Sleeping & Eating

Disorders
Instructor version
NORMAL SLEEP
PATTERNS

Cycle through five stages in one to
two hours- Need REM sleep
Individuals vary in time spent in each
stage
Needed for restoration and repair


INSOMNIA

Difficulty initiating or maintaining sleep
Primary insomnia has no external cause (eg
substance abuse, medical problems etc)
Symptoms must last at least 1 month
One-half to two-thirds of elderly experience
sleep disturbance
Multiple drug treatments may affect elderly
sleep patterns
(continues)
INSOMNIA
Inability to sleep causes a vicious cycle of
stress which further inhibits the ability to sleep.
Significant impairment to social, occupational
functioning due to lack of sleep
Irritability, inability to concentrate, decreased
attention span
Inappropriate use of both hypnotics for sleep &
stimulants to combat fatigue
SLEEP HYGIENE
Use bed for sleep and sexual activities
only
If sleepless, get up until drowsy
Arise at same time every day
Exercise each day
Keep bedroom quiet, dark, cool
Drinking milk 3-4 hours prior to going
to bed may help
(continues)
SLEEP HYGIENE
Avoid daytime napping
Caffeine and alcohol disturbs sleep
Use quiet alarm clock
Break cycle of insomnia by staying
awake for entire night
DAYTIME SLEEPINESS
Primary hypersomnia ( somnolence)
daytime sleepiness without explanation
( not just physically tired or weary)
Develop problems because of self medication
Narcolepsyirresistible need for brief periods of
sleep
At risk for hurting self ( while driving, smoking etc
Appears confused when coming out of it



Sleep Disorders
Parasomnias- Unusual to undesirable behaviors
occurring during sleep
Nightmare Disorder: frightening dreams leading to
become fully awake.
Fear or anxiety returning to sleep
Sleep Terror: sudden arousal from sleep with piercing
scream or cry without recall of dream or event
Sleepwalkingarising from sleep and walking in
semiconscious condition. May be a continuation of a
problem noted in childhood
Breathing-related sleep disordersobstructive sleep
apnea



ASSESSMENT
Assess for normal sleep patterns
Diagnosis: Disturbed sleep pattern

OUTCOME
IDENTIFICATION
Will experience restorative sleep
Will describe falling asleep easily
PLANNING/INTERVENTIO
NS
Standard sleep hygiene protocol
Guided relaxation
Music therapy, Yogi
Massage
Support and reassurance for
nightmares
Do not sleep w/ the TV on
EVALUATION
Outcomes will be subjective
Sleep may not be directly observed
Eating Disorders
America is fatter than ever before
The rate of type 2 diabetes is greater than at
any other time
The media is obsessed with weight & how we
appear while at the same time the number of
food commercials have increased dramatically
Social approval in being thin
Appetite regulation center is the hypothalmus.
The hypothalmus exerts control over the
actions of the autonomic nervous system and
regulates appetite & temperature

Eating Disorder
Individuals with eating disorders cope ineffectively with
stress & anxiety by maladaptive eating patterns. Choose
to eat or not eat to deal with unconscious stressors. It
eventually becomes an addiction in the fight for
control or fear of loss of control

As these patients fight for control they become rigid in
their thinking, are inflexible & frequently have a
distorted body image (unaware of ).
Examples:
Anorexia Nervosa
Bulimia Nervosa
Compulsive Overeating
ANOREXIA NERVOSA
Believes that worth is based solely on thinness
Weight loss of 10% of normal body weight
Weight loss of more than 30% of ideal body weight
w/in 6 months requires hospitalization. Other criteria
include temp less than 36 C, HR<40 bpm, Systolic B/P
< 70mm Hg
Noted in women & female adolescents (90% of cases)
Onset varies from preadolescents to early adulthood
Increase in numbers seen in 12 15 age group
Amenorrhea- lack of nourishment slows Pituitary
functioning
Delayed sexual development



ANOREXIA NERVOSA
Sees self as fat even though emaciated( will often say
I am fat & ugly)
Denies seriousness of problem
Eating anything or thought of eating produces high
anxiety in the patient
Has intense fear of gaining weight
Compulsive resistance to eating- fears morbid obesity
They do not lose their appetite rather they suppress
their appetite in an effort to remain thin

ANOREXIA NERVOSA
Think of food & eating much of the time
Devious Behavior collects cookbooks, hoarding food,
making elaborate meals for others but not eating
themselves
Illness (the weight loss) is insidious & noticed only
after significant weight loss has occurred.
Often wear several layers of loose clothing to appear
larger so as to initially hide weight loss
Psychological symptoms associated w/ anorexia
Depression, Suicide, Irritability, social withdrawal, obsessive
symptoms

