Eating Disorder and Mental Health Components

Introduction

To begin my final project I would like to offer background about my topic in terms of why I choose this and why it is important to me. Mental health is something that has made recent headline’s and is yet shoved under the bed. Mental illness awareness and mental health in general is a touchy topic for most because it does not always convey physical signs and symptoms and often has a negative connotation. Mental health is the well being physically, spiritually, mentally and emotionally.

Mental illness can have a variation of definitions. Mental illness being controversial is a large playing field in psychiatric nursing partnering with co-morbidities one may have. Mental health is within every single person on the planet and could be triggered by a life event. It can happen to anyone to a variation of different degrees. At one point in our life you will undergo a remarkable change that may or may not disrupt certain processes of your daily life. With that being said your mental health may be altered or impacted in some way. To many their is a variation or coping mechanisms that are healthy and somewhat acceptable. To others they are forever changed and require deeper intervention such as therapy and medication to correct the offset chemical imbalance perhaps. Some are born with a disruption in function of chemical reactions and they are triggered throughout life and come out as the brain develops and grows.

My background is I am currently a Licensed Vocation Nurse with a speciality emphasizing as in Psych nursing, eating disorders. The qualification differences between a Licensed Vocation Nurse and Registered Nurse is education requirements ( Bachelors in Nursing ) vs. a two year program that I completed. The skill set however is the exact same. The environments and fields differ as well by state. Here in California LVN’s typically work outpatient or in a speciality fields such as psych, not in ER settings or typically hospitals as an RN does. My current job that I hold is working as a treatment nurse at a residential facility for adolescences boys and girls with eating disorders and mental health components that accompany that disorder. The primary disorder is Anorexia nervosa. The population as mentioned is adolescent mixed boys and girls and the goal is to live within the residential private facility and learn how to function around food. These children are highly suicidal and at times homicidal and require 24 hours a day supervision. My job consists of regular nursing duties such as daily medication administration, EKG’s, blood draw’s and urinary analysis. The children that come to live within the residential treatment are discharged from a hospital setting and usually fresh off tube feedings. They are severely orthostatic and have the risk of passing out frequently, nose bleeding and exhaustion. The eating disorder takes over their body after a certain point of living with it and begins to exhaust their organs and eventually stop their heart.

About the disorder

Anorexia nervosa displays a relentless pursuit of thinness, a morbid fear of obesity, a distorted body image, and restriction of intake relative to requirements needed for a daily basis, leading to a significantly low body weight and death. People with anorexia will typically restrict the number of calories and the types of food they eat and can have many restrictions within this. Some people with the disorder also exercise compulsively, purge day and night after meals and abuse over the counter laxatives, and/or binge eat. The diagnosis for anorexia nervosa is clinical. The treatment begins with some form of psychologic and behavioral therapy. Anorexia nervosa is the highest mortality rate of any mental illness.

Anorexia can affect people of all ages, genders, sexual orientations, races, and ethnicities. Historians and psychologists have found evidence of people displaying symptoms of anorexia for hundreds or thousands of years.  Although the disorder most frequently begins during adolescence, an increasing number of children and older adults are also being diagnosed with anorexia. You cannot tell if a person is struggling with anorexia by looking at them. A person does not need to be emaciated or underweight to be struggling. Studies have found that larger-bodied individuals can also have anorexia, although they may be less likely to be diagnosed due to cultural prejudice against fat and obesity.

To be diagnosed with anorexia nervosa, the following criteria must be met:

•  Restriction of food intake resulting in a significantly low body weight
•  Fear of excessive weight gain or obesity (stated specifically by the patient or manifested as behavior that interferes with weight gain)
•  Body image disturbance (misperception of body weight and/or appearance) or denial of the seriousness of illness

Physical Symptoms include

•  Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.)
•  Difficulties concentrating
•  Abnormal laboratory findings (anemia, low thyroid and hormone levels, low potassium, low blood cell counts, slow heart rate)
•  Dizziness
•  Fainting/syncope
•  Feeling cold all the time
•  Sleep problems
•  Menstrual irregularities—amenorrhea, irregular periods or only having a period while on hormonal contraceptives (this is not considered a “true” period)
•  Cuts and calluses across the top of finger joints (a result of inducing vomiting)
•  Dental problems, such as enamel erosion, cavities, and tooth sensitivity
•  Dry skin
•  Dry and brittle nails
•  Swelling around area of salivary glands
•  Fine hair on body (lanugo)
•  Thinning of hair on head, dry and brittle hair
•  Cavities, or discoloration of teeth, from vomiting
•  Muscle weakness
•  Yellow skin (in context of eating large amounts of carrots)
•  Cold, mottled hands and feet or swelling of feet
•  Poor wound healing
•  Impaired immune functioning

