for or actual) related to decreased fluid intake; self-induced vomiting; laxative and/or diuretic abuse
Ineffective denial related to retarded ego development and fear of losing the only aspect of life over which he or she perceives some control (eating)
Imbalanced nutrition: More than body requirements related to compulsive overeating
Disturbed body image/low self-esteem related to retarded ego development, dysfunctional family system, or feelings of dissatisfaction with body appearance
Anxiety (moderate to severe) related to feelings of helplessness and lack of control over life events
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Outcome
Has achieved and maintained at least 80
percent of expected body weight.
Has vital signs, blood pressure, and
laboratory serum studies within normal
limits.
Verbalizes importance of adequate
nutrition.
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Planning/Implementation
Tables 20–2 and 20–3 provide plans of
care for clients with eating disorders.
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Client/Family Education
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Treatment Modalities
Behavior modification
Individual therapy
Family therapy
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Psychopharmacology:
Fluoxetine (Prozac) and clomipramine (Anafranil) in clients with anorexia nervosa, and particularly those with depression or obsessive–compulsive symptoms.
Cyproheptadine (Periactin), in its unlabeled use as an appetite stimulant
antipsychotic chlorpromazine (Thorazine) have also been used to treat this disorder in selected clients.
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Fluoxetine (Prozac) has been found to be useful in the treatment of bulimia nervosa
A dosage of 60 mg/day (triple the usual antidepressant dosage) was found to be most effective with bulimic clients.
It is possible that fluoxetine, a selective serotonin reuptake inhibitor, may decrease the craving for carbohydrates, thereby decreasing the incidence of binge eating, which is often associated with consumption of large amounts of carbohydrates.
Other antidepressants, such as imipramine (Tofranil), desipramine (Norpramine), amitriptyline (Elavil), nortriptyline (Aventyl), and phenelzine (Nardil), also have been shown to be effective in controlled treatment studies
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Topiramate (Topamax), a novel anticonvulsant, in the long-term treatment of binge-eating disorder with obesity
Topiramate treat clients with bulimia nervosa.
Episodes of binging and purging decreased, and clients lost weight and reported a significant improvement in health-related quality of life when compared with the placebo group.
Fluoxetine has been successful in treating clients who are overweight
The effective dosage for promoting weight loss is 60 mg/day.
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Withdrawal from anorexiants may result in
a rebound weight gain and, in some
clients, a concomitant lethargy and
depression.
Two anorexiants that were once widely
used, fenfluramine and dexfenfluramine,
have been removed from the market
because of their association with serious
heart and lung disease.
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Sibutramine to treat obesity
Common side effects include headache, dry mouth, constipation and insomnia.
increased blood pressure, rapid heart rate, and seizures.
possible cardiac disease associated with the use of sibutramine.
Several individuals have claimed cardiovascular-related deaths in association with use of the drug.
Caution must be taken in prescribing this medication for an individual with a history of cardiac disease
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