ANOREXIA NERVOSA/BULIMIA NERVOSA

DSM-IV
307.1 Anoxexia nervosa
307.51 Bulimia nervosa
307.50 Eating disorders NOS
Binge-eating disorder (proposed re!uiring "urt#er stud$%
Anorexia nervosa is an illness o" starvation &roug#t on &$ severe distur&an'e o"
&od$ image and a mor&id "ear o" o&esit$.
Bulimia nervosa is an eating disorder (&inge-purge s$ndrome% '#ara'teri(ed &$
extreme overeating "ollo)ed &$ sel"-indu'ed vomiting. *t ma$ in'lude a&use o"
laxatives and diureti's.
Binge-eating is de+ned as re'urrent episodes o" overeating asso'iated )it#
su&,e'tive and &e#avioral indi'ators o" impaired 'ontrol over and signi+'ant distress
a&out t#e eating &e#avior &ut )it#out t#e use o" inappropriate 'ompensator$
&e#aviors (e.g. purging "asting ex'essive exer'ise%.
ETIOLOGICAL THEORIES
Psychodynamcs
-#e individual re.e'ts a developmental arrest in t#e ver$ earl$ '#ild#ood $ears.
-#e tas/s o" trust autonom$ and separation-individuation are un"ul+lled and t#e
individual remains in t#e dependent position. Ego development is retarded.
S$mptoms are o"ten asso'iated )it# a per'eived loss o" 'ontrol in some aspe't o" li"e
and ma$ 'enter on "ears o" sexual maturit$/intima'$. Alt#oug# t#ese disorders a0e't
)omen primaril$ approximatel$ 51 to 101 o" t#ose a2i'ted are men. Additionall$
eating disorders are o"ten asso'iated )it# depression anxiet$ p#o&ias and 'ognitive
pro&lems.
Bo!o"ca!
-#ese disorders ma$ &e 'aused &$ neuroendo'rine a&normalities )it#in t#e
#$pot#alamus. S$mptoms are lin/ed to various '#emi'al distur&an'es normall$
regulated &$ t#e #$pot#alamus. 3urt#ermore a p#$siologi'al de"e't ma$ ma/e it
di4'ult "or t#e individual to interpret sensations o" #unger and "ullness.
#am!y Dynamcs
*ssues o" 'ontrol &e'ome t#e overriding "a'tors in t#e "amil$ o" t#e 'lient )it# an
eating disorder. -#ese "amilies o"ten 'onsist o" a passive "at#er a domineering
mot#er and an overl$ dependent '#ild. -#ere is a #ig# value pla'ed on per"e'tionism
in t#is "amil$ and t#e '#ild &elieves s#e or #e must please ot#ers and satis"$ t#ese
standards.
CLIENT ASSESSMENT DATA BASE
Ac$%$y/R&s$
5istur&ed sleep patterns (e.g. earl$ morning insomnia6 "atigue%
3eeling 7#$per8 and/or anxious
*n'reased a'tivit$/avid exer'iser parti'ipation in #ig#-energ$ sports
Emplo$ment in positions/pro"essions t#at re!uire 'ontrol o" )eig#t (at#leti's su'# as
g$mnasts s)immers ,o'/e$s )restlers6 modeling .ig#t attendants%
C'c(!a$on
3eeling 'old even )#en room is )arm
9o) B:6 ta'#$'ardia d$sr#$t#mias
E"o In$&"'$y
:o)erlessness/#elplessness la'/ o" 'ontrol over eating (e.g. 'annot stop
eating/'ontrol )#at or #o) mu'# is eaten ;&ulimia<6 "eeling disgusted )it# sel"
depressed or ver$ guilt$ a"ter overeating ;&inge-eating<%
5istorted (unrealisti'% &od$ image=reports sel" as "at regardless o" )eig#t (denial%
and sees t#in &od$ as "at6 persistent over'on'ern )it# &od$ s#ape and )eig#t=
"ears gaining )eig#t ("emales%
>on'erned )it# a'#ieving mas'uline &od$ &uild (males% rat#er t#an a'tual )eig#t or
)eig#t gain
Stress "a'tors (e.g. "amil$ move/divor'e onset o" pu&ert$%
?ig# sel"-expe'tations
Suppression o" anger6 emotional states o" depression )it#dra)al anger anxiet$
pessimisti' outloo/
E!mna$on
5iarr#ea/'onstipation
5e'reased "re!uen'$ o" voiding/urine output urine dar/ am&er (de#$dration%
@ague a&dominal pain and distress &loating
9axative/diureti' use
#ood/#!(d
>onstant #unger or denial o" #unger6 normal or exaggerated appetite t#at rarel$
vanis#es until late in t#e disorder (anorexia%
*ntense "ear o" gaining )eig#t ("emale%6 ma$ #ave prior #istor$ o" &eing over)eig#t
(parti'ularl$ males%
*nordinate pleasure in )eig#t loss )#ile den$ing sel" pleasure in ot#er areas
Ae"usal to maintain &od$ )eig#t at or a&ove minimal norm "or age/#eig#t (anorexia%
Ae'urrent episodes o" &inge-eating6 a "eeling o" la'/ o" 'ontrol over &e#avior during
eating &inges6 minimum average o" B &inge eating episodes a )ee/ "or at least 3
mont#s (&ulimia%6 ingests large amounts o" "ood )#en not "eeling p#$si'all$
#ungr$ o"ten 'onsuming as mu'# as B0000 'alories in a B-#our period6 eating
mu'# more rapidl$ t#an normal in a dis'rete period o" time (e.g. )it#in a B-#our
period% an amount o" "ood t#at is de+nitel$ larger t#an most people )ould eat
(&inge-eating%6 "eels un'om"orta&l$ "ull
Aegularl$ engages in eit#er sel"-indu'ed vomiting (&inge-purge s$ndrome ;&ulimia<%
independentl$ or as a 'ompli'ation o" anorexia or stri't dieting or "asting6
ex'essive gum '#e)ing
Ceig#t loss/maintenan'e o" &od$ )eig#t 151 or more &elo) t#at expe'ted (anorexia%
or )eig#t ma$ &e normal or slig#tl$ a&ove or &elo) (&ulimia%
>a'#e'ti' appearan'e6 s/in ma$ &e dr$ $ello)is#/pale )it# poor turgor
