Generalized Anxiety Disorder

GENERALIZED ANXIETY DISORDER
DSM-IV
300.02 Generalized anxiety disorder Although some degree of anxiety is normal in life’s stresses, anxiety can be adaptive or maladaptive. roblems arise !hen the client has coping mechanisms that are inade"uate to deal !ith the danger, !hich may be recognized or unrecognized. #he essential feature of this inade"uacy is unrealistic or excessive anxiety and !orries about life circumstances. Anxiety disorders are the most common of all ma$or groups of mental disorders in the %nited &tates, sharing comorbidity !ith ma$or depression and substance abuse, increasing the client’s ris' of suicide.

ETIOLOGICAL THEORIES Psychodynamics
#he (reudian vie! involves conflict bet!een demands of the id and superego, !ith the ego serving as mediator. Anxiety occurs !hen the ego is not strong enough to resolve the conflict. &ullivanian theory states that fear of disapproval from the mothering figure is the basis for anxiety. )onditional love results in a fragile ego and lac' of self*confidence. #he individual !ith anxiety disorder has lo! self*esteem, fears failure, and is easily threatened. +ollard and ,iller -./001 believe anxiety is a learned response based on an innate drive to avoid pain. Anxiety results from being faced !ith t!o competing drives or goals. )ognitive theory suggests that there is a disturbance in the central mechanism of cognition or information processing !ith the conse"uent disturbance in feeling and behavior. Anxiety is maintained by this distorted thin'ing !ith mista'en or dysfunctional appraisal of a situation. #he individual feels vulnerable, and the distorted thin'ing results in a negative outcome.

io!o"ica!
Although biological and neurophysiological influences in the etiology of anxiety disorders have been investigated, no relationship has yet been established. 2o!ever, there does seem to be a genetic influence !ith a high family incidence. #he autonomic nervous system discharge that occurs in response to a frightening impulse and3or emotion is mediated by the limbic system, resulting in the peripheral effects of the autonomic nervous system seen in the presence of anxiety. &ome medical conditions have been associated !ith anxiety and panic disorders, such as abnormalities in the hypothalamic*pituitary*adrenal and hypothalamic*pituitary* thyroid axes, acute myocardial infarction, pheochromocytomas, substance intoxication and !ithdra!al, hypoglycemia, caffeine intoxication, mitral valve prolapse, and complex partial seizures.

#ami!y Dynamics
#he individual exhibiting dysfunctional behavior is seen as the representation of family system problems. #he 4identified patient5 -6 1 is carrying the problems of the other members of the family, !hich are seen as the result of the interrelationships -dise"uilibrium1 bet!een family members rather than as isolated individual problems. 6t is recognized that multiple factors contribute to anxiety disorders.

CLIENT ASSESSMENT DATA ASE Ac$i%i$y&R's$
7estlessness, pacing anxiously, or, if seated, restlessly moving extremities (eeling 4'eyed up534on edge,5 unable to relax 8asily fatigued +ifficulty falling or staying asleep9 restlessness, unsatisfying sleep

Ci(c)!a$ion
2eart pounding or racing3palpitations9 cold and clammy hands9 hot or cold spells, s!eating9 flushing, pallor 2igh resting pulse, increased blood pressure

E"o In$'"(i$y
8xcessive !orry about a number of events3activities, occurring more days than not for at least : months )omplains vociferously about inner turmoil, has difficulty controlling !orry ,ay demand help (acial expression in 'eeping !ith level of anxiety felt -e.g., furro!ed bro!, strained face, eyelid t!itch1 ,ay report history of threat to either physical integrity -illness, inade"uate food and housing, etc.1 or self*concept -loss of significant other9 assumption of ne! role1

E!imina$ion
(re"uent urination9 diarrhea

#ood&#!)id

;ac' of interest in food, dysfunctional eating pattern -e.g., responding to internal cues other than hunger1 +ry mouth, upset stomach, discomfort in the pit of the stomach, lump in the throat

N')(os'nso(y
Absence of other mental disorder, such as depressive disorder or schizophrenia ,otor tension< sha'iness, $itteriness, $umpiness, trembling, muscle tension, easily startled +izziness, lightheadedness, tingling hands or feet Apprehensive expectation< anxiety, !orry, fear, rumination, anticipation of misfortune to self or others, inability to act differently -feeling stuc'1 8xcessive vigilance3hyperattentiveness resulting in distractibility, difficulty in concentrating or mind going blan', irritability, impatience (ree*floating anxiety usually chronic or persisting over !ee's3months

Pain&Discom*o($
,uscle aches, headaches

R's+i(a$o(y
6ncreased respiratory rate, shortness of breath, smothering sensation

S',)a!i$y
=omen t!ice as li'ely to be affected as men

Socia! In$'(ac$ions
&ignificant impairment in social3occupational functioning

T'achin"&L'a(nin"
Age of onset usually 20s and 30s

DIAGNOSTIC ST-DIES
D()" Sc(''n. 7ules out drugs as contribution to cause of symptoms. >ther diagnostic studies may be conducted to rule out physical disease as basis for individual symptoms -e.g., 8)G for severe chest pain, echocardiogram for mitral valve prolapse9 88G to identify seizure activity9 thyroid studies1.

N-RSING PRIORITIES
.. Assist client to recognize o!n anxiety. 2. romote insight into anxiety and related factors. 3. rovide opportunity for learning ne!, adaptive coping responses. ?. 6nvolve client and family in educational3support activities.

DISCHARGE GOALS
.. (eelings of anxiety recognized and handled appropriately. 2. )oping s'ills developed to manage anxiety*provo'ing situations. 3. 7esources identified and used effectively. ?. )lient3family participating in ongoing therapy program. 0. lan in place to meet needs after discharge.

N-RSING DIAGNOSIS ANXIETY /s'%'('0&PO1ERLESSNESS May ' R'!a$'d $o. 7eal or perceived threat to physical integrity or self*concept -may or may not be able to identify the threat1 %nconscious conflict about essential values -beliefs1 and goals of life9 unmet needs @egative self*tal' Possi2!y E%id'nc'd 2y. ersistent feelings of apprehension and uneasiness -related to unidentified stressor or stimulus1 that client has difficulty alleviating &ympathetic stimulation9 restlessness9 extraneous movements -foot shuffling, hand3arm fidgeting, roc'ing movements1 oor eye contact9 focus on self 6mpaired functioning9 verbal expressions of having no control or influence over situation, outcome, or self*care (ree*floating anxiety @onparticipation in care or decision*ma'ing !hen opportunities are provided

D'si('d O)$com's&E%a!)a$ion C(i$'(ia3 Aerbalize a!areness of feelings of anxiety. C!i'n$ 1i!!. 6dentify effective coping mechanisms to successfully deal !ith stress. 7eport anxiety is reduced to a manageable level. +emonstrate problem*solving s'ills3lifestyle changes as indicated for individual situation.

