interventions client anorexia nervosa

Which of the following interventions would be appropriate for a client with anorexia nervosa?

Eating disorders mostly affect women aged 15-25 years (beat: Beating Eating Disorders, 2007a) but men are also affected.

Abstract

VOL: 103, ISSUE: 28, PAGE NO: 28

Lynn Walsh, MSc, BSc, RMN, RGN, RNT, DipPP, is lecturer, School of Health Sciences, University of Wales

A review of specialised care provision across the UK (Copperman, 2000) found that approximately 10% of people with eating disorders were men and that, as they were less likely to be diagnosed by GPs and psychiatrists, the illness was often well established before treatment was offered.

Eating disorders are caused by grossly disturbed eating behaviours. Several potential contributing factors are outlined in Box 1. beat (2007b) believes that 1.15 million people in the UK have a significant problem and between 60,000 and 90,000 people are receiving treatment for eating disorders. However due to the nature of the illness and the desire for patients to keep it a secret, many cases may go undiagnosed. For this reason, it is important for nurses to be vigilant when caring for patients in all care settings.

Anorexia nervosa and bulimia nervosa are the two most common eating disorders.

ANOREXIA NERVOSA

Anorexia nervosa is a chronic and severe disorder with a high incidence of morbidity and mortality (Gowers et al, 2000). Individuals who have anorexia nervosa:

- Fear obesity;

- Have a disturbed perception of their own body image;

- Suffer significant weight loss;

- Refuse to maintain normal body weight.

The age of onset is usually adolescence but anorexia can affect individuals from pre-puberty to middle age. The condition primarily affects young women but there is an increase in the disorder among younger males and nurses need to be aware of this.

In some people anorexia may occur as an acute episode but it can become a chronic condition suffered over many years. Signs and symptoms to look out for include:

- Weight loss;

- Refusal to eat;

- Appetite loss;

- Fear of becoming obese;

- Self-induced vomiting;

- Difficulty in swallowing;

- Use or abuse of laxatives;

- Constipation;

- Preoccupation with food, weight loss and/or body image.

Physical problems that stem from the condition - some of which can become life threatening - include electrolyte imbalance, bradycardia, hypotension, hypothermia, fatigue, oedema and amenorrhoea.

BULIMIA NERVOSA 

People with bulimia consume large amounts of food by binge eating, which is followed by vomiting or heavy laxative use known as purging behaviour. Bulimia occurs primarily in women during adolescence and early adulthood. Most individuals affected by bulimia remain within their normal weight range but their lives are controlled by this conflict with food.

Nurses are in a position to identify this behaviour and help patients to obtain the help and support required. The following signs and symptoms will help nurses to recognise bulimia (beat, 2007c):

- Inadequate nutritional intake;

- Overuse of laxatives and diuretics;

- Preoccupation with food, diet and weight;

- Induced vomiting after eating;

- Solitary eating or eating in secret;

- Fatigue;

- Distorted body image;

- Excessive exercise;

- Anxiety;

- Perfectionism;

- Poor interpersonal relationships.

ROLE OF THE NURSE

Having knowledge and understanding will enable nurses to monitor food intake and observe for potential eating disorders. Treatment will depend on an individual’s symptoms and relate specifically to the individual problem.

Patients may be cared for: in primary or secondary care environments; at home; as inpatients in a hospital, nursing or residential home; at a private clinic; or at an outpatient clinic. Nurses must remember that many patients may also be receiving treatment for other psychological or physical conditions and that the eating disorder may have a major impact on their overall condition.

It is essential to observe patients’ nutritional status as eating disorders can be life threatening. It is also important to ensure they maintain adequate nutrition and electrolyte balance. If an eating disorder has been identified, the nurse must monitor weight on a regular basis.

This can be achieved by encouraging the supervision of patients during and after mealtimes in order to prevent vomiting after eating. Setting time limits for each meal will help to set realistic expectations and encourage a relaxed atmosphere at mealtimes that will, in turn, help to reduce stress and anxiety. 