:reo''upation )it# "ood (e.g. 'alorie-'ounting gourmet 'oo/ing6 #iding "ood 'utting
"ood into small pie'es rearranging "ood on plate%
:erip#eral edema
S)ollen salivar$ glands6 sore in.amed &u''al 'avit$ erosion o" toot# enamel6 gums
in poor 'ondition6 'ontinuous sore t#roat (&ulimia%
@omiting6 &lood$ vomitus (ma$ indi'ate esop#ageal tearing=Dallor$-Ceiss%
Hy"&n&
*n'reased #air gro)t# on &od$ (lanugo%6 #air loss (axillar$/pu&i'%6 #air dull/not s#in$
Brittle nails
Signs o" erosion o" toot# enamel6 gum a&s'esses ul'erations o" mu'osa
N&('os&nso'y
Appropriate a0e't ex'ept in regard to &od$ and eating6 or depressive a0e't
(depression%
Dental '#angesE apat#$ 'on"usion memor$ impairment (&roug#t on &$
malnutrition/starvation%
?$steri'al or o&sessive personalit$ st$le6 no ot#er ps$'#iatri' illness or eviden'e o" a
ps$'#iatri' t#oug#t disorder present (alt#oug# a signi+'ant num&er ma$ s#o)
eviden'e o" an a0e'tive disorder%
Pan/Dscom)o'$
?eada'#es sore t#roat general vague 'omplaints
Sa)&$y
Bod$ temperature &elo) normal
Ae'urrent in"e'tious pro'esses (indi'ative o" depressed immune s$stem%
E'(ema/ot#er s/in pro&lems
A&rasions/'allouses ma$ &e noted on t#e &a'/ o" #ands (sti'/ing +nger do)n t#roat
to indu'e vomiting%
S&*(a!$y
A&sen'e o" at least 3 'onse'utive menstrual '$'les (de'reased levels o" estrogen in
response to malnutrition%
:romis'uit$ or denial/loss o" sexual interest
?istor$ o" sexual a&use
Breast atrop#$ amenorr#ea
Soca! In$&'ac$ons
Diddle-'lass or upper-'lass "amil$ &a'/ground
:assive "at#er/dominant mot#er "amil$ mem&ers enmes#ed toget#erness pri(ed
personal &oundaries not respe'ted
?istor$ o" &eing a !uiet 'ooperative '#ild
:ro&lems o" 'ontrol issues in relations#ips di4'ult 'ommuni'ations )it#
ot#ers/aut#orit$ +gures6 poor 'ommuni'ations )it#in "amil$ o" origin
Engagement in po)er struggles
Altered relations#ips or pro&lems )it# relations#ips (not married/divor'ed%
)it#dra)al "rom "riends/so'ial 'onta'ts
A&usive "amil$ relations#ips
Sense o" #elplessness
Da$ #ave #istor$ o" legal di4'ulties (e.g. s#opli"ting%
T&achn"/L&a'nn"
?ig# a'ademi' a'#ievement
3amil$ #istor$ o" #ig#er t#an normal in'iden'e o" depression ot#er "amil$ mem&ers
)it# eating disorders (geneti' predisposition%
Onset o" t#e illness usuall$ &et)een t#e ages o" 10 and BB
?ealt# &elie"s/pra'ti'es (e.g. 'ertain "oods #ave 7too man$8 'alories use o" 7#ealt#8
"oods%
No medi'al illness evident to a''ount "or )eig#t loss
DIAGNOSTIC STUDIES
CBC +$h D,&'&n$a!- 5etermines presen'e o" anemia leu/openia l$mp#o'$tosis.
:latelets s#o) signi+'antl$ less t#an normal a'tivit$ &$ t#e en($me monoamine
oxidase (t#oug#t to &e a mar/er "or depression%.
E!&c$'o!y$&s- *m&alan'es ma$ in'lude de'reased potassium sodium '#loride and
magnesium.
Endoc'n& S$(d&s-
Thy'od #(nc$on- -#$roxine (-
F
% levels usuall$ normal6 #o)ever 'ir'ulating triio-
dot#$ronine (-
3
% levels ma$ &e lo).
P$($a'y #(nc$on- -#$roid-stimulating #ormone (-S?% response to t#$rotropin-
releasing "a'tor (-A3% is a&normal in anorexia nervosa. :ropranolol-glu'agon
stimulation test (studies t#e response o" #uman gro)t# #ormone% reveals
depressed level o" G? in anorexia nervosa. Gonadotropi' #$po"un'tion is noted.
Co'$so!- Deta&olism ma$ &e elevated.
D&*am&$hason& S(..'&sson T&s$ /DST0- Evaluates #$pot#alami'-pituitar$
"un'tion dexamet#asone resistan'e indi'ates 'ortisol suppression suggesting
malnutrition/depression.
L($&n1n" Ho'mon& S&c'&$ons T&s$- :attern o"ten resem&les t#ose o"
prepu&ertal girls.
Es$'o"&n- 5e'reased.
B!ood S("a' and Basa! M&$a2o!c Ra$& /BMR0- Da$ &e lo).
O$h&' Ch&ms$'&s- AS- elevated in'reased 'arotene level6 de'reased protein and
'#olesterol levels.
MHP 3 L&%&!s- 5e'reased suggestive o" malnutrition/depression.
U'na!yss and R&na! #(nc$on- BHN ma$ &e elevated6 /etones present re.e'ting
starvation6 de'reased urinar$ 17-/etosteroids6 in'reased spe'i+' gravit$
(de#$dration%.
E4G- A&normal tra'ing )it# lo) voltage --)ave inversion d$sr#$t#mias.
NURSING PRIORITIES
1. Aeesta&lis# ade!uate/appropriate nutritional inta/e.
B. >orre't .uid and ele'trol$te im&alan'e.
3. Assist 'lient to develop realisti' &od$ image/improve sel"-esteem.
F. :rovide support/involve SO i" availa&le in treatment program to 'lient/SO.
5. >oordinate total treatment program )it# ot#er dis'iplines.
I. :rovide in"ormation a&out disease prognosis and treatment.
DISCHARGE GOALS
1. Ade!uate nutrition and .uid inta/e maintained.
B. Daladaptive 'oping &e#aviors and stressors t#at pre'ipitate anxiet$ re'ogni(ed.
3. Adaptive 'oping strategies and te'#ni!ues "or anxiet$ redu'tion and sel"-'ontrol
implemented.
F. Sel"-esteem in'reased.
5. 5isease pro'ess prognosis and treatment regimen understood.