ACTIONS&INTERVENTIONS RATIONALE Ind'+'nd'n$
8stablish and maintain a trusting relationship #he client may perceive the nurse as a threat, through the use of !armth, empathy, and respect. !hich may increase the client’s anxiety. Attending rovide ade"uate time for response. )ommunicate behaviors can increase the degree of comfort the support of the client’s self*expression. client experiences !ith the nurse. Be a!are of any negative or anxious feelings nurse @egative reactions to the client !ill bloc' future may have because of client’s conscious or progress. Anxiety is 4contagious,5 and nurse unconscious resistance of nurse’s helpful efforts. needs to recognize and control o!n anxiety. 6dentify behaviors of the client that produce anxiety romotes gro!th and change and helps client in the nurse. 8xplore these behaviors !ith the client realize ho! o!n behavior affects others. once relationship is established. %se supportive confrontation as indicated. )onfrontation can be useful !hen client’s progress is bloc'ed but may heighten anxiety to a level that is detrimental to the therapy process. #herefore, it should be used !ith caution. 2ave client identify and describe the sensations of #o adopt ne! coping responses, the 40 7’s5 of emotional and physical feelings. Assist the client to anxiety reduction are used. #he client first needs to lin' behavior and feelings. Aalidate all inferences RECOGNIZE anxiety and be a!are of feelings, and assumptions !ith the client. ho! they lin' to certain maladaptive coping responses, and o!n responsibility in learning to control behavior. 2elp to explore conflictual issues by beginning !ith Anxious client does not thin' clearly, and nonthreatening topics and progressing to more beginning !ith simple topics promotes comfort conflict*laden ones. level, increasing sense of success and progress. ,onitor the anxiety level of the nurse3client ,oderate anxiety may be productive for3motivate interaction on an ongoing basis. client, but too high a level of anxiety can interfere !ith the interaction and ability to attend to information. Assist the client to identify the situations and After the client recognizes feelings of anxiety, interactions that immediately precede the anxiety. examination of the development of the anxiety

&uggest that the client 'eep an 4anxiety noteboo'5 -e.g., !hat precipitates it, the strength of the that focuses on feelings and !hat is going on in the stressorCsD1 and !hat resources are available can environment !hen anxious feelings begin. help the client develop ne! coping s'ills. #herapeutic !riting serves to decrease the anxiety !hile the client is learning about it, ma'ing it more tangible3controllable. 2elp client correlate cause*and*effect relationships Gives more control over situation. 6ncreases sense bet!een stressor and anxiety. of po!er if client can identify cause of anxiety. @ote !hen reports of anxiety move from one (eelings of anxiety can become 4free*floating,5 concern to another -e.g., money, health, becoming attached to one concern after another, relationships1, and help client recognize !hat is and the client needs to recognize this so it can be happening. dealt !ith. ;in' the present experience !ith relevant ones from rovides opportunity for client to ma'e the past. As' "uestions li'e, 4+oes that seem connections bet!een these events and familiar to youE =hat does it remind you of from development of current anxiety, promoting insight the pastE5 and learning experience. 8xplore ho! client dealt !ith anxiety in the past 6ncreases confidence in o!n ability to deal !ith and !hat methods produced relief. 8ncourage use stress. #he client is capable of learning ne!, of adaptive coping responses that have !or'ed in adaptive coping responses by analyzing coping the past. mechanisms used previously, identifying available resources, and accepting personal responsibility for change, effectively REMOVING the threat or stressors underlying the anxiety. -7efer to @+< )oping, 6ndividual, ineffective.1 6nclude significant others as resources and social 8nhances ability to cope !hen one does not feel supports in helping client learn ne! coping alone. 6n addition, because anxiety may have an responses. interpersonal basis, involvement of &>-s1 can enhance the client’s relationship s'ills. RELATIONSHIPS can provide support, help, and reassurance, enabling the use of others as resources rather than using !ithdra!al to cope. As' client to remember times !hen she or he ,ay be useful to help client understand the anticipated the !orst and it did not happen. (ocus dynamics of negative thin'ing and its relationship attention on those situations. to feelings of anxiety. 8ncourage and support more realistic thoughts, e.g., 7eplacing negative thoughts !ith positive or 46 don’t 'no! for certain that -blan'1 !ill happen.5 calming thoughts can be helpful in stopping the 4=hatever happens, 6 can manage.5 46’ll delay cycle of negative thin'ing. !orrying for no! and thin' about something calming.5 Feep the focus of responsibility for change on the 6ncreases feelings of self*control and self*esteem. client.

8xpose client slo!ly to anxiety*provo'ing situations9 RE-ENGAGEMENT allo!s the client time to use role*playing as appropriate. identify3implement and practice ne!, adaptive coping responses and to become comfortable in using them. Assist to reevaluate goals, modify behavior, use Goals may have been too rigid and may have set resources, and test out ne! coping responses. up client for anxiety that could be avoided by change in behavior3responses. +evelop regular physical activity program. 8xcess energy is discharged in a healthful manner through physical exercise. Biochemical effects of exercise therapy decrease feelings of anxiety. 8ncourage client to use relaxation techni"ues -e.g., RELAXATION is the ultimate stress management meditation, massage, breathing techni"ues, exercises, techni"ue because it brings about a decreased guided imagery, and biofeedbac'1. heart rate, lo!ers metabolism, and decreases respiration rate. #he relaxation response is the physiological opposite of the anxiety response.

Co!!a2o(a$i%'
Administer medication as indicated, e.g., buspirone Anxiolytics provide relief from the immobilizing -Bu&par1, benzodiazepines, e.g., alprazolam -Ganax1, effects of anxiety. BH+s have fe! side effects, clonazepam -Flonopin1, clorazepate -#ranxene1, are generally !ell tolerated, have a fairly rapid chloridiazepoxide -;ibrium1, diazepam -Aalium1, rate of onset, and do not impair sleep. No$'. =hen oxazepam -&erax1. anxiety is associated !ith depression, anti* depressant agents alone may provide relief of symptoms. %nli'e BH+s, Bu&par is nonaddicting, has a delayed onset of action -.0 daysI2 !ee's1, and must be ta'en on a regular basis -not 7@1.

N-RSING DIAGNOSIS COPING4 INDIVID-AL4 in'**'c$i%' May ' R'!a$'d $o. ;evel of anxiety being experienced by client 6nade"uate coping methods ersonal vulnerability9 unmet expectations9 inade"uate support systems ;ittle or no exercise ,ultiple stressors, repeated over period of time Possi2!y E%id'nc'd 2y. ,aladaptive coping s'ills9 verbalization of inability to cope )hronic !orry, emotional tension9 muscular tension3headaches9 chronic fatigue, insomnia 6nability to problem*solve Alteration in societal participation 2igh rate of accidents9 overeating, excessive smo'ing, or drin'ing3drug use

D'si('d O)$com's&E%a!)a$ion C(i$'(ia3 6dentify ineffective coping behaviors and C!i'n$ 1i!!. conse"uences. 8xpress feelings appropriately. 6dentify options and use resources effectively. %se effective problem*solving techni"ues.

ACTIONS&INTERVENTIONS RATIONALE Ind'+'nd'n$
Assess current functional capacity, developmental Fno!ing ho! client’s coping ability is affected by level of functioning, and level of coping. +etermine current events determines need for3type of defense mechanisms used -e.g., denial, repression, intervention. eople tend to regress during conversion, dissociation, reaction formation, illness3crisis and need acceptance and support to undoing, displacement or pro$ection1. regain3improve coping ability. 6dentify previous methods of coping !ith life 2o! client has handled in the past problems is a problems. reliable predictor of ho! current problems !ill be handled. +etermine use of substances -e.g., alcohol, other &ubstances are often used as coping mechanism to drugs9 smo'ing habits9 eating patterns1. control anxiety and can interfere !ith client’s ability to deal !ith current situation. >bserve and describe behavior in ob$ective terms. rovides accurate picture of client situation and Aalidate observations !ith client as possible. @ote avoids $udgmental evaluations. Anxious people physical complaints. may have increased somatic concerns. -7efer to ) < &omatoform +isorders.1 Assess for premenstrual tension syndrome, !hen 6ncreased progesterone may cause increased indicated. anxiety for !omen during the luteal phase of the menstrual cycle. Active*listen client concerns and identify romotes sense of self*!orth and value for beliefs perceptions of !hat is happening. and clarifies client vie! of situation. )onfront client behaviors in context of trusting 2elps client to become a!are of distortions of relationship, pointing out differences bet!een reality resulting from anxiety state. !ords and actions, !hen appropriate. 2elp client identify maladaptive effects of present romotes understanding of relationship of !hat coping mechanisms. the individual does to undesired conse"uences. rovide information about different !ays to deal rovides opportunity for client to learn ne! !ith situations that promote anxious feelings -e.g., coping s'ills and incorporate these into o!n