Emotional & behavioral

•  Dramatic weight loss
•  Dresses in layers to hide weight loss or stay warm
•  Is preoccupied with weight, food, calories, fat grams, and dieting
•  Refuses to eat certain foods, progressing to restrictions against whole categories of food (e.g., no carbohydrates, etc.)
•  Makes frequent comments about feeling “fat” or overweight despite weight loss
•  Complains of constipation, abdominal pain, cold intolerance, lethargy, and/or excess energy
•  Denies feeling hungry
•  Develops food rituals (e.g., eating foods in certain orders, excessive chewing, rearranging food on a plate)
•  Cooks meals for others without eating
•  Consistently makes excuses to avoid mealtimes or situations involving food
•  Expresses a need to “burn off” calories taken in
•  Maintains an excessive, rigid exercise regimen – despite weather, fatigue, illness, or injury
•  Withdraws from usual friends and activities and becomes more isolated, withdrawn, and secretive
•  Seems concerned about eating in public
•  Has limited social spontaneity
•  Resists or is unable to maintain a body weight appropriate for their age, height, and build
•  Has intense fear of weight gain or being “fat,” even though underweight
•  Has disturbed experience of body weight or shape, undue influence of weight or shape on self-evaluation, or denial of the seriousness of low body weight
•  Post puberty female loses menstrual period
•  Feels ineffective
•  Has strong need for control
•  Shows inflexible thinking
•  Has overly restrained initiative and emotional expression

Pathophysiology

For young women menses usually cease. For men and women bone mass declines. In the patient is severely malnourished, virtually every major organ system may be affected especially the heart. However, susceptibility to infections is typically not increased. Dehydration and metabolic alkalosis may occur, and serum potassium and/or sodium may be low; all are aggravated by induced vomiting and laxative or diuretic use. Cardiac muscle mass, chamber size, and output decrease; mitral valve prolapse is commonly detected. Some patients have prolonged QT intervals (even when corrected for heart rate), which, with the risks imposed by electrolyte disturbances, may predispose to tachy-arrhythmias. Sudden death may occur and that is most likely due to ventricular tachy-arrhythmias.

Lab Tests

•  Physical exam. This may include measuring height and weight; checking vital signs, such as heart rate, blood pressure and temperature; checking skin turgor and nails for problems; listening to heart and lungs; and examining abdomen.
•  Lab tests. These may include a complete blood count (CBC) and more-specialized blood tests to check electrolytes and protein as well as functioning of liver, kidney and thyroid. A urinalysis also may be done.
•  Psychological evaluation. A doctor or mental health professional will likely ask the patient their thoughts, feelings and eating habits.
•  Other studies. X-rays may be taken to check bone density, check for stress fractures or broken bones, or check for pneumonia or heart problems. Electrocardiograms may be done to look for heart irregularities.

Endocrine abnormalities are common in anorexia nervosa; they include

•  Low levels of gonadal hormones
•  Mildly reduced levels of thyroxine (T4) and triiodothyronine (T3)
•  Increased cortisol secretion

Treatment, Education, & Teaching

The general principles of treatment of eating disorders are to take an interdisciplinary approach. Ideally, the treatment team should include a medical doctor, a psychiatrist, a dietitian, many nurses, and a therapist. Education and involvement of the family and other support network is crucial and positive intervention is needed. Consistency in the treatment plan needs to be implemented and rewarding behavior changes are shown to be effective. Cognitive-behavioral therapy, interpersonal therapy, and family therapy along with family therapy within the residential facility are important. Despite initial promise, none of the medicines available have been shown to be very effective on their own in the treatment of anorexia nervosa.

There are many that can help stimulate the appetite but will not overcome the mental aspect of the appetite suppression by the individual. OTC things like Lactaid are given for the introduction of dairy back into the diet. Dairy is ofter used due to the higher amount of fat in its product so the individual will gain weight. The APA guidelines state that psychotropic medications should not be used as the sole or primary treatment for anorexia nervosa, but they can be considered for the prevention of relapse in weight restored patients or to treat depression or obsessive-compulsive disorder. In the facility, I work depression is in every single patient, and in one particular patient, the OCD factor is so high a combination of antidepressants is prescribed. There is limited evidence that antidepressants may help maintain weight gain in successfully treated patients.