I. :lan in pla'e to meet needs a"ter dis'#arge.
NURSING DIAGNOSIS NUTRITION- a!$&'&d5 !&ss $han 2ody
'&6('&m&n$s
May B& R&!a$&d $o- *nade!uate "ood inta/e6 sel"-indu'ed vomiting
>#roni'Jex'essive laxative use
Poss2!y E%d&nc&d 2y- Bod$ )eig#t 151 (or more% &elo) expe'ted
(anorexia% or ma$ &e )it#in normal range
(&ulimia &inge-eating%
:ale 'on,un'tiva and mu'ous mem&ranes6 poor
s/in turgorJmus'le tone edema
Ex'essive loss o" #air6 in'reased gro)t# o" &od$
#air (lanugo%
Amenorr#ea
?$pot#ermia
Brad$'ardia 'ardia' irregularities #$potension
Ele'trol$te im&alan'es
D&s'&d O($com&s/E%a!(a$on C'$&'a7 @er&ali(e understanding o" nutritional needs.
C!&n$ 8!!- Esta&lis# a dietar$ pattern )it# 'alori' inta/e
ade!uate to regainJmaintain appropriate )eig#t.
5emonstrate )eig#t gain to)ard expe'ted goal
range.
ACTIONS/INTERVENTIONS RATIONALE
Ind&.&nd&n$
Esta&lis# a minimum )eig#t goal and dail$ Dalnutrition is a mood-altering 'ondition leading
nutritional re!uirements. to depression and agitation and a0e'ting
'ognitive
"un'tioning/de'ision-ma/ing. *mproved
nutritional status en#an'es t#in/ing a&ilit$ and
ps$'#ologi'al )or/ 'an &egin.
*nvolve 'lient )it# team in setting up/'arr$ing out :rovides stru'tured eating stimulation )#ile
program o" &e#avior modi+'ation. :rovide re)ard allo)ing 'lient some 'ontrol in '#oi'es. Be#avior
"or )eig#t gain as individuall$ determined6 ignore modi+'ation ma$ &e e0e'tive onl$ in mild 'ases
or
loss. "or s#ort-term )eig#t gain. No$&- >om&ination o"
'ognitive-&e#avioral approa'# is pre"erred "or
treating &ulimia.
Hse a 'onsistent approa'#. Sit )it# 'lient )#ile >lient dete'ts urgen'$ and rea'ts to pressure.
An$
eating6 present and remove "ood )it#out 'omment t#at mig#t &e seen as 'oer'ion
provides
persuasion and/or 'omment. :romote pleasant "o'us on "ood. C#en sta0 mem&er responds
environment and re'ord inta/e. 'onsistentl$ 'lient 'an &egin to trust #er or #is
responses. -#e single area in )#i'# 'lient #as
exer'ised po)er and 'ontrol is "ood/eating and
s#e or #e ma$ experien'e guilt or re&ellion i"
"or'ed to eat. Stru'turing meals and de'reasing
dis'ussions a&out "ood )ill de'rease po)er
struggles )it# 'lient and avoid manipulative
games.
:rovide smaller meals and supplemental sna'/s Gastri' dilation ma$ o''ur i" re"eeding is too rapid
as appropriate. "ollo)ing a period o" starvation dieting. No$&-
>lient ma$ "eel &loated "or 3KI )ee/s )#ile &od$
read,usts to "ood inta/e.
Da/e sele'tive menu availa&le and allo) 'lient to >lient )#o gains sel"-'on+den'e and "eels in
'ontrol '#oi'es as mu'# as possi&le. 'ontrol o" environment is more li/el$ to eat
pre"erred "oods.
Be alert to '#oi'es o" lo)-'alorie "oods/&everages6 >lient )ill tr$ to avoid ta/ing in )#at is
vie)ed as
#oarding "ood6 disposing o" "ood in various pla'es ex'essive 'alories and ma$ go to great lengt#s to
su'# as po'/ets or )aste&as/ets. avoid eating.
Daintain a regular )eig#ing s'#edule su'# as :rovides a''urate ongoing re'ord o" )eig#t
Donda$/3rida$ &e"ore &rea/"ast in same attire on loss/gain. Also diminis#es o&sessing a&out
same s'ale and grap# results. '#anges in )eig#t.
Ceig# )it# &a'/ to s'ale (depending on program Alt#oug# some programs pre"er 'lient to see t#e
proto'ols%. results o" )eig#ing t#is approa'# 'an "or'e t#e
issue o" trust in 'lient )#o usuall$ does not trust
ot#ers.
Avoid room '#e'/s and ot#er 'ontrol devi'es External 'ontrol rein"or'es 'lientLs "eelings o"
)#enever possi&le. po)erlessness and are t#ere"ore usuall$ not
#elp"ul.
:rovide 1E1 supervision and #ave t#e 'lient :revents vomiting during/a"ter eating. >lient ma$
remain in t#e da$room area )it# no &at#room desire "ood and use a &inge-purge s$ndrome to
privileges "or a spe'i+ed period (e.g. B #ours% maintain )eig#t. No$&- :urging ma$ o''ur "or t#e
"ollo)ing eating i" 'ontra'ting is unsu''ess"ul. +rst time in a 'lient as a response to
esta&lis#ment
o" )eig#t gain program.
Donitor exer'ise program and set limits on p#$si'al Doderate exer'ise #elps maintain mus'le
tone/
a'tivities. >#art a'tivit$/level o" )or/ (pa'ing and)eig#t and 'om&at depression. ?o)ever 'lient
so on%. ma$ exer'ise ex'essivel$ to &urn 'alories.
Daintain matter-o"-"a't non,udgmental attitude i" :er'eption o" punis#ment is 'ounterprodu'tive to
giving enteral "eedings parenteral nutrition et'. promoting sel"-'on+den'e and "ait# in o)n a&ilit$
to 'ontrol destin$.
Be alert to possi&ilit$ o" 'lient dis'onne'ting tu&e Sa&otage &e#avior is 'ommon in attempt to
and empt$ing parenteral nutrition i" used. >#e'/ prevent )eig#t gain.
.uid measurements and tape tu&ing snugl$.
Co!!a2o'a$%&
>onsult )it# dietitian/nutritional t#erap$ team. ?elp"ul in determining individual dietar$ needs
and appropriate sour'es. No$&- *nsu4'ient
'alorie
and protein inta/e 'an lo)er resistan'e to
in"e'tion
and 'ause 'onstipation #allu'inations and liver
damage.