identification and appropriate expression of feelings lifestyle. and problem*solving s'ills1. %se role*play and rehearsal techni"ues as indicated. romotes practice of ne! s'ills in a nonthreatening environment. 8ncourage and support client in evaluating lifestyle, 2elps client to loo' at difficult areas that may noting activities and stresses of family, !or', and contribute to anxiety and to ma'e changes social situations. gradually !ithout undue3debilitating anxiety. 2ave client identify short* and long*term goals that 2elps provide direction, enables evaluation of are attainable, prioritized according to individual progress, promotes feelings of success as goals are client needs and realistic time re"uirements. attained. %nrealistic goals set client up for failure and reinforce feelings of po!erlessness. 7ecommend dividing tas's into manageable units. (ocuses on achieving goals by small steps. Giving ;et client 'no! it is >F to say 4@o5 to re"uests for permission to refuse to ta'e on more than client additional !or'3other commitments. can handle frees individual from added stressors, increasing li'elihood of success. &uggest simplifying !or' environment9 interrupting 8nhances coping s'ills by reducing distractions, stressful periods !ith brea's for relaxation. promoting sense of control, and allo!ing individual to return to tas' refreshed. 8mphasize importance of structuring life to provide &tructure provides feeling of security for the ade"uate exercise3sleep, diversional activities, and anxious client. romotes a less stressful lifestyle, nutrition. enhances feelings of general !ell*being and ability to cope.

Co!!a2o(a$i%'
7efer to outside resources -e.g., support groups, ,ay need additional assistance or support to psychotherapy3counselor, spiritual advisor, maintain improvement3control. sexual counseling1 as indicated.

N-RSING DIAGNOSIS SOCIAL INTERACTION4 im+ai('d&SOCIAL ISOLATION May ' R'!a$'d $o. %se of unsuccessful social interaction behaviors 6nade"uate personal resources9 absence of available significant others3peers &elf*concept disturbance Altered mental status, hypervigilance Possi2!y E%id'nc'd 2y. Aerbalized3observed discomfort in social situations9 dysfunctional interactions 8xpression of feelings of difference from others9 preoccupation !ith o!n thoughts, irritability, impatience, difficulty in concentrating &ad, dull affect9 uncommunicative, !ithdra!n behavior9 absence of eye contact

D'si('d O)$com's&E%a!)a$ion C(i$'(ia3 7ecognize anxiety and identify factors involved C!i'n$ 1i!!. !ith feelings of isolation3impaired social interactions. articipate in activities to enhance interactions !ith others. Give self positive reinforcement for changes that are achieved.

ACTIONS&INTERVENTIONS RATIONALE Ind'+'nd'n$
;isten to client comments regarding sense of rovides information about individual isolation. +ifferentiate isolation from solitude and concerns3problems of feelings of aloneness. )lient loneliness. may not be a!are of difference bet!een being alone by choice and feeling of being alone even !hen others are around. &pend time !ith client, discussing areas of concern rovides opportunity for learning !ays to deal -e.g., reasons anxious feelings interfere !ith ability !ith feelings of anxiety in social situations. to be involved !ith others1. 8xpress positive regard )ommunicates belief in client’s self*!orth and for the client9 Active*listen concerns. provides safe environment for self*disclosure. +evelop plan of action !ith client9 loo' at available 6nvolvement of client communicates sense of resources, ris'*ta'ing behaviors, appropriate self*care. competence and ability to change behavior, even in presence of anxious feelings. Assess client’s use of coping s'ills and defense A!areness of defenses individual is using mechanisms. provides for choice of changing behavior. 2elps to develop s'ills that can be used to manage anxiety and promote social interaction. 2elp client learn social s'ills and use role*playing rovides for ne! !ays to handle anxiety in for practice. interaction !ith others. 8ncourage $ournal*'eeping and daily recording of 2elps client recognize the comfort3discomfort that social interactions for revie!. is experienced and possible causes, providing insight that may reduce anxiety. #herapeutic !riting is also useful in evaluating individual responses3coping behaviors. -7efer to @+< )oping, 6ndividual, ineffective.1 7ecommend that client share3discuss situation 2elps others understand condition, reducing ris' !ith peers3co!or'ers. of misinterpretation and decreasing individual anxiety. rovides opportunity for client to hear o!n !ords, gain ne! perspective, and begin to problem*solve ne! !ays of handling stressors.

Co!!a2o(a$i%'
6nvolve in classes3programs directed at resolution +eveloping positive social s'ills3behaviors of problems -e.g., assertiveness training, group provides opportunity for diminishing anxiety and therapy, outdoor education program1. promoting involvement !ith others.

N-RSING DIAGNOSIS SLEEP PATTERN dis$)(2anc' May ' R'!a$'d $o. sychological stress 7epetitive thoughts Possi2!y E%id'nc'd 2y. 7eports of difficulty in falling asleep3a!a'ening earlier or later than desired9 not feeling rested +ar' circles under eyes9 fre"uent ya!ning D'si('d O)$com's&E%a!)a$ion C(i$'(ia3 Aerbalize understanding of relationship of anxiety C!i'n$ 1i!!. and sleep disturbance. 6dentify appropriate interventions to promote sleep. 7eport improvement in sleep pattern, increased sense of !ell*being, and feeling !ell*rested.

ACTIONS&INTERVENTIONS RATIONALE Ind'+'nd'n$
+etermine type of sleep pattern disturbance present, 6dentification of individual situation and degree of including usual bedtime, rituals3routines, number interference !ith functioning determines need of hours of sleep, time of arising, environmental for3appropriate interventions. needs, and ho! much of a problem it is to client. rovide "uiet environment, comfort measures -e.g., romotes relaxation and cues for falling asleep. bac' rub, !ash hands3face, bath1, and sleep aids, &timulating effects of caffeine3alcohol interfere such as !arm mil'. 7estrict use of caffeine and !ith ability to fall asleep. alcohol before bedtime. +iscuss use of relaxation techni"ues3thoughts, romotes reduction of anxious feelings, resulting visualization. in improved sleep3rest. &uggest !ays to handle !a'ing3not sleeping -e.g., 2aving a plan can reduce anxiety about not do not lie in bed and thin', but get up and remain sleeping. inactive, or do something boring1.

6nvolve client in exercise program, avoiding exercise 6ncreases fatigue, promotes sleep but avoids !ithin 2 hours of going to bed. excessive stimulation from activity before bedtime. Avoid use of sedatives, !hen possible. &edative drugs interfere !ith 78, sleep and affect "uality of rest. A rebound effect may lead to intense dreaming, nightmares, and more disturbed sleep.

Co!!a2o(a$i%'
Administer medications as indicated, e.g., zolpidem Although drug is recommended for short*term use -Ambien1. only, it may be beneficial until other therapeutic interventions are successful.

N-RSING DIAGNOSIS #AMILY COPING. in'**'c$i%'4 (is5 *o( com+(omis'd Ris5 #ac$o(s May Inc!)d'. 6nade"uate or incorrect information or understanding by a primary person #emporary family disorganization and role changes rolonged disability that exhausts the supportive capacity of significant other-s1 Possi2!y E%id'nc'd 2y. C@ot applicable, presence of signs and symptoms establishes an actual diagnosis.D D'si('d O)$com's&E%a!)a$ion C(i$'(ia3 6dentify resources !ithin themselves to deal !ith #ami!y 1i!!. situation. 6nteract appropriately !ith the client, providing support and assistance as needed. 7ecognize o!n needs for support, see' assistance, and use resources effectively.

