Nurse Care Plan

Bulimia nervosa (BN) is an eating disorder that is characterized by repeated episodes of binge eating. During binges, the individual rapidly consumes large amounts of high-caloric food (upward of 2000 to 5000 calories), usually in secrecy. The binge is followed by self-deprecating thoughts, guilt, and anxiety over fear of weight gain. Purging is used to relieve these fears. The strict definition used by the Diagnostic and Statistical Manual of Mental Disorders indicates that persons need to have two binge-eating episodes per week for at least 3 months. Most bulimic patients purge by inducing vomiting or using laxatives, but some use excessive exercise and diuretics. The individual is caught in a binge-purge cycle that can recur multiple times each day, several times a week, or at an interval of up to 2 weeks to months. Bulimic patients experience frequent weight fluctuations of 10 pounds or more but are usually able to maintain a near-normal weight.

As persons with anorexia nervosa (AN) mature, they may turn to bulimic behavior as a way of controlling food intake. In contrast to people with AN, bulimic individuals are aware that their behavior is abnormal but conceal their illness because of embarrassment. Persons with bulimia typically have difficulty with direct expression of feelings, are prone to impulsive behavior, and
may have problems with alcohol and other substance abuse. Because they can maintain a near normal weight and, if females, have regular menstrual periods, the problem may go undetected. Bulimic behaviors have been known to persist for decades. Depending on the severity and duration of the condition, there are significant health consequences. Chronic induced vomiting of stomach contents produces volume depletion and a hypochloremic alkalosis. Dizziness, syncope, thirst, orthostatic changes in vital signs, and dehydration occur with volume depletion. Renal compensation for the metabolic alkalosis and volume depletion leads to further electrolyte imbalances, which may predispose the AN patient to cardiac dysrhythmias, muscle cramps, and weakness. Discoloration of the teeth and dental caries are common because of chronic self-induced vomiting. Laxative abuse is a potentially dangerous form of purging, leading to volume depletion, increased colonic motility, abdominal cramping, and loss of electrolytes in a watery diarrhea. Irritation of intestinal mucosa or hemorrhoids from rapid and frequent stools may cause rectal bleeding. When laxative abuse stops, transient fluid retention, edema, and constipation are common.

The cause of BN is unknown, but bulimia is generally attributed to a combination of psychological, genetic, and physiological causes. The onset occurs in late adolescence when the individual has left or is preparing to leave home. Experts suggest that the stress and depression that accompany this transition lead to binging and purging as a way of coping with these changes. Obesity usually precedes the onset of bulimia , and strict dieting usually triggers the binge-purge cycling. Changes in neurotransmitter metabolism, and in particular serotonin, and response to antidepressants suggest a biochemical component to the condition. Cultural pressures toward thinness may also contribute to the onset of bulimia .

Nursing care plan assessment and examination
Bulimic patients often report a family history of affective disorders, especially depression. The patient may describe patterns of weight fluctuation and frequent dieting, along with a preoccupation with food; this cluster of characteristics may be the first sign of bulimia . Complaints such as hematemesis, heartburn, constipation, rectal bleeding, and fluid retention may be the initial reasons the patient seeks healthcare from a primary healthcare provider. Patients may also have evidence of esophageal tears or ruptures, such as pain during swallowing and substernal burning. If patients seek treatment for bulimia , they usually have exhausted a variety of ways to control their binging and purging behavior. A detailed history of dieting, laxative and diuretic use, and the frequency and pattern of binging and purging episodes is essential. You may need to make a direct inquiry about binging and purging patterns for those patients who are seeking help but are ashamed to volunteer the information. Assess which foods and situations are most likely to trigger a binge.

Often, no symptoms are noted on the physical examination. Obtain the patient’s weight and compare it with the normal weight range for age and height. In patients with chronic vomiting, you may notice parotid swelling, which gives the patient a characteristic “chipmunk” facial appearance. Assess the patient for signs of dehydration such as poor skin turgor, dry mucous membranes, and dry skin. Note dental discoloration and caries from excessive vomiting, scars on the back of the hand from chronic self-induced vomiting, and conjunctival hemorrhages. Poor abdominal muscle tone may be evidence of rapid weight fluctuations. Tearing or fissures of the rectum may be present on rectal examination because of frequent enemas. A neurological assessment is important to rule out possible signs of a brain tumor or seizure disorder. Chronic hypokalemia from laxative or diuretic abuse may lead to an irregular pulse or even cardiac arrest and sudden death.

Assess the patient’s current career goals, peer and intimate relationships, psychosexual development, self-esteem, and perception of body image. Pay particular attention to any signs of depression and suicidal ideation and behavior. Assess the patient’s ability to express feelings and anger; determine the patient’s methods for coping with anxiety, as well as impulse control. Assess the family’s communication patterns, especially how the family deals with conflict and solves problems. Assess the degree to which the family supports the patient’s growth toward independence and separation.

Nursing care plan primary nursing diagnosis: Altered nutrition: Less than body requirements related to recurrent vomiting after eating; excessive laxative and diuretic use; and preoccupation with weight, food, or diets.

Nursing care plan intervention and treatment
Patients with bulimia generally do not need hospitalization unless they experience severe electrolyte imbalance, dehydration, or rectal bleeding. The bulimia is usually managed with individual behavioral and group therapy, family education and therapy, medication, and nutritional counseling. Work with the interdisciplinary team to coordinate efforts and refer the patient to the physician to evaluate the need for antidepressants and anti-anxiety medication. Work with the patient to evaluate the effectiveness of antidepressant or antianxiety medications, as well as to explore ways to identify situations that precede depression and anxiety. Work with the dietitian to ensure that the patient is educated about appropriate nutrition and dietary intake. Encourage the patient to participate in individual, family, and group sessions to help the patient develop ways to express feelings, handle anger, enhance self-esteem, explore career choices, and develop sexual identity and assertiveness skills.

Teach the patient to choose correct portion sizes. Encourage the patient to eat slowly and avoid performing other activities such as reading or watching television while eating. Most patients are encouraged not to use diet foods or drinks until a stable body weight is established. Encourage the patient to eat a low-sodium diet to prevent fluid retention. Fluid retention is common until the body readjusts its fluid balance; the patient may need support if she or he experiences edema of the fingers, ankles, and face. As he or she begins to eat and drink normally, support the patient if he or she becomes upset about weight gain and reassure the patient that the weight gain and swelling are temporary. Also encourage the patient to establish a normal exercise routine but to avoid extremes.

The goals of nursing interventions are to enhance self-esteem, facilitate growth in independence, manage separation from the family, develop sexual identity, and make career choices. Explore ways for the patient to identify and express feelings, manage anger and stress, develop assertive communication skills, and control impulses or delay gratification. Help the patient learn ways to cope with feelings of anxiety and depression, as opposed to binging and purging.

Explore ways to reduce the patient’s vomiting, laxative, and diuretic abuse. Some patients respond well to contracting or behavioral management to reduce these behaviors. Educate the family about appropriate nutrition. Explore ways the family can manage conflict, and support the patient’s move toward independence.

Nursing care plan discharge and home health care guidelines
Teach the patient ways to avoid binge-purge episodes through a balanced diet. Discuss effective ways of coping with needs and feelings. Explore ways to identify and handle stress and anxiety. Teach the patient strategies to increase self-esteem. Explore ways to maintain increased independence
and the patient’s own choices.