Ae"er "or dental 'are. :eriodontal disease and loss o" toot# enamel
leading to 'aries and loose +llings re!uires
prompt
intervention to improve nutritional inta/e and
general )ell-&eing.
:rovide diet and sna'/s )it# su&stitutions o" ?aving a variet$ o" "oods availa&le )ill ena&le t#e
pre"erred "oods )#en availa&le. 'lient to #ave a '#oi'e o" potentiall$ en,o$a&le
"oods.
Administer li!uid diet tu&e "eedings/parenteral C#en 'alori' inta/e is insu4'ient to sustain
nutrition as appropriate. meta&oli' needs nutritional support 'an &e used
to prevent malnutrition )#ile t#erap$ is
'ontinuing. ?ig#-'alorie li!uid "eedings ma$ &e
given as medi'ation at times separate "rom
meals
as an alternate means o" in'reasing 'alori'
inta/e.
Enteral "eedings are pre"erred as t#e$ preserve G*
"un'tion and redu'e atrop#$ o" t#e gut. -:N is
usuall$ reserved "or li"e-t#reatening situations.
Blenderi(e and tu&e "eed an$t#ing le"t on t#e tra$Da$ &e used as part o" &e#avior modi+'ation
a"ter a given period o" time i" indi'ated. program to provide total inta/e o" needed
'alories.
Avoid giving laxatives. 9axative use is 'ounterprodu'tive as it ma$ &e
used &$ 'lient to rid &od$ o" "ood/'alories. No$&-
Detamu'il/&ran ma$ &e used to treat
'onstipation.
Donitor la&orator$ values as appropriate (e.g. *denti+es t#erapeuti' needs/e0e'tiveness o"
preal&umin trans"errin serum protein levels6 treatment. Ele'trol$te im&alan'es 'an 'ause
ele'trol$tes%. 'ardia' d$sr#$t#mias severe mus'le spasms
and
even sudden deat#.
Administer medi'ations as indi'ated e.g.
>$pro#eptadine (:eria'tin%6 A serotonin and #istamine antagonist used in
#ig#
doses to stimulate t#e appetite de'rease
preo''upation )it# "ood and 'om&at depression.
5oes not appear to #ave serious side e0e'ts
alt#oug# de'reased mental alertness ma$ o''ur.
-ri'$'li' antidepressants e.g. amitript$line 9i"ts depression and stimulates appetite. SSA*s
(Elavil Endep% imipramine (-o"ranil% redu'e &inge-purge '$'les and ma$ also &e
#elp"ul
desipramine (Norpramin%6 sele'tive serotonin in treating anorexia. No$&- Hse must &e 'losel$
reupta/e in#i&itors e.g. .uoxetine (:ro(a'%6 monitored o)ing to potential side e0e'ts
alt#oug# side e0e'ts "rom SSA*s are less
signi+'ant
t#an t#ose asso'iated )it# tri'$'li's.
Antianxiet$ agents e.g. alpro(olam (Manax%6 Aedu'es tension and anxiet$/nervousness and
ma$ #elp 'lient to parti'ipate in treatment.
Antips$'#oti's e.g. '#lorproma(ine (-#ora(ine%6 :romotes )eig#t gain and 'ooperation
)it#
ps$'#ot#erapeuti' program #o)ever used onl$
)#en a&solutel$ ne'essar$ &e'ause o"
extrap$ramidal side e0e'ts.
DAO in#i&itors e.g. tran$l'$promine sul"ate Da$ &e used to treat depression )#en ot#er drug
(:arnate%. t#erap$ is ine0e'tive6 de'reases urge to &inge in
'lients )it# &ulimia.
:repare "or/assist )it# ele'tro'onvulsive t#erap$ *n rare and di4'ult 'ases in )#i'# malnutrition is
(E>-% i" indi'ated. 5is'uss reasons "or use and #elp severe/li"e-t#reatening a s#ort-term E>-
series
'lient understand t#is t#erap$ is not punis#ment. ma$ ena&le t#e 'lient to &egin eating and
&e'ome
a''essi&le to ps$'#ot#erap$.
-rans"er to a'ute medi'al setting "or nutritional -#e underl$ing pro&lem 'annot &e 'ured )it#out
t#erap$ )#en 'ondition is li"e-t#reatening. improved nutritional status. ?ospitali(ation
provides a 'ontrolled environment in )#i'# "ood
inta/e vomiting/elimination medi'ations and
a'tivities 'an &e monitored. *t also separates t#e
'lient "rom SO(s% and provides exposure to ot#ers
)it# t#e same pro&lem 'reating an atmosp#ere
"or
s#aring.
NURSING DIAGNOSIS #LUID VOLUME d&9c$5 's: )o' o' ac$(a!
May B& R&!a$&d $o- *nade!uate inta/e o" "ood and li!uids
>onsistent sel"-indu'ed vomiting
>#roni'Jex'essive laxative or diureti' use
Poss2!y E%d&nc&d 2y /Ac$(a!0- 5r$ s/in and mu'ous mem&ranes de'reased s/in
turgor
*n'reased pulse rate &od$ temperature6
#$potension
Output greater t#an input (diureti' use%6
'on'entrated urineJde'reased urine output
(de#$dration%
Cea/ness
>#ange in mental state
?emo'on'entration altered ele'trol$te
&alan'e
D&s'&d O($com&s/E%a!(a$on C'$&'a7 DaintainJdemonstrate improved .uid &alan'e as
C!&n$ 8!!- eviden'ed &$ ade!uate urine output sta&le vital
signs moist mu'ous mem&ranes good s/in
turgor.
@er&ali(e understanding o" 'ausative "a'tors
and &e#aviors ne'essar$ to 'orre't .uid
de+'it.
ACTIONS/INTERVENTIONS RATIONALE
Ind&.&nd&n$
Donitor vital signs 'apillar$ re+ll status o" mu'ous *ndi'ators o" ade!ua'$ o" 'ir'ulating
volume.
mem&ranes s/in turgor. Ort#ostati' #$potension ma$ o''ur )it# ris/
o" "alls/in,ur$ "ollo)ing sudden '#anges in
position.
Donitor amount and t$pes o" .uid inta/e. Deasure >lient ma$ a&stain "rom all inta/e
resulting in
urine output a''uratel$ as indi'ated. de#$dration or ma$ su&stitute .uids "or 'alori'
inta/e a0e'ting ele'trol$te &alan'e.