ACTIONS&INTERVENTIONS RATIONALE Ind'+'nd'n$
Assess information available to and understood by ;ac' of understanding of client’s behavior can lead family3&>-s1. to dysfunctional interactional patterns, !hich contribute to anxiety in family members. 6dentify client’s role in family and ho! the illness +egree of disability suffered by the client that has changed the family organization -e.g., mother interferes !ith performance of usual family role !ho does not maintain household, father !ho does can contribute to family stress3disorganization. not go to !or'1.

@ote other factors besides illness -e.g., anxiety, &ystems theory maintains that other members of personality disorders1 that affect family members’ the family also exhibit dysfunctional behavior, but ability to provide needed support. the client is the 4identified patient.5 +iscuss underlying reasons for client’s behaviors. 2elps family understand and accept behaviors that may be difficult to handle. Assist family and client to understand !ho 4o!ns5 romotes responsibility of 'no!ing that !hoever the problem and !ho is responsible for resolution. has the problem has to solve it. #he individual can as' for help, but others do not rescue or try to solve it for the person. 8ncourage development of problem*solving s'ills. 2elps family learn ne! !ays to deal !ith conflicts and reduce anxiety*provo'ing situations.

Co!!a2o(a$i%'
7efer to appropriate resources as indicated -e.g., ,ay need additional assistance to maintain family counseling, psychotherapy9 financial, spiritual integrity. advisors1.

Ano(',ia N'(%osa& )!imia N'(%osa
DSM-IV
30J.. Anoxexia nervosa 30J.0. Bulimia nervosa 30J.00 8ating disorders @>& Binge*eating disorder -proposed, re"uiring further study1 Anorexia nervosa is an illness of starvation, brought on by severe disturbance of body image and a morbid fear of obesity. Bulimia nervosa is an eating disorder -binge*purge syndrome1 characterized by extreme overeating, follo!ed by self*induced vomiting. 6t may include abuse of laxatives and diuretics. Binge*eating is defined as recurrent episodes of overeating associated !ith sub$ective and behavioral indicators of impaired control over and significant distress about the eating behavior but !ithout the use of inappropriate compensatory behaviors -e.g., purging, fasting, excessive exercise1.

ETIOLOGICAL THEORIES Psychodynamics
#he individual reflects a developmental arrest in the very early childhood years. #he tas's of trust, autonomy, and separation*individuation are unfulfilled, and the individual remains in the dependent position. 8go development is retarded. &ymptoms are often associated !ith a perceived loss of control in some aspect of life and may center on fears of sexual maturity/intimacy. Although these disorders affect !omen primarily, approximately 0K to .0K of those afflicted are men. Additionally, eating disorders are often associated !ith depression, anxiety, phobias, and cognitive problems.

io!o"ica!
#hese disorders may be caused by neuroendocrine abnormalities !ithin the hypothalamus. &ymptoms are lin'ed to various chemical disturbances normally regulated by the hypothalamus. (urthermore, a physiological defect may ma'e it difficult for the individual to interpret sensations of hunger and fullness.

#ami!y Dynamics
6ssues of control become the overriding factors in the family of the client !ith an eating disorder. #hese families often consist of a passive father, a domineering mother, and an overly dependent child. #here is a high value placed on perfectionism in this family, and the child believes she or he must please others and satisfy these standards.

CLIENT ASSESSMENT DATA ASE Ac$i%i$y&R's$
+isturbed sleep patterns -e.g., early morning insomnia9 fatigue1 (eeling 4hyper5 and/or anxious 6ncreased activity/avid exerciser, participation in high*energy sports 8mployment in positions/professions that re"uire control of !eight -athletics, such as gymnasts, s!immers, $oc'eys, !restlers9 modeling, flight attendants1

Ci(c)!a$ion
(eeling cold even !hen room is !arm ;o! B 9 tachycardia, dysrhythmias

E"o In$'"(i$y
o!erlessness/helplessness, lac' of control over eating -e.g., cannot stop eating/control !hat or ho! much is eaten CbulimiaD9 feeling disgusted !ith self, depressed, or very guilty after overeating Cbinge*eatingD1 +istorted -unrealistic1 body imageLreports self as fat regardless of !eight -denial1, and sees thin body as fat9 persistent overconcern !ith body shape and !eightLfears gaining !eight -females1 )oncerned !ith achieving masculine body build -males1, rather than actual !eight or !eight gain &tress factors -e.g., family move/divorce, onset of puberty1 2igh self*expectations &uppression of anger9 emotional states of depression, !ithdra!al, anger, anxiety, pessimistic outloo'

E!imina$ion
+iarrhea/constipation +ecreased fre"uency of voiding/urine output, urine dar' amber -dehydration1 Aague abdominal pain and distress, bloating ;axative/diuretic use

#ood&#!)id
)onstant hunger or denial of hunger9 normal or exaggerated appetite that rarely vanishes until late in the disorder -anorexia1 6ntense fear of gaining !eight -female19 may have prior history of being over!eight -particularly males1 6nordinate pleasure in !eight loss, !hile denying self pleasure in other areas 7efusal to maintain body !eight at or above minimal norm for age /height -anorexia1 7ecurrent episodes of binge*eating9 a feeling of lac' of control over behavior during eating binges9 minimum average of 2 binge eating episodes a !ee' for at least 3 months -bulimia19 ingests large amounts of food !hen not feeling physically hungry, often consuming as much as 20,000 calories in a 2*hour period9 eating much more rapidly than normal in a discrete period of time -e.g., !ithin a 2*hour period1, an amount of food that is definitely larger than most people !ould eat -binge*eating19 feels uncomfortably full 7egularly engages in either self*induced vomiting -binge*purge syndrome CbulimiaD1 independently or as a complication of anorexia or strict dieting or fasting9 excessive gum che!ing =eight loss/maintenance of body !eight .0K or more belo! that expected -anorexia1 or !eight may be normal or slightly above or belo! -bulimia1 )achectic appearance9 s'in may be dry, yello!ish/pale, !ith poor turgor reoccupation !ith food -e.g., calorie*counting, gourmet coo'ing9 hiding food, cutting food into small pieces, rearranging food on plate1 eripheral edema &!ollen salivary glands9 sore, inflamed buccal cavity, erosion of tooth enamel9 gums in poor condition9 continuous sore throat -bulimia1 Aomiting9 bloody vomitus -may indicate esophageal tearingL,allory*=eiss1

Hy"i'n'
6ncreased hair gro!th on body -lanugo19 hair loss -axillary/pubic19 hair dull/not shiny Brittle nails &igns of erosion of tooth enamel9 gum abscesses, ulcerations of mucosa

N')(os'nso(y

Appropriate affect, except in regard to body and eating9 or depressive affect -depression1 ,ental changes< apathy, confusion, memory impairment -brought on by malnutrition/starvation1 2ysterical or obsessive personality style9 no other psychiatric illness or evidence of a psychiatric thought disorder present -although a significant number may sho! evidence of an affective disorder1

Pain&Discom*o($
2eadaches, sore throat, general vague complaints

Sa*'$y
Body temperature belo! normal 7ecurrent infectious processes -indicative of depressed immune system1 8czema/other s'in problems Abrasions/callouses may be noted on the bac' of hands -stic'ing finger do!n throat to induce vomiting1

S',)a!i$y
Absence of at least 3 consecutive menstrual cycles -decreased levels of estrogen in response to malnutrition1 romiscuity or denial/loss of sexual interest 2istory of sexual abuse Breast atrophy, amenorrhea

