Nursing management in eating disorders

1. Nursing management in eating disorders • Imbalanced nutrition less than body requirements related to refusal to eat/ drink, self induced vomiting, abuse of laxatives/ diuretics evidenced by loss of weight, poor muscle tone and skin turgor, lanugo, bradycardia, hypotension, cardiac arrythmias, pale, dry mucous membranes

2. Explain the client the privileges and restrictions will be based on compliance with treatment and direct weight gain • Do not focus on food and eating • Weigh client daily, immediately upon arising and following first voiding • Stay with client during established time for meals. (30 minutes ) and 1 hour after meals • If weight loss occurs, use restrictions

3. Ineffective denial related to retarded ego development and fear of losing the only aspect of life over which client perceives some control evidenced by inability to admit the impact of maladaptive eating behaviors on life pattern

4. Develop a trusting relationship • Convey positive regard • Avoid arguing or bargaining with the client • Encourage client to verbalize feelings • Help clients to recognize ways in which he or she can gain control over these problematic areas of life.

5. Disturbed bodyimage or low self esteem related to retarded ego development and dysfunctional family system evidenced by distorted body image, difficulty accepting positive reinforcement, depressed mood and self deprecating thoughts

6. Help client to develop a realistic perception of body image and relationship with food • Promote feelings of control with in the environment through participation and independent decision making • Help client realize that perfection is unrealistic, and explore this need with him

7. imbalanced nutrition more than body requirements related to compulsive over eating evidenced by weight gain more than 20% over expected body weight for age and height

8. Encourage client to keep a diary of ood intake • Discuss feelings and emotions associated with eating • With the input from client, formulate an eating plan • Identify realistic increment goals for weekly weight loss • Plan progressive exercise programme • Provide instructions about medications to assist with weight loss , if ordered by physician

9. Disturbed body image/ low self esteem related to dissatisfaction with appearance, evidenced by verbalization of negative feelings about the way he or she looks and desire to lose weight

10. Assess clients feelings and attitudes about being obese • Ensure the client has privacy during self care activities • Explore the coping patterns of client • Determine the motivation of client in weight loss • Reflect on strengths and accomplishments of client • Refer to support or group therapy

11. Sexual Disorders

12. Categories of sexual disorders • Sexual dysfunctions • Paraphilias • Gender identity disorders

13. Sexual dysfunctions • It prevents or reduces an individuals enjoyment of normal sex and prevent or reduce the normal physiological changes brought on normally by sexual arousal. • It may occur because of fatigue, sickness, alcohol, or drugs

14. Types • Desire phase • Hypo active desire- complete or almost absence of desire to have any type of sexual activity • Aversion to sex- it repulses the person from sexual thoughts and activity

15. Arousal phase • Erectile dysfunction (in males, inability to attain enough erection for coitus) • Sexual arousal disorder (in females, inability to become sexually aroused in spite of the activities)

16. Orgasm phase • Pre mature ejaculation (before the end of coitus) • Ejaculatory incompetence (lack or delay in reaching orgasm) • Inhibited female orgasm (lack or delay in reaching orgasm in females)

17. Sexual pain disorders • Dyspareunia (painful intercourse in females) • Vaginismus (involuntary spasmodic muscle contractions at the entrance to the vagina when an attempt is made to insert penis, resulting it as a painful act)

18. Gender identity disorder F64 • It leads to confusion, vagueness or conflict in their feelings about their own sexual identity. There is a struggle between the individual’s anatomical sex gender and subjective feelings about choosing a masculine or feminine style of life.

19. Transsexualism • There is a persistent and significant sense of discomfort regarding one’s anatomical sex and a feeling that it is inappropriate to one’s perceived gender. • GID of childhood • Duel role transvestism – it is characterized by wearing clothes of the opposite sex in order to enjoy the temporary experience of membership of the opposite sex. • Intersexuality- the patient has gross anatomical or physiological features of the other sex

20. causes • Physiological • Injuries to spine • Enlarged prostate gland • Diseases like, diabetic neuropathy, multiple sclerosis, tumors • Drugs like, alcohol, nicotine, narcotis, stimulants, antihypertensives, anti histamines

21. Endocrine disorders (thyroid, pitutary or adrenal gland problems) • Hormonal deficiencies (low testosterone, estrogen, or androgens) • Problem with blood supply • Birth defects

22. Psychological factors • Physical changes may generate psychological reactions that compound the dysfunction • Mood disorders (low desire and arousal) • Women with anxiety disorders ( low desire, arousal and orgasm) • Various fears, being vulnerable, being rejected, or of losing control and low self esteem.