5is'uss strategies to stop vomiting and laxative/ ?elping 'lient deal )it# "eelings t#at lead to
diureti' use. vomiting and/or laxative/diureti' use ma$
prevent 'ontinued .uid loss. No$&- -#e 'lient
)it#
&ulimia #as learned t#at vomiting provides a
release o" anxiet$.
*denti"$ a'tions ne'essar$ to regain/maintain *nvolving 'lient in plan to 'orre't .uid im&alan'es
optimal .uid &alan'e (e.g. spe'i+' s'#edule "or improves '#an'es "or su''ess.
.uid inta/e%.
Co!!a2o'a$%&
Aevie) results o" ele'trol$te/renal "un'tion test 3luid/ele'trol$te s#i"ts de'reased renal "un'tion
results. 'an adversel$ a0e't 'lientLs re'over$/prognosis
and ma$ re!uire additional intervention.
Administer/monitor *@ -:N6 potassium Hsed as an emergen'$ measure to 'orre't
supplements as indi'ated. .uid/ele'trol$te im&alan'e. Da$ &e re!uired to
prevent 'ardia' d$sr#$t#mias.
NURSING DIAGNOSIS THOUGHT PROCESSES5 a!$&'&d
May B& R&!a$&d $o- Severe malnutritionJele'trol$te im&alan'e
:s$'#ologi'al 'on.i'ts (e.g. sense o" lo) sel"-
)ort# per'eived la'/ o" 'ontrol%
Poss2!y E%d&nc&d 2y- *mpaired a&ilit$ to ma/e de'isions pro&lem-solve
NonKrealit$-&ased ver&ali(ations
*deas o" re"eren'e
Altered sleep patterns e.g. ma$ go to &ed late
(sta$ up to &ingeJpurge% and get up earl$
Altered attention spanJdistra'ti&ilit$
:er'eptual distur&an'es )it# "ailure to re'ogni(e
#unger "atigue anxiet$ and depression
D&s'&d O($com&s/E%a!(a$on C'$&'a7 @er&ali(e understanding o" 'ausative "a'tors and
C!&n$ 8!!- a)areness o" impairment.
5emonstrate &e#aviors to '#angeJprevent
malnutrition.
5ispla$ improved a&ilit$ to ma/e de'isions
pro&lem-solve.
ACTIONS/INTERVENTIONS RATIONALE
Ind&.&nd&n$
Be a)are o" 'lientLs distorted t#in/ing a&ilit$. Allo)s t#e 'aregiver to #ave more realisti'
expe'tations o" t#e 'lient and provide appropriate
in"ormation and support.
9isten to/avoid '#allenging irrational illogi'al *t is not possi&le to respond logi'all$ )#en
t#in/ing. :resent realit$ 'on'isel$ and &rie.$. t#in/ing a&ilit$ is p#$siologi'all$ impaired. -#e
'lient needs to #ear realit$ &ut '#allenging t#e
'lient leads to distrust and "rustration.
Ad#ere stri'tl$ to nutritional regimen. *mproved nutrition is essential to improved &rain
"un'tioning. (Ae"er to N5E NutritionE altered less
t#an &od$ re!uirements.%
Co!!a2o'a$%&
Aevie) ele'trol$te/renal "un'tion tests. *m&alan'es negativel$ a0e't 'ere&ral "un'tioning
and ma$ re!uire 'orre'tion &e"ore t#erapeuti'
interventions 'an &egin.
NURSING DIAGNOSIS BOD; IMAGE ds$('2anc&/SEL# ESTEEM5
ch'onc !o+
May B& R&!a$&d $o- Dor&id "ear o" o&esit$6 per'eived loss o" 'ontrol in
some aspe't o" li"e
Hnmet dependen'$ needs personal vulnera&ilit$
>ontinued negative evaluation o" sel"
5$s"un'tional "amil$ s$stem
Poss2!y E%d&nc&d 2y- 5istorted &od$ image (vie)s sel" as "at even in
t#e presen'e o" normal &od$ )eig#t or severe
eman'iation%
Expresses little 'on'ern uses denial as a de"ense
me'#anism and "eels po)erless to preventJma/e
'#anges
Expresses s#ameJguilt
Overl$ 'on"orming dependent on ot#ersL
opinions
D&s'&d O($com&s/E%a!(a$on C'$&'a7 Esta&lis# a more realisti' &od$ image.
C!&n$ 8!!- A'/no)ledge sel" as an individual.
A''ept responsi&ilit$ "or o)n a'tions.
ACTIONS/INTERVENTIONS RATIONALE
Ind&.&nd&n$
Esta&lis# a t#erapeuti' nurse/'lient relations#ip. Cit#in a #elping relations#ip 'lient 'an &egin to
trust and tr$ out ne) t#in/ing and &e#aviors.
:romote sel"-'on'ept )it#out moral ,udgment. >lient sees sel" as )ea/-)illed even t#oug# part
o" person ma$ "eel a sense o" po)er and 'ontrol
(e.g. dieting/)eig#t loss%.
?ave 'lient dra) pi'ture o" sel". :rovides opportunit$ to dis'uss 'lientLs
per'eption
o" sel"/&od$ image and realities o" individual
situation.
State rules 'learl$ regarding )eig#ing s'#edule >onsisten'$ is important in esta&lis#ing trust. As
remaining in sig#t during medi'ation and eating part o" t#e &e#avior-modi+'ation program 'lient
times and 'onse!uen'es o" not "ollo)ing t#e rules. /no)s ris/s involved in not "ollo)ing
esta&lis#ed
Cit#out undue 'omment &e 'onsistent in 'arr$ing rules (e.g. de'rease in privileges%. 3ailure
to "ollo)
out rules. rules is vie)ed as t#e 'lientLs '#oi'e and
a''epted
&$ t#e sta0 in matter-o"-"a't manner so as not to
provide rein"or'ement "or t#e undesira&le
&e#avior.
Aespond ('on"ront% )it# realit$ )#en 'lient ma/es>lient ma$ &e den$ing t#e ps$'#ologi'al aspe'ts
o"
unrealisti' statements su'# as 7*Lm gaining )eig#t o)n situation and is o"ten expressing a
sense o"
so t#ereLs not#ing reall$ )rong )it# me.8 inade!ua'$ and depression.
Be a)are o" o)n rea'tion to 'lientLs &e#avior. Avoid 3eelings o" disgust #ostilit$ and
in"uriation are
arguing. not un'ommon )#en 'aring "or t#ese 'lients.