Socia! In$'(ac$ions
,iddle*class or upper*class family bac'ground assive father/dominant mother, family members enmeshed, togetherness prized, personal boundaries not respected 2istory of being a "uiet, cooperative child roblems of control issues in relationships, difficult communications !ith others/authority figures9 poor communications !ithin family of origin 8ngagement in po!er struggles

Altered relationships or problems !ith relationships -not married /divorced1, !ithdra!al from friends/social contacts Abusive family relationships &ense of helplessness ,ay have history of legal difficulties -e.g., shoplifting1

T'achin"&L'a(nin"
2igh academic achievement (amily history of higher than normal incidence of depression, other family members !ith eating disorders -genetic predisposition1 >nset of the illness usually bet!een the ages of .0 and 22 2ealth beliefs/practices -e.g., certain foods have 4too many5 calories, use of 4health5 foods1 @o medical illness evident to account for !eight loss

DIAGNOSTIC ST-DIES
C C 6i$h Di**'('n$ia!. +etermines presence of anemia, leu'openia, lymphocytosis. latelets sho! significantly less than normal activity by the enzyme monoamine oxidase -thought to be a mar'er for depression1. E!'c$(o!y$'s. 6mbalances may include decreased potassium, sodium, chloride, and magnesium. Endoc(in' S$)di's. Thy(oid #)nc$ion. #hyroxine -#?1 levels usually normal9 ho!ever, circulating triio* dothyronine -#31 levels may be lo!. Pi$)i$a(y #)nc$ion. #hyroid*stimulating hormone -#&21 response to thyrotropin* releasing factor -#7(1 is abnormal in anorexia nervosa. ropranolol*glucagon stimulation test -studies the response of human gro!th hormone1 reveals depressed level of G2 in anorexia nervosa. Gonadotropic hypofunction is noted. Co($iso!. ,etabolism may be elevated. D',am'$hason' S)++('ssion T's$ 7DST8. 8valuates hypothalamic*pituitary function, dexamethasone resistance indicates cortisol suppression, suggesting malnutrition/depression.

L)$'ini9in" Ho(mon' S'c('$ions T's$. attern often resembles those of prepubertal girls. Es$(o"'n. +ecreased. !ood S)"a( and asa! M'$a2o!ic Ra$' 7 MR8. ,ay be lo!. O$h'( Ch'mis$(i's. A&# elevated, increased carotene level9 decreased protein and cholesterol levels. MHP : L'%'!s. +ecreased, suggestive of malnutrition/depression. -(ina!ysis and R'na! #)nc$ion. B%@ may be elevated9 'etones present reflecting starvation9 decreased urinary .J*'etosteroids9 increased specific gravity -dehydration1. E;G. Abnormal tracing !ith lo! voltage, #*!ave inversion, dysrhythmias.

N-RSING PRIORITIES
.. 7eestablish ade"uate/appropriate nutritional inta'e. 2. )orrect fluid and electrolyte imbalance. 3. Assist client to develop realistic body image /improve self*esteem. ?. rovide support/involve &>, if available, in treatment program to client/&>. 0. )oordinate total treatment program !ith other disciplines. :. rovide information about disease, prognosis, and treatment.

DISCHARGE GOALS
.. Ade"uate nutrition and fluid inta'e maintained. 2. ,aladaptive coping behaviors and stressors that precipitate anxiety recognized. 3. Adaptive coping strategies and techni"ues for anxiety reduction and self*control implemented. ?. &elf*esteem increased. 0. +isease process, prognosis, and treatment regimen understood. :. lan in place to meet needs after discharge.

N-RSING DIAGNOSIS N-TRITION. a!$'('d4 !'ss $han 2ody ('<)i('m'n$s May ' R'!a$'d $o. 6nade"uate food inta'e9 self*induced vomiting )hronic3excessive laxative use Possi2!y E%id'nc'd 2y. Body !eight .0K -or more1 belo! expected -anorexia1, or may be !ithin normal range -bulimia, binge*eating1 ale con$unctiva and mucous membranes9 poor s'in turgor3muscle tone, edema 8xcessive loss of hair9 increased gro!th of body hair -lanugo1 Amenorrhea 2ypothermia Bradycardia, cardiac irregularities, hypotension 8lectrolyte imbalances D'si('d O)$com's&E%a!)a$ion C(i$'(ia3 Aerbalize understanding of nutritional needs. C!i'n$ 1i!!. 8stablish a dietary pattern !ith caloric inta'e ade"uate to regain3maintain appropriate !eight. +emonstrate !eight gain to!ard expected goal range.

ACTIONS&INTERVENTIONS RATIONALE Ind'+'nd'n$
8stablish a minimum !eight goal and daily ,alnutrition is a mood*altering condition leading nutritional re"uirements. to depression and agitation and affecting cognitive functioning/decision*ma'ing. 6mproved nutritional status enhances thin'ing ability, and psychological !or' can begin. 6nvolve client !ith team in setting up/carrying out rovides structured eating stimulation !hile program of behavior modification. rovide re!ard allo!ing client some control in choices. Behavior for !eight gain as individually determined9 ignore modification may be effective only in mild cases or loss. for short*term !eight gain. No$'. )ombination of cognitive*behavioral approach is preferred for treating bulimia. %se a consistent approach. &it !ith client !hile )lient detects urgency and reacts to pressure. Any eating9 present and remove food !ithout comment that might be seen as coercion provides persuasion and/or comment. romote pleasant focus on food. =hen staff member responds environment and record inta'e. consistently, client can begin to trust her or his responses. #he single area in !hich client has exercised po!er and control is food/eating, and she or he may experience guilt or rebellion if

forced to eat. &tructuring meals and decreasing discussions about food !ill decrease po!er struggles !ith client and avoid manipulative games. rovide smaller meals and supplemental snac's, Gastric dilation may occur if refeeding is too rapid as appropriate. follo!ing a period of starvation dieting. No$'. )lient may feel bloated for 3I: !ee's !hile body read$usts to food inta'e. ,a'e selective menu available and allo! client to )lient !ho gains self*confidence and feels in control choices, as much as possible. control of environment is more li'ely to eat preferred foods. Be alert to choices of lo!*calorie foods/beverages9 )lient !ill try to avoid ta'ing in !hat is vie!ed as hoarding food9 disposing of food in various places excessive calories and may go to great lengths to such as poc'ets or !astebas'ets. avoid eating. ,aintain a regular !eighing schedule, such as rovides accurate ongoing record of !eight ,onday/(riday before brea'fast in same attire, on loss/gain. Also diminishes obsessing about same scale, and graph results. changes in !eight. =eigh !ith bac' to scale -depending on program Although some programs prefer client to see the protocols1. results of !eighing, this approach can force the issue of trust in client !ho usually does not trust others. Avoid room chec's and other control devices 8xternal control reinforces client’s feelings of !henever possible. po!erlessness and are therefore usually not helpful. rovide .<. supervision and have the client revents vomiting during/after eating. )lient may remain in the dayroom area !ith no bathroom desire food and use a binge*purge syndrome to privileges for a specified period -e.g., 2 hours1 maintain !eight. No$'. urging may occur for the follo!ing eating, if contracting is unsuccessful. first time in a client as a response to establishment of !eight gain program. ,onitor exercise program and set limits on physical ,oderate exercise helps maintain muscle tone / activities. )hart activity/level of !or' -pacing, and !eight and combat depression. 2o!ever, client so on1. may exercise excessively to burn calories. ,aintain matter*of*fact, non$udgmental attitude if erception of punishment is counterproductive to giving enteral feedings, parenteral nutrition, etc. promoting self*confidence and faith in o!n ability to control destiny. Be alert to possibility of client disconnecting tube &abotage behavior is common in attempt to and emptying parenteral nutrition, if used. )hec' prevent !eight gain. fluid measurements and tape tubing snugly.