Anxiolytic medications may be helpful before meals for the anorexic patient who is having anxiety before eating. Those are typically administered throughout the day several times a day as needed. Several reports have been published in which olanzapine (Zyprexa®, Eli Lilly) (antipsychotic drug typically used to treat schizophrenia) was successfully used in patients with severe anorexia nervosa for stimulating appetite and weight gain. This medication has been found to help some people with anorexia gain weight and change their obsessive thinking. Other medications used are antidepressants, and they are typically prescribed to treat underlying mental health problems. Fluoxetine (Prozac) may help people with anorexia overcome their depression and maintain a healthy weight once they have gotten their weight and eating under control. Fluoxetine is in a class of drugs called selective serotonin uptake inhibitors (SSRIs). These drugs increase serotonin levels.

Prozac (fluoxetine hydrochloride):

•  Antidepressant SSRI – selective serotonin reuptake inhibitor); SSRIs selectively affect neurotransmitter (the chemicals that send messages to and from the brain) mechanisms in the central nervous system.
•  Oral administration

Used to treat mental depression, obsessive-compulsive disorder and panic disorders.

Xanax (alprazolam):

•  Anxiety medication (a type of central nervous system (CNS) depressant or medicine that slows down the nervous system).
•  Oral administration
•  Used to treat anxiety, anxiety associated with depression and panic disorders.

Nursing Interventions & Rationals

As a nurse you will always take your work home with you and the point of this paper is to raise awareness about the disorder and how it is more than it seems. In my profession the things we focus on are interventions and rationals and we carry them out via care plan customized for each patient. The little things count in the mental health psych nursing world. Every interaction triggers a reaction and every reaction triggeres an interaction. By this I mean what you do for a patient int treatment will stick with them throughout their treatment and remission. From a nursing point of view here are some interventions and rationals we use on a daily basis.

Intervention;

Supervise the patient during mealtimes and for a specified period after meals (usually one hour)

Rational;

To ensure compliance with the dietary treatment program. For hospitalized patient with anorexia, food is considered a medication.

Intervention;

Offer liquids they are more acceptable than solid to a new recovering patient.

Rational;

Fluids eliminate the need to choose between foods – something the patient with anorexia may find difficult.

Intervention;

If edema or bloating occurs after the patient has returned to normal eating behavior, reassure her that this phenomenon is temporary.

Rational;

Patient may fear that they are becoming fat and stop complying with the plan of treatment.

Therapeutic Communication

The nurse and patient ability to interact and have honesty between them is essential in treatment. Presenting a true, calm, patient attitude, non judgmental mindset rather than attempting to make a patient speak helps decrease fears and anxieties demonstrates respect and acceptance.

Actively listen, observe for verbal and nonverbal cues and behaviors. Always being vigilant when a patient speaks to you and voices concerns keeping in the back of the mind that they may be suicidal. If things are mentioned along the lines be calm and ask about “the plan”. This seeks intervention as needed and can even save a life. All of this can help piece together communication methods in an effort to understand the patient and where they are coming from. Most patients want to get better. They have huge hearts and this could be a temporary time in their life. Encourage other ways of communicating such as painting, drawing, reading, singing or writing. This demonstrates empathy, helps develop trust, and continues to encourage communication with art. The goals of therapeutic communications are to focus on the client and foster the therapeutic relationship. If a patient is upset encourage them to use their words and offers healthy coping mechanisms like throwing ice outside or scratching a frozen lime. These two techniques are offered as a preventive of the patient potentially self harming.

Therapeutic Relationship

The nurse patient relationship is also another essential factor in treatment. The goals of a therapeutic relationship differ form others for so many reasons. First the focus of energies is primarily on the patient and their feelings and emotions. Second the therapeutic relationship is consciously directed by the facilitator. Nurse’s and providers consciously establish connection to help patients cope with their life demands.

This includes trust, empathy, autonomy, caring, and hope. With therapeutic relationships their are different dimensions. Affective, afflictive, behavioral, cognitive, temporal, and contextual. Plan time, setting and outline of goals for each meeting with your patient. This helps to define and focus on the goals of the relationship. Establishing an atmosphere of warmth and acceptance during the first meeting. This communicates respect and a willingness to become involved. Helping the patient define their problems reduces emotional reactions.

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