It is essential to monitor patients’ elimination pattern as excessive use of diuretics and laxatives is common among patients with eating disorders. As a consequence, patients may require intervention to treat constipation.

Monitoring skin condition for breakdown and poor healing is an important part of the nurse’s role. A lack of protein, needed to aid tissue repair, makes the skin more likely to break down. In addition, it is vital that good oral hygiene is achieved as recurrent vomiting may cause dental problems.

Finally, it is important to monitor patients’ activity levels. With anorexia they may undertake excessive exercise that can be detrimental to their physiological state. Additionally, if they also have a physical illness, excessive exercise could slow their recovery.

PSYCHOLOGICAL CARE

Nurses must be non-judgemental and accepting of patients with eating disorders. This can be achieved by building a trusting relationship and by encouraging patients to talk about their concerns.

An important part of the nurse’s role is to educate family and carers about a patient’s eating disorder. The family can then be encouraged to participate in the patient’s care and provide support. Observing for potential suicide risk must also be considered.

Within mental health settings, behaviour modification approaches are used to reward patients for weight gain. This positive reinforcement helps to encourage the desired behaviour.

It is important to ensure that patients take some responsibility for treatment of their condition. This can be achieved by establishing a contract with them over the amount and type of food to be eaten at each meal. By ensuring that positive feedback is given, compliance with the eating regimen can be maintained and patients’ self-esteem promoted.

The National Collaborating Centre for Mental Health developed a clinical guideline in relation to eating disorders for NICE (NICE, 2004). It produced core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders.

The following priorities were identified for patients with anorexia nervosa:

- Most people with anorexia are managed as outpatients and should be able to access specialised care;

- When requiring inpatient admission, people with anorexia will receive skilled implementation of refeeding with physical monitoring and psychological interventions;

- Appropriate family interventions will be provided for children and adolescents with anorexia nervosa.

The following core interventions are noted for care of those with bulimia nervosa:

- Patients diagnosed with bulimia nervosa will be encouraged to follow an evidence-based self-help programme;

- Adults with bulimia may also be offered a trial of an antidepressant drug;

- Cognitive behaviour therapy (CBT) programmes of 16-20 sessions over four or five months can be offered to adults with bulimia nervosa. Adolescents with bulimia can also be treated with CBT suitable for their age and circumstances. If possible, the family will be included as part of the individual’s treatment.

It is important that all nurses are knowledgeable about eating disorders and that they have appropriate understanding of the nursing care provided for vulnerable patients with eating disorders that often go unrecognised and undiagnosed. Nurses have an important role to play in supporting patients with eating disorders and in ensuring that they can and do access the treatment and support that is required.

LEARNING OBJECTIVES

- Understand the various causes of eating disorders

- Recognise the signs and symptoms of anorexia nervosa

- Recognise the signs and symptoms of bulimia nervosa

- Be aware of the nurse’s role in managing eating disorders

GUIDED LEARNING

- Identify signs and symptoms of eating disorders

- List factors that contribute to the development of these disorders

- Describe psychological aspects of care for people with eating disorders

- Outline physical problems resulting from eating disorders

This article has been double-blind peer-reviewed.

What interventions are effective for individuals with anorexia?

For anorexia nervosa, the family approach showed greater effectiveness. Other effective approaches were interpersonal psychotherapy, dialectic behavioral therapy, support therapy and self-help manuals.

What is the appropriate advice for a person with anorexia nervosa?

Instead of dieting, eat nutritious, balanced meals. Be mindful about how you talk about your body and your eating. Avoid self-critical remarks or negative comments about others' appearance. Instead, focus on the qualities on the inside that really make a person attractive.

What is the most effective way to approach the treatment of anorexia nervosa?

Treatment for anorexia is generally done using a team approach, which includes doctors, mental health professionals and dietitians, all with experience in eating disorders. Ongoing therapy and nutrition education are highly important to continued recovery.

What is an appropriate goal for a client with anorexia nervosa?

In general, the aims of psychological treatment are to promote weight gain and healthy eating, to reduce other eating disorder related symptoms and to promote psychological recovery.

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