Co!!a2o(a$i%'

)onsult !ith dietitian/nutritional therapy team. 2elpful in determining individual dietary needs and appropriate sources. No$'. 6nsufficient calorie and protein inta'e can lo!er resistance to infection and cause constipation, hallucinations, and liver damage. 7efer for dental care. eriodontal disease and loss of tooth enamel leading to caries and loose fillings re"uires prompt intervention to improve nutritional inta'e and general !ell*being. rovide diet and snac's !ith substitutions of 2aving a variety of foods available !ill enable the preferred foods !hen available. client to have a choice of potentially en$oyable foods. Administer li"uid diet, tube feedings/parenteral =hen caloric inta'e is insufficient to sustain nutrition as appropriate. metabolic needs, nutritional support can be used to prevent malnutrition !hile therapy is continuing. 2igh*calorie li"uid feedings may be given as medication, at times separate from meals, as an alternate means of increasing caloric inta'e. 8nteral feedings are preferred as they preserve G6 function and reduce atrophy of the gut. # @ is usually reserved for life*threatening situations. Blenderize and tube feed anything left on the tray ,ay be used as part of behavior modification after a given period of time if indicated. program to provide total inta'e of needed calories. Avoid giving laxatives. ;axative use is counterproductive, as it may be used by client to rid body of food/calories. No$'. ,etamucil/bran may be used to treat constipation. ,onitor laboratory values, as appropriate -e.g., 6dentifies therapeutic needs /effectiveness of prealbumin, transferrin, serum protein levels9 treatment. 8lectrolyte imbalances can cause electrolytes1. cardiac dysrhythmias, severe muscle spasms, and even sudden death. Administer medications as indicated, e.g., )yproheptadine - eriactin19 A serotonin and histamine antagonist used in high doses to stimulate the appetite, decrease preoccupation !ith food, and combat depression. +oes not appear to have serious side effects, although decreased mental alertness may occur. #ricyclic antidepressants, e.g., amitriptyline ;ifts depression and stimulates appetite. &&76s -8lavil, 8ndep1, imipramine -#ofranil1, reduce binge*purge cycles and may also be helpful desipramine -@orpramin19 selective serotonin in treating anorexia. No$'. %se must be closely reupta'e inhibitors, e.g., fluoxetine - rozac19 monitored o!ing to potential side effects, although side effects from &&76s are less significant than those associated !ith tricyclics.

Antianxiety agents, e.g., alprozolam -Ganax19 7educes tension and anxiety/nervousness and may help client to participate in treatment. Antipsychotics, e.g., chlorpromazine -#horazine19 romotes !eight gain and cooperation !ith psychotherapeutic program, ho!ever, used only !hen absolutely necessary because of extrapyramidal side effects. ,A> inhibitors, e.g., tranylcypromine sulfate ,ay be used to treat depression !hen other drug - arnate1. therapy is ineffective9 decreases urge to binge in clients !ith bulimia. repare for/assist !ith electroconvulsive therapy 6n rare and difficult cases in !hich malnutrition is -8)#1 if indicated. +iscuss reasons for use and help severe /life*threatening, a short*term 8)# series client understand this therapy is not punishment. may enable the client to begin eating and become accessible to psychotherapy. #ransfer to acute medical setting for nutritional #he underlying problem cannot be cured !ithout therapy, !hen condition is life*threatening. improved nutritional status. 2ospitalization provides a controlled environment in !hich food inta'e, vomiting/elimination, medications, and activities can be monitored. 6t also separates the client from &>-s1 and provides exposure to others !ith the same problem, creating an atmosphere for sharing.

N-RSING DIAGNOSIS #L-ID VOL-ME d'*ici$4 (is5 *o( o( ac$)a! May ' R'!a$'d $o. 6nade"uate inta'e of food and li"uids )onsistent self*induced vomiting )hronic3excessive laxative or diuretic use Possi2!y E%id'nc'd 2y 7Ac$)a!8. +ry s'in and mucous membranes, decreased s'in turgor 6ncreased pulse rate, body temperature9 hypotension >utput greater than input -diuretic use19 concentrated urine3decreased urine output -dehydration1 =ea'ness )hange in mental state 2emoconcentration, altered electrolyte balance D'si('d O)$com's&E%a!)a$ion C(i$'(ia3 ,aintain3demonstrate improved fluid balance as C!i'n$ 1i!!. evidenced by ade"uate urine output, stable vital signs, moist mucous membranes, good s'in turgor.

Aerbalize understanding of causative factors and behaviors necessary to correct fluid deficit.

ACTIONS&INTERVENTIONS RATIONALE Ind'+'nd'n$
,onitor vital signs, capillary refill, status of mucous 6ndicators of ade"uacy of circulating volume. membranes, s'in turgor. >rthostatic hypotension may occur, !ith ris' of falls/in$ury follo!ing sudden changes in position. ,onitor amount and types of fluid inta'e. ,easure )lient may abstain from all inta'e, resulting in urine output accurately as indicated. dehydration, or may substitute fluids for caloric inta'e, affecting electrolyte balance. +iscuss strategies to stop vomiting and laxative/ 2elping client deal !ith feelings that lead to diuretic use. vomiting and/or laxative/diuretic use may prevent continued fluid loss. No$'. #he client !ith bulimia has learned that vomiting provides a release of anxiety. 6dentify actions necessary to regain/maintain 6nvolving client in plan to correct fluid imbalances optimal fluid balance -e.g., specific schedule for improves chances for success. fluid inta'e1.

Co!!a2o(a$i%'
7evie! results of electrolyte/renal function test (luid/electrolyte shifts, decreased renal function results. can adversely affect client’s recovery/prognosis and may re"uire additional intervention. Administer/monitor 6A, # @9 potassium %sed as an emergency measure to correct supplements, as indicated. fluid/electrolyte imbalance. ,ay be re"uired to prevent cardiac dysrhythmias.

N-RSING DIAGNOSIS THO-GHT PROCESSES4 a!$'('d May ' R'!a$'d $o. &evere malnutrition3electrolyte imbalance sychological conflicts -e.g., sense of lo! self*!orth, perceived lac' of control1 Possi2!y E%id'nc'd 2y. 6mpaired ability to ma'e decisions, problem*solve @onIreality*based verbalizations 6deas of reference

Altered sleep patterns, e.g., may go to bed late -stay up to binge3purge1 and get up early Altered attention span3distractibility erceptual disturbances !ith failure to recognize hunger, fatigue, anxiety and depression D'si('d O)$com's&E%a!)a$ion C(i$'(ia3 Aerbalize understanding of causative factors and C!i'n$ 1i!!. a!areness of impairment. +emonstrate behaviors to change3prevent malnutrition. +isplay improved ability to ma'e decisions, problem*solve.

ACTIONS&INTERVENTIONS RATIONALE Ind'+'nd'n$
Be a!are of client’s distorted thin'ing ability. Allo!s the caregiver to have more realistic expectations of the client and provide appropriate information and support. ;isten to/avoid challenging irrational, illogical 6t is not possible to respond logically !hen thin'ing. resent reality concisely and briefly. thin'ing ability is physiologically impaired. #he client needs to hear reality, but challenging the client leads to distrust and frustration. Adhere strictly to nutritional regimen. 6mproved nutrition is essential to improved brain functioning. -7efer to @+< @utrition< altered, less than body re"uirements.1

Co!!a2o(a$i%'
7evie! electrolyte/renal function tests. 6mbalances negatively affect cerebral functioning and may re"uire correction before therapeutic interventions can begin.