:rognosis o"ten remains poor even )it# )eig#t
gain &e'ause ot#er pro&lems ma$ remain. Dan$
'lients 'ontinue to see t#emselves as "at and
t#ere
is also a #ig# in'iden'e o" a0e'tive disorders
so'ial p#o&ias o&sessive-'ompulsive s$mptoms
drug a&use and ps$'#osexual d$s"un'tion. Nurse
needs to deal )it# o)n response/"eelings so t#e$
do not inter"ere )it# 'are o" t#e 'lient.
Assist 'lient to assume 'ontrol in areas ot#er t#an3eelings o" personal ine0e'tiveness lo) sel"-
dieting/)eig#t loss (e.g. management o" o)n 'on'ept and per"e'tionism are o"ten part o" t#e
dail$ a'tivities )or//leisure '#oi'es%. pro&lem. >lient "eels #elpless to '#ange and
re!uires assistan'e to pro&lem-solve met#ods o"
'ontrol in li"e situations. ?elps dire't energ$ a)a$
"rom eating/&od$ image to ot#er li"e-en#an'ing
and personall$ satis"$ing a'tivities.
?elp 'lient "ormulate goals "or sel" (not related to >lient needs to re'ogni(e a&ilit$ to 'ontrol ot#er
eating% and 'reate a managea&le plan to rea'# t#ose areas in li"e and ma$ need to learn
pro&lem-
goals a single goal at a time progressing "rom solving s/ills in order to a'#ieve t#is 'ontrol.
simple to more 'omplex. Setting realisti' goals "osters su''ess.
5is'uss t#e meaning o" illness and e0e't o" t#ese Giving up an illness t#at #as #elped "orm t#e
&e#aviors. individualLs personal identit$ t#e un'ons'ious
&ene+t o" t#e 7si'/ role8 and t#e overvalued
&elie"s a&out an ideal &od$ and t#e &ene+ts o"
t#inness must &e addressed &e"ore t#e 'lient 'an
'on"ront t#e "ull role t#e illness #as pla$ed in t#e
'lientLs li"e.
Assist 'lient to 'on"ront sexual "ears. :rovide sex Da,or p#$si'al/ps$'#ologi'al '#anges in
edu'ation as ne'essar$. adoles'en'e 'an 'ontri&ute to development o"
eating disorders. 3eelings o" po)erlessness and
loss o" 'ontrol o" "eelings (parti'ularl$ sexual% and
sensations lead to an un'ons'ious desire to
desexuali(e t#emselves. >lients o"ten &elieve
t#at
t#ese "ears 'an &e over'ome &$ ta/ing 'ontrol o"
&odil$ appearan'e/development/"un'tion. No$&-
Some 'lients )it# anorexia &elieve sta$ing small
and ema'iated )ill #elp /eep t#em '#ildli/e (and
t#ere"ore sexuall$ unappealing% )#ereas 'lients
)it# &inge-eating disorders )is# to remain o&ese
&elieving ex'ess &od$ "at )ill lessen sexual
attra'tion.
5etermine #istor$ o" sexual a&use and institute >lient ma$ use eating as a means o" gaining
appropriate t#erap$. 'ontrol in li"e )#en sexual a&use #as &een
experien'ed.
Note 'lientLs )it#dra)al "rom and/or dis'om"ort Da$ indi'ate "eelings o" isolation and "ear o"
in so'ial settings. re,e'tion/,udgment &$ ot#ers. Avoidan'e o" so'ial
situations and 'onta't )it# ot#ers 'an 'ompound
"eelings o" )ort#lessness.
En'ourage 'lient to ta/e '#arge o" o)n li"e in a more >lient o"ten does not /no) )#at s#e or #e
ma$
#ealt#"ul )a$ &$ ma/ing o)n de'isions and )ant "or sel". :arents (usuall$ mot#er% o"ten ma/e
a''epting sel" as is at t#is moment (in'luding de'isions "or 'lient. >lient ma$ also &elieve s#e or
inade!ua'ies and strengt#s%. #e #as to &e t#e &est in ever$t#ing and #olds sel"
responsi&le "or &eing per"e't.
9et 'lient /no) t#at it is a''epta&le to &e di0erent 5eveloping a sense o" identit$ as separate
"rom
"rom "amil$ parti'ularl$ mot#er. "amil$ and maintaining sense o" 'ontrol in ot#er
)a$s &esides dieting and )eig#t loss is a
desira&le goal o" t#erap$/program.
*nvolve in personal development program 9earning a&out met#ods o" en#an'ing personal
pre"era&l$ in a group setting. :rovide in"ormation appearan'e ma$ &e #elp"ul to long-range sense
o"
a&out proper appli'ation o" ma/eup and grooming. sel"-'on'ept/image. 3eed&a'/ "rom ot#ers
'an
promote "eelings o" sel"-)ort#.
Suggest disposing o" 7t#in8 'lot#es as )eig#t gain:rovides in'entive to at least maintain and not
lose
o''urs. Ae'ommend 'onsultation )it# an image )eig#t. Aemoves visual reminder o" t#inner sel".
'onsultant. :ositive image en#an'es sense o" sel"-esteem.
Hse interpersonal ps$'#ot#erap$ approa'# rat#er *ntera'tion &et)een persons is more #elp"ul "or
t#e
t#an interpretive t#erap$. 'lient to dis'over "eelings/impulses/needs "rom
)it#in o)n sel". >lient #as not learned t#is
internal 'ontrol as a '#ild and ma$ not &e a&le to
interpret or atta'# meaning to &e#avior. No$&-
>ognitive t#erap$ is usuall$ more e0e'tive "or
'lients diagnosed as &ulimi' or &inge-eaters &ut
ma$ not &e use"ul "or anore'ti' 'lients during t#e
period o" a'ute #ospitali(ation.
En'ourage 'lient to express anger and a'/no)ledge *mportant to /no) t#at anger is part o"
sel" and as
)#en it is ver&ali(ed. su'# is a''epta&le. Expressing anger ma$ need
to
&e taug#t to 'lient &e'ause anger is o"ten
'onsidered una''epta&le in t#e "amil$ and
t#ere"ore 'lient does not express it.
Assist 'lient to learn strategies ot#er t#an eating "or 3eelings are t#e underl$ing issue and
'lients o"ten
dealing )it# "eelings. ?ave 'lient /eep a diar$ o" use "ood instead o" dealing )it# "eelings
"eelings parti'ularl$ )#en t#in/ing a&out "ood. appropriatel$. -#erapeuti' )riting #elps 'lient
re'ogni(e "eelings and #o) to express t#em
'learl$
and dire'tl$.