23. Previous experiences • Past negative sexual or other experiences may lead to low self esteem, shame or guilt • Emotional, physical, or sexual abuse during childhood or adolescence • Early traumatic loss of parent or other loved one

24. Contextual causes • Relationship context- lack of trust, negative feelings, reduced attraction toward a sex partner • Sexual context- surroundings that not be sufficiently erotic, private or safe. • Cultural context- cultural restrictions • Distractions with family, work or finance

25. Management • Assessment • Medical history • Relationship with partner • Current sexual context • Effective triggering factors • Inhibitors of arousal • Orgasms • dyspareunia

26. Self image • Developmental history • Past sexual experiences • Personality factors

27. Treatment • Hormone replacement • Identify and treat cause • Couple therapy • Drug therapy • Topical applications • Psychoanalytic psychotherapy • Group psychotherapy • hypnosis

28. Nursing management • Establish therapeutic relationship • Accept the client as he is • Allow the patient to express his feelings • Teach relaxation techniques • Motivate the client to discuss physiological changes occurring in the body • Understand cultural, social, ethnic, racial, religious factors

29. Educate client regarding sexuality and sexual functioning • Remove misconception in partners • Motivate them to develop improved relationship • Provide conducive environment to the clients to have verbal catharsis • Provide adequate counseling • Help them in planning and executing treatment regimen

30. Health education • Follow doctors advice • Limit alcohol and smoking • Deal with anxiety and emotional problems effectively • Develop healthy communication with partner • Do not force

31. Nursing diagnosis • Disturbed personal identity related to parenting patterns that encourage culturally unacceptable behaviors for assigned gender evidenced by statements of desiring to be of the opposite gender, exhibiting behaviors culturally associated with the opposite gender

32. Spend time with client and show positive regard • Be aware of own feelings and attitude towards the client and his behavior • Allow client to describe his or her perception of problem • Discuss with him the types of behaviors that are more culturallyacceptable

33. Impaired social interaction related to social and culturally unacceptable behaviors evidenced by peer rejection and identification with members of the opposite gender • . Low self esteem related to rejection by peers.

34. Personality disorders • Definition • DSM IV defines personality disorders, only when personality traits are inflexible and maladaptive, and cause either significant functional impairment or subjective distress

35. James Pritchard, father of personality disorders defines personality disorders as “a morbid perversion of natural feelings, afflictions, inclinations, temper, habit, moral disposition, and natural impulses with out any remarkable disorder or defect of the intellect or knowing and reasoning faculties and particularly with out any insane illusion or hallucination.”

36. classification • ICD- 10 (F60- F69) • Paranoid PD • Schizoid PD • Dissocial PD (antisocial) • Emotionally disturbed PD • A. impulsive type • B.borderline type • Histrionic PD

37. Obsessive Compulsive PD • Anxious Avoidant PD • Dependent PD • Other specific PD (narcissistic PD)

38. DSMIV classification • In DSM IV, it is coded on axis II and divided in to three clusters. • Cluster A- paranoid, schizoid, schizotypal • Cluster B (dramatic, emotional and erratic, antisocial, histrionic, narcissistic) • Cluster C (anxious and fearful, avoidant, dependent, obsessive compulsive)

39. Incidence • General population – 5-10%

40. Incidents • Exact cause is unknown • Genetic • Biological • Social • Psychological • Developmental • Environmental

41. Genetic • Biological basis of brain function and personality structure is influenced by genetic factor

42. Biological factors • Poor regulation of brain circuits that control emotion , increases the risk

43. Psychodynamic theories • Suggests that deficiencies in ego and superego development • Deficiencies may relate to mother- child relationships marked by unresponsiveness, over protectiveness or early seperation

44. other related factors • Maternal deprivation- antisocial personality • Childhood abuse- borderline personality • Failure to resolve oedipal complex and excessive use of repression – histrionic personality • Fixation in the oral stage- dependent personality • Absence of trust- paranoid personality.

45. Clinical features • Paranoid personality disorder • Suspicious • Mistrustful • Sensitive • Argumentative • Stubborn • Self important • Hypertensive • Jealous and irritable

46. Schizoid Personality disorder • Detachment • Social withdrawal • Loneliness • No close friends • Emotionally cold • Aloof • Humorless • Introspective • No desire of enjoyment • Inability to experience pleasure

47. Schizotypal disorder • Odd thinking/ magical thinking • Social and interpersonal deficits • Inappropriate affect • Social withdrawal • Not fitting easily with others

48. Antisocial (Dissocial) personality disorder (sociopath/ psychopath) • Chronic antisocial behavior • Violates others rights • Unable to maintain consistent, responsible functioning • Failure to sustain relationships • Disregard for feeling of others • Impulsive actions • Low tolerance to frustration

49. Tendency to cause violence • Lack of guilt • Failure to learn from experience • Failure to plan ahead

50. Histrionic personality disorder • Excessive emotionality and attention seeking behavior • More in females • Dramatic emotionality • Emotional blackmail • Suicide attempts • Craving for novelty and excitement • Shallow and labile affectivity