N-RSING DIAGNOSIS ODY IMAGE dis$)(2anc'&SEL# ESTEEM4 ch(onic !o6 May ' R'!a$'d $o. ,orbid fear of obesity9 perceived loss of control in some aspect of life %nmet dependency needs, personal vulnerability )ontinued negative evaluation of self +ysfunctional family system

Possi2!y E%id'nc'd 2y. +istorted body image -vie!s self as fat even in the presence of normal body !eight or severe emanciation1 8xpresses little concern, uses denial as a defense mechanism, and feels po!erless to prevent3ma'e changes 8xpresses shame3guilt >verly conforming, dependent on others’ opinions D'si('d O)$com's&E%a!)a$ion C(i$'(ia3 8stablish a more realistic body image. C!i'n$ 1i!!. Ac'no!ledge self as an individual. Accept responsibility for o!n actions.

ACTIONS&INTERVENTIONS RATIONALE Ind'+'nd'n$
8stablish a therapeutic nurse/client relationship. =ithin a helping relationship, client can begin to trust and try out ne! thin'ing and behaviors. romote self*concept !ithout moral $udgment. )lient sees self as !ea'*!illed, even though part of person may feel a sense of po!er and control -e.g., dieting/!eight loss1. 2ave client dra! picture of self. rovides opportunity to discuss client’s perception of self/body image and realities of individual situation. &tate rules clearly regarding !eighing schedule, )onsistency is important in establishing trust. As remaining in sight during medication and eating part of the behavior*modification program, client times, and conse"uences of not follo!ing the rules. 'no!s ris's involved in not follo!ing established =ithout undue comment, be consistent in carrying rules -e.g., decrease in privileges1. (ailure to follo! out rules. rules is vie!ed as the client’s choice and accepted by the staff in matter*of*fact manner so as not to provide reinforcement for the undesirable behavior. 7espond -confront1 !ith reality !hen client ma'es )lient may be denying the psychological aspects of unrealistic statements such as 46’m gaining !eight, o!n situation and is often expressing a sense of so there’s nothing really !rong !ith me.5 inade"uacy and depression. Be a!are of o!n reaction to client’s behavior. Avoid (eelings of disgust, hostility, and infuriation are arguing. not uncommon !hen caring for these clients. rognosis often remains poor even !ith !eight gain because other problems may remain. ,any clients continue to see themselves as fat, and there is also a high incidence of affective disorders, social phobias, obsessive*compulsive symptoms,

drug abuse, and psychosexual dysfunction. @urse needs to deal !ith o!n response/feelings so they do not interfere !ith care of the client. Assist client to assume control in areas other than (eelings of personal ineffectiveness, lo! self* dieting/!eight loss -e.g., management of o!n concept, and perfectionism are often part of the daily activities, !or'/leisure choices1. problem. )lient feels helpless to change and re"uires assistance to problem*solve methods of control in life situations. 2elps direct energy a!ay from eating/body image to other life*enhancing and personally satisfying activities. 2elp client formulate goals for self -not related to )lient needs to recognize ability to control other eating1 and create a manageable plan to reach those areas in life and may need to learn problem* goals, a single goal at a time, progressing from solving s'ills in order to achieve this control. simple to more complex. &etting realistic goals fosters success. +iscuss the meaning of illness and effect of these Giving up an illness that has helped form the behaviors. individual’s personal identity, the unconscious benefit of the 4sic' role,5 and the overvalued beliefs about an ideal body and the benefits of thinness must be addressed before the client can confront the full role the illness has played in the client’s life. Assist client to confront sexual fears. rovide sex ,a$or physical /psychological changes in education as necessary. adolescence can contribute to development of eating disorders. (eelings of po!erlessness and loss of control of feelings -particularly sexual1 and sensations lead to an unconscious desire to desexualize themselves. )lients often believe that these fears can be overcome by ta'ing control of bodily appearance/development/function. No$'. &ome clients !ith anorexia believe staying small and emaciated !ill help 'eep them childli'e -and therefore sexually unappealing1, !hereas clients !ith binge*eating disorders !ish to remain obese, believing excess body fat !ill lessen sexual attraction. +etermine history of sexual abuse and institute )lient may use eating as a means of gaining appropriate therapy. control in life !hen sexual abuse has been experienced. @ote client’s !ithdra!al from and/or discomfort ,ay indicate feelings of isolation and fear of in social settings. re$ection/$udgment by others. Avoidance of social situations and contact !ith others can compound feelings of !orthlessness. 8ncourage client to ta'e charge of o!n life in a more )lient often does not 'no! !hat she or he may healthful !ay by ma'ing o!n decisions and !ant for self. arents -usually mother1 often ma'e

accepting self as is at this moment -including decisions for client. )lient may also believe she or inade"uacies and strengths1. he has to be the best in everything and holds self responsible for being perfect. ;et client 'no! that it is acceptable to be different +eveloping a sense of identity as separate from from family, particularly mother. family and maintaining sense of control in other !ays, besides dieting and !eight loss, is a desirable goal of therapy/program. 6nvolve in personal development program, ;earning about methods of enhancing personal preferably in a group setting. rovide information appearance may be helpful to long*range sense of about proper application of ma'eup and grooming. self*concept/image. (eedbac' from others can promote feelings of self*!orth. &uggest disposing of 4thin5 clothes as !eight gain rovides incentive to at least maintain and not lose occurs. 7ecommend consultation !ith an image !eight. 7emoves visual reminder of thinner self. consultant. ositive image enhances sense of self*esteem. %se interpersonal psychotherapy approach rather 6nteraction bet!een persons is more helpful for the than interpretive therapy. client to discover feelings /impulses/needs from !ithin o!n self. )lient has not learned this internal control as a child and may not be able to interpret or attach meaning to behavior. No$'. )ognitive therapy is usually more effective for clients diagnosed as bulimic or binge*eaters but may not be useful for anorectic clients during the period of acute hospitalization. 8ncourage client to express anger and ac'no!ledge 6mportant to 'no! that anger is part of self and as !hen it is verbalized. such is acceptable. 8xpressing anger may need to be taught to client, because anger is often considered unacceptable in the family, and therefore client does not express it. Assist client to learn strategies other than eating for (eelings are the underlying issue, and clients often dealing !ith feelings. 2ave client 'eep a diary of use food instead of dealing !ith feelings feelings, particularly !hen thin'ing about food. appropriately. #herapeutic !riting helps client recognize feelings and ho! to express them clearly and directly. Assess feelings of helplessness/hopelessness. ;ac' of control is a common/underlying problem for this client and may be accompanied by more serious emotional disorders. No$'. 0?K of clients !ith anorexia have a history of ma$or affective disorder, and 33K have a history of minor affective disorder. Be alert to suicidal ideation/behavior. 6ntensity of anxiety/panic about !eight gain, depression, hopeless feelings may lead to suicidal attempts, particularly if client is impulsive.

Co!!a2o(a$i%'

6nvolve in group therapy. rovides an opportunity to tal' about feelings and try out ne! behaviors. 7efer to occupational/recreational therapy. )an develop interests and s'ills to fill time that has been occupied by obsession !ith eating. 6nvolvement in recreational activities encourages social interactions !ith others and promotes fun and relaxation. 8ncourage participation in directed activities -e.g., Although exercise is often used negatively by bicycle tours, !ilderness adventures, such as these clients -i.e., for !eight loss /control1, >ut!ard Bound rogram1. directed activities provide an opportunity to learn self*reliance, enhance self*esteem, and realize that food is the fuel re"uired by the body to do its !or'. 7efer to therapist trained in dealing !ith sexuality. ,ay need professional assistance to accept self as a sexual adult.