Assess "eelings o" #elplessness/#opelessness. 9a'/ o" 'ontrol is a 'ommon/underl$ing pro&lem
"or t#is 'lient and ma$ &e a''ompanied &$ more
serious emotional disorders. No$&- 5F1 o" 'lients
)it# anorexia #ave a #istor$ o" ma,or a0e'tive
disorder and 331 #ave a #istor$ o" minor
a0e'tive disorder.
Be alert to sui'idal ideation/&e#avior. *ntensit$ o" anxiet$/pani' a&out )eig#t gain
depression #opeless "eelings ma$ lead to sui'idal
attempts parti'ularl$ i" 'lient is impulsive.
Co!!a2o'a$%&
*nvolve in group t#erap$. :rovides an opportunit$ to tal/ a&out "eelings and
tr$ out ne) &e#aviors.
Ae"er to o''upational/re'reational t#erap$. >an develop interests and s/ills to +ll time t#at
#as
&een o''upied &$ o&session )it# eating.
*nvolvement in re'reational a'tivities en'ourages
so'ial intera'tions )it# ot#ers and promotes "un
and relaxation.
En'ourage parti'ipation in dire'ted a'tivities (e.g. Alt#oug# exer'ise is o"ten used negativel$
&$
&i'$'le tours )ilderness adventures su'# as t#ese 'lients (i.e. "or )eig#t loss/'ontrol%
Out)ard Bound :rogram%. dire'ted a'tivities provide an opportunit$ to learn
sel"-relian'e en#an'e sel"-esteem and reali(e
t#at
"ood is t#e "uel re!uired &$ t#e &od$ to do its
)or/.
Ae"er to t#erapist trained in dealing )it# sexualit$. Da$ need pro"essional assistan'e to
a''ept sel" as a
sexual adult.
NURSING DIAGNOSIS #AMIL; PROCESSES5 a!$&'&d
May B& R&!a$&d $o- *ssues o" 'ontrol in "amil$
SituationalJmaturational 'rises
?istor$ o" inade!uate 'oping met#ods
Poss2!y E%d&nc&d 2y- 5issonan'e among "amil$ mem&ers6 "amil$ needs
not &eing met
3amil$ developmental tas/s not &eing met
*ll-de+ned "amil$ rules "un'tions and roles
3o'us on 7identi+ed patient8 (*:%6 "amil$
mem&er(s% a'ting as ena&lers "or *:
D&s'&d O($com&s/E%a!(a$on C'$&'a7 5emonstrate individual involvement in pro&lem-
#am!y 8!!- solving pro'esses dire'ted at en'ouraging 'lient
to)ard independen'e.
Express "eelings "reel$ and appropriatel$.
5emonstrate more autonomous 'oping &e#aviors
)it# individual "amil$ &oundaries more 'learl$
de+ned.
Ae'ogni(e and resolve 'on.i't appropriatel$ )it#
t#e individuals involved.
ACTIONS/INTERVENTIONS RATIONALE
Ind&.&nd&n$
*denti"$ patterns o" intera'tion. En'ourage ea'# ?elp"ul in"ormation "or planning interventions.
"amil$ mem&er to spea/ "or sel". 5o not allo) B -#e enmes#ed overinvolved "amil$ mem&ers
mem&ers to dis'uss a t#ird )it#out t#at mem&erLs o"ten spea/ "or ea'# ot#er and need to
learn to &e
parti'ipation. responsi&le "or t#eir o)n )ords and a'tions.
5is'ourage mem&ers "rom as/ing "or approval Ea'# individual needs to develop o)n internal
"rom ea'# ot#er. Be alert to ver&al or nonver&al sense o" sel"-)ort#. *ndividual o"ten is living up to
'#e'/ing )it# ot#ers "or approval. A'/no)ledge ot#ersL ("amil$Ls% expe'tations rat#er t#an
ma/ing
'ompetent a'tions o" 'lient. o)n '#oi'es. A'/no)ledgment provides
re'ognition o" sel" in positive )a$s.
9isten )it# regard )#en t#e 'lient spea/s. Sets an example and provides a sense o"
'ompeten'e and sel"-)ort# in t#at t#e 'lient #as
&een #eard and attended to.
En'ourage individuals not to ans)er to ever$t#ing. Aein"or'es individuali(ation and return to
priva'$.
>ommuni'ate message o" separation t#at it is *ndividuation needs rein"or'ement. Su'# a
a''epta&le "or "amil$ mem&ers to &e di0erent "rom message 'on"ronts rigidit$ and opens
options "or
ea'# ot#er. di0erent &e#aviors.
En'ourage and allo) expression o" "eelings (e.g. O"ten t#ese "amilies #ave not allo)ed "ree
'r$ing anger% &$ individuals. expression o" "eelings and )ill need #elp and
permission to learn and a''ept t#is.
:revent intrusion in d$ads &$ ot#er mem&ers o" *nappropriate interventions in "amil$ su&s$stems
"amil$. prevent individuals "rom )or/ing out pro&lems
su''ess"ull$.
Aein"or'e importan'e o" parents as a 'ouple )#o -#e "o'us on t#e '#ild )it# an eating disorder is
#ave rig#ts o" t#eir o)n. ver$ intense and o"ten is t#e onl$ area t#roug#
)#i'# t#e 'ouple intera't. -#e 'ouple needs to
explore t#eir o)n relations#ip and restore t#e
&alan'e )it#in it to prevent its disintegration.
:revent 'lient "rom intervening in 'on.i'ts &et)een -riangulation o''urs in )#i'# a parent-
'#ild
parents. ?elp parents identi"$ and solve t#eir 'oalition exists. Sometimes t#e '#ild is openl$
marital di0eren'es. pressed to align )it# 1 parent against t#e ot#er.
-#e s$mptom or &e#avior (eating disorder% is t#e
regulator in t#e "amil$ s$stem and t#e parents
den$ t#eir o)n 'on.i'ts.
Be a)are o" and 'on"ront sa&otage &e#avior on t#e 3eelings o" &lame s#ame and
#elplessness ma$
part o" "amil$ mem&ers. lead to un'ons'ious &e#avior designed to
maintain
t#e status !uo.