N-RSING DIAGNOSIS #AMILY PROCESSES4 a!$'('d May ' R'!a$'d $o. 6ssues of control in family &ituational3maturational crises 2istory of inade"uate coping methods Possi2!y E%id'nc'd 2y. +issonance among family members9 family needs not being met (amily developmental tas's not being met 6ll*defined family rules, functions, and roles (ocus on 4identified patient5 -6 19 family member-s1 acting as enablers for 6 D'si('d O)$com's&E%a!)a$ion C(i$'(ia3 +emonstrate individual involvement in problem* #ami!y 1i!!. solving processes directed at encouraging client to!ard independence. 8xpress feelings freely and appropriately. +emonstrate more autonomous coping behaviors !ith individual family boundaries more clearly defined. 7ecognize and resolve conflict appropriately !ith the individuals involved.

ACTIONS&INTERVENTIONS RATIONALE Ind'+'nd'n$

6dentify patterns of interaction. 8ncourage each 2elpful information for planning interventions. family member to spea' for self. +o not allo! 2 #he enmeshed, overinvolved family members members to discuss a third !ithout that member’s often spea' for each other and need to learn to be participation. responsible for their o!n !ords and actions. +iscourage members from as'ing for approval 8ach individual needs to develop o!n internal from each other. Be alert to verbal or nonverbal sense of self*!orth. 6ndividual often is living up to chec'ing !ith others for approval. Ac'no!ledge others’ -family’s1 expectations rather than ma'ing competent actions of client. o!n choices. Ac'no!ledgment provides recognition of self in positive !ays. ;isten !ith regard !hen the client spea's. &ets an example and provides a sense of competence and self*!orth in that the client has been heard and attended to. 8ncourage individuals not to ans!er to everything. 7einforces individualization and return to privacy. )ommunicate message of separation, that it is 6ndividuation needs reinforcement. &uch a acceptable for family members to be different from message confronts rigidity and opens options for each other. different behaviors. 8ncourage and allo! expression of feelings -e.g., >ften these families have not allo!ed free crying, anger1 by individuals. expression of feelings and !ill need help and permission to learn and accept this. revent intrusion in dyads by other members of 6nappropriate interventions in family subsystems family. prevent individuals from !or'ing out problems successfully. 7einforce importance of parents as a couple !ho #he focus on the child !ith an eating disorder is have rights of their o!n. very intense and often is the only area through !hich the couple interact. #he couple needs to explore their o!n relationship and restore the balance !ithin it to prevent its disintegration. revent client from intervening in conflicts bet!een #riangulation occurs in !hich a parent*child parents. 2elp parents identify and solve their coalition exists. &ometimes the child is openly marital differences. pressed to align !ith . parent against the other. #he symptom or behavior -eating disorder1 is the regulator in the family system, and the parents deny their o!n conflicts. Be a!are of and confront sabotage behavior on the (eelings of blame, shame, and helplessness may part of family members. lead to unconscious behavior designed to maintain the status "uo.

Co!!a2o(a$i%'
7efer to community resources, such as family group ,ay help reduce overprotectiveness, support/ therapy, parents’ groups, as indicated9 and arent facilitate the process of dealing !ith unresolved 8ffectiveness classes. conflicts and change.

N-RSING DIAGNOSIS S;IN INTEGRITY4 im+ai('d4 (is5 *o( o( ac$)a! May ' R'!a$'d $o. Altered nutritional state9 edema +ehydration3cachectic changes -s'eletal prominence1 Possi2!y E%id'nc'd 2y. +ry3scaly s'in !ith poor s'in turgor9 tissue fragility Brittle3dry hair +ry rash, reports of itching, dermal abrasions -from scratching1 D'si('d O)$com's&E%a!)a$ion C(i$'(ia3 Aerbalize understanding of causative factors and C!i'n$ 1i!!. relief of discomfort. 6dentify and demonstrate behaviors to maintain soft, supple, intact s'in.

ACTIONS&INTERVENTIONS RATIONALE Ind'+'nd'n$
>bserve for reddened, blanched, excoriated areas. 6ndicators of increased ris' of brea'do!n re"uiring more intense treatment. 8ncourage bathing every other day instead of daily. (re"uent baths contribute to s'in dryness. %se s'in cream t!ice a day and al!ays after bathing. ;ubricates s'in and decreases itching. ,assage s'in gently, especially over bony 6mproves s'in circulation, enhances s'in tone. prominences. +iscuss importance of fre"uent change of position, 8nhances circulation and perfusion to s'in by need for remaining active. preventing prolonged pressure on tissues. 8mphasize importance of ade"uate nutrition/fluid 6mproved nutrition and hydration !ill improve inta'e. -7efer to @+< @utrition< altered, less than s'in condition. body re"uirements.1

N-RSING DIAGNOSIS ;NO1LEDGE d'*ici$ 7LEARNING NEED8 ('"a(din" condi$ion4 +(o"nosis4 s'!* ca(' and $('a$m'n$ n''ds May ' R'!a$'d $o. ;ac' of exposure to3unfamiliarity !ith information resources9 misinterpretation ;ac' of interest in learning ;earned maladaptive coping s'ills Possi2!y E%id'nc'd 2y. Aerbalization of misconception

reoccupation !ith extreme fear of obesity and distortion of o!n body image 7efusal to eat, binging3purging Abuse of laxatives3diuretics9 excessive exercising 8xpression of desire to learn more adaptive !ays of coping !ith stress or of relationship of current situation and behaviors 6nappropriate behaviors -e.g., apathy1 D'si('d O)$com's&E%a!)a$ion C(i$'(ia3 Aerbalize a!areness of and plan for lifestyle C!i'n$ 1i!!. changes to maintain desired !eight. 6dentify relationship of signs3symptoms -e.g., !eight loss, tooth decay1 to behaviors of not eating3binge*purging. Assume responsibility for o!n learning. &ee' out sources3resources to assist !ith ma'ing identified changes. (ormulate plan to meet individual goals for !ellness.

ACTIONS&INTERVENTIONS RATIONALE Ind'+'nd'n$
+etermine level of 'no!ledge and readiness to ;earning is easier !hen it begins !here the learner learn. is. @ote bloc's to learning -e.g., physical/intellectual/ ,alnutrition, family problems, drug abuse, emotional1. affective disorders, obsessive*compulsive symptoms can interfere !ith learning, re"uiring resolution before effective learning can occur. 7evie! dietary needs, ans!ering "uestions as )lient/family may need assistance !ith planning indicated. 8ncourage inclusion of high*fiber foods for ne! !ay of eating. As constipation may occur and ade"uate fluid inta'e. !hen laxative use is curtailed, dietary considerations may prevent need for more aggressive therapy. +iscuss conse"uences of behavior. &udden death may occur o!ing to electrolyte imbalances9 suppression of the immune system and liver damage may result from protein deficiency9 or gastric rupture may follo! binge* eating/vomiting.

8ncourage the use of relaxation and other stress* @e! !ays of coping !ith feelings of anxiety and management techni"ues -e.g., visualization, guided fear !ill help client manage these feelings more imagery, biofeedbac'1. effectively, assisting in giving up maladaptive behaviors of not eating/binging*purging. Assist !ith establishing a sensible exercise program. 8xercise can help develop a positive body image )aution regarding overexercise. and combats depression -release of endorphins in the brain enhances sense of !ell*being1. )lient may use excessive exercise as a !ay of controlling !eight. rovide !ritten information for client/&>-s1. 2elpful as reminder of and reinforcement for learning. +iscuss need for information about sex and sexuality. Because avoidance of o!n sexuality is an issue for this client, realistic information can be helpful in beginning to deal !ith self as a sexual being. 7efer to @ational Association of Anorexia @ervosa ,ay be a helpful source of support and and Associated +isorders, >vereaters Anonymous, information for client and &>-s1. and other local resources.