Co!!a2o'a$%&
Ae"er to 'ommunit$ resour'es su'# as "amil$ group Da$ #elp redu'e overprote'tiveness
support/
t#erap$ parentsL groups as indi'ated6 and :arent"a'ilitate t#e pro'ess o" dealing )it# unresolved
E0e'tiveness 'lasses. 'on.i'ts and '#ange.
NURSING DIAGNOSIS S4IN INTEGRIT;5 m.a'&d5 's: )o' o' ac$(a!
May B& R&!a$&d $o- Altered nutritional state6 edema
5e#$drationJ'a'#e'ti' '#anges (s/eletal
prominen'e%
Poss2!y E%d&nc&d 2y- 5r$Js'al$ s/in )it# poor s/in turgor6 tissue
"ragilit$
BrittleJdr$ #air
5r$ ras# reports o" it'#ing dermal a&rasions
("rom s'rat'#ing%
D&s'&d O($com&s/E%a!(a$on C'$&'a7 @er&ali(e understanding o" 'ausative "a'tors and
C!&n$ 8!!- relie" o" dis'om"ort.
*denti"$ and demonstrate &e#aviors to maintain
so"t supple inta't s/in.
ACTIONS/INTERVENTIONS RATIONALE
Ind&.&nd&n$
O&serve "or reddened &lan'#ed ex'oriated areas. *ndi'ators o" in'reased ris/ o" &rea/do)n
re!uiring more intense treatment.
En'ourage &at#ing ever$ ot#er da$ instead o" dail$. 3re!uent &at#s 'ontri&ute to s/in dr$ness.
Hse s/in 'ream t)i'e a da$ and al)a$s a"ter &at#ing. 9u&ri'ates s/in and de'reases it'#ing.
Dassage s/in gentl$ espe'iall$ over &on$ *mproves s/in 'ir'ulation en#an'es s/in tone.
prominen'es.
5is'uss importan'e o" "re!uent '#ange o" position En#an'es 'ir'ulation and per"usion to s/in
&$
need "or remaining a'tive. preventing prolonged pressure on tissues.
Emp#asi(e importan'e o" ade!uate nutrition/.uid *mproved nutrition and #$dration )ill improve
inta/e. (Ae"er to N5E NutritionE altered less t#an s/in 'ondition.
&od$ re!uirements.%
NURSING DIAGNOSIS 4NO8LEDGE d&9c$ /LEARNING NEED0
'&"a'dn" cond$on5 .'o"noss5 s&!) ca'&
and $'&a$m&n$ n&&ds
May B& R&!a$&d $o- 9a'/ o" exposure toJun"amiliarit$ )it# in"ormation
resour'es6 misinterpretation
9a'/ o" interest in learning
9earned maladaptive 'oping s/ills
Poss2!y E%d&nc&d 2y- @er&ali(ation o" mis'on'eption
:reo''upation )it# extreme "ear o" o&esit$ and
distortion o" o)n &od$ image
Ae"usal to eat &ingingJpurging
A&use o" laxativesJdiureti's6 ex'essive exer'ising
Expression o" desire to learn more adaptive )a$s
o" 'oping )it# stress or o" relations#ip o" 'urrent
situation and &e#aviors
*nappropriate &e#aviors (e.g. apat#$%
D&s'&d O($com&s/E%a!(a$on C'$&'a7 @er&ali(e a)areness o" and plan "or li"est$le
C!&n$ 8!!- '#anges to maintain desired )eig#t.
*denti"$ relations#ip o" signsJs$mptoms (e.g.
)eig#t loss toot# de'a$% to &e#aviors o" not
eatingJ&inge-purging.
Assume responsi&ilit$ "or o)n learning.
See/ out sour'esJresour'es to assist )it# ma/ing
identi+ed '#anges.
3ormulate plan to meet individual goals "or
)ellness.
ACTIONS/INTERVENTIONS RATIONALE
Ind&.&nd&n$
5etermine level o" /no)ledge and readiness to 9earning is easier )#en it &egins )#ere t#e
learner
learn. is.
Note &lo'/s to learning (e.g. p#$si'al/intelle'tual/Dalnutrition "amil$ pro&lems drug a&use
emotional%. a0e'tive disorders o&sessive-'ompulsive
s$mptoms 'an inter"ere )it# learning re!uiring
resolution &e"ore e0e'tive learning 'an o''ur.
Aevie) dietar$ needs ans)ering !uestions as >lient/"amil$ ma$ need assistan'e )it# planning
indi'ated. En'ourage in'lusion o" #ig#-+&er "oods "or ne) )a$ o" eating. As 'onstipation ma$ o''ur
and ade!uate .uid inta/e. )#en laxative use is 'urtailed dietar$
'onsiderations ma$ prevent need "or more
aggressive t#erap$.
5is'uss 'onse!uen'es o" &e#avior. Sudden deat# ma$ o''ur o)ing to ele'trol$te
im&alan'es6 suppression o" t#e immune s$stem
and liver damage ma$ result "rom protein
de+'ien'$6 or gastri' rupture ma$ "ollo) &inge-
eating/vomiting.
En'ourage t#e use o" relaxation and ot#er stress- Ne) )a$s o" 'oping )it# "eelings o" anxiet$ and
management te'#ni!ues (e.g. visuali(ation guided "ear )ill #elp 'lient manage t#ese "eelings
more
imager$ &io"eed&a'/%. e0e'tivel$ assisting in giving up maladaptive
&e#aviors o" not eating/&inging-purging.
Assist )it# esta&lis#ing a sensi&le exer'ise program. Exer'ise 'an #elp develop a positive &od$
image
>aution regarding overexer'ise. and 'om&ats depression (release o" endorp#ins in
t#e &rain en#an'es sense o" )ell-&eing%. >lient
ma$ use ex'essive exer'ise as a )a$ o"
'ontrolling
)eig#t.
:rovide )ritten in"ormation "or 'lient/SO(s%. ?elp"ul as reminder o" and rein"or'ement "or
learning.
5is'uss need "or in"ormation a&out sex and sexualit$. Be'ause avoidan'e o" o)n sexualit$ is an
issue "or
t#is 'lient realisti' in"ormation 'an &e #elp"ul in
&eginning to deal )it# sel" as a sexual &eing.
Ae"er to National Asso'iation o" Anorexia Nervosa Da$ &e a #elp"ul sour'e o" support and
and Asso'iated 5isorders Overeaters Anon$mous in"ormation "or 'lient and SO(s%.
and ot#er lo'al resour'es.