ANOREXIA NERVOSA
Other noted signs
Bradycardia
Dry yellow skin ( R/T release of carotenes as fat stores
are burned for energy)
languno related to starvation
Delayed gastric empting causing them to feel full longer
Constipation( bec of slower abdominal peristalsis &
decreased food intake-starvation) which leads them to
use laxatives
Dehydration resulting in hypotension, & decreased
urinary output. Kidney functions compromised
Osteoporosis & osteopenia (prolonged amenorrhea)
Family Constellation of
Anorexia
Covert addiction in family esp. alcoholism
Usually youngest daughter of the family (social stigma
associated with the disease). Feelings of guilt by
family members
The token patient in the family especially in a
dysfunctional family system where to address the
patients problem would mean that other family
problems would also need to be addressed
Theories
Perfectionist,
introverted girl w/ self esteem & relationship problems. But
also seen in:
Accomplished, outgoing & active girl
ANOREXIA NERVOSA
Fall into 2 groups
Food restrictors
Are usually normal to slightly overweight prior to
illness
Withdraw to room to avoid family & friends in
situations where they might be expected to eat
May be obsessive with activities that will produce
weight loss - taking walks, exercising
Are usually unable to relax

ANOREXIA NERVOSA
Vomiters- purgers
More often overweight prior at start of eating disorder
Young women tries to loose weigh by inducing vomiting,
or excess use of laxatives or diuretics
Typically deny concerns about their weight & eat normally
in social situations
Purge of food soon after consumption (although they have
not eaten excessively)
Dental problems (due to acidic vomitus decays)
Purgers are more likely to have histories of behavioral
problems, substance abuse, & open family conflict than
restrictive anorectics
Nsg Intervention
Safety- Suicide is #1 problem
Electrolyte imbalance #2 problem- Strict I & O (more with the
purgers)
Assess the clients eating pattern by asking what they eat on a
typical day but after do not discuss food on a casual basis with
them as they are obsessed with food
Explore feelings about weight & distortions in body image
Help patient reestablish an appropriate eating behavior. Must
adhere to menu of agreed upon foods & time of meals-
behavior modification
Sit with pt during meals & 30 minutes afterwards to prevent
purging & exercising
Observe patient for 1 hour after meals
Daily weight- Do not discuss w/ patient. Weigh not facing scale,
show no response to weight gain or loss

TREATMENT
Requires long term treatment for successful changes to occur
Psychotherapy
Prozac to treat the feelings of depression and anxiety that
often accompanies the anorexia
Hospitalization
Behavioral Modification- eat this amount of food, you get this
privilege. Do not discuss weight.
Forced feeding when necessary- NG tube feeding (realistic goal
is about 1 pound a week- unspoken)
Cognitive therapy- Assist patient to explore feelings. Discuss
fear of loss of control. Increase self esteem
Review patients coping pattern & examine deep feelings of
anger, fear
Assist patient to understand that perfection is unrealistic
ASSESSMENT
May see nurse as the enemy who is
trying to get them to gain weight- so
control issue may exist from the start
Weight history
Eating and purging experiences
Degree of distress/anxiety
Identify motivation for treatment-
usually are sent by concerned family
member
NURSING DIAGNOSIS
Imbalanced nutrition: less than body
requirements
Disturbed body image
Chronic low self-esteem
Social isolation
Ineffective health maintenance
Outcomes Identification
Identify realistic outcomes
Recognize chronic nature of diseases
Focus on short-term outcomes
Planning & Intervention
Four stages of treatment:
Nutritional rehabilitation
Psychotherapy
Maintenance
Follow-up care
Evaluation
Done on basis of stated outcomes
Remember complexity of diseases

BULIMIA NERVOSA
More common in women in late teens, early
20s & 30s (late adolescence or early
adulthood)
Fasting, binging, purging- May eat normal
meals in front of nurse
Preoccupation with weight and body image
Usually w/in close to normal weight
Knows that they are doing something
abnormal thats why it is done in secret


BULIMIA NERVOSA
Has episodes of out of control eating- feels has lost
control in stopping to eat once they have started.
Many report that they stop eating only when they
have run out of food, are vomiting ( induced or
spontaneous), or physically exhausted
Eats a variety of foods but high calorie, high
carbohydrate snack foods- Eats foods rapidly
Binges in secret because of shameful feeling.
Eating in & of itself Is then associated with anxiety
for the patient
Deviant behavior- shop lifts food, visits several
different fast food & grocery stores during a binge
episode

BULIMIA NERVOSA
May feel guilty after the binge- May become depressed
May purge with laxatives, diuretics, vomiting (dehydration,
electrolyte imbalance, nutritional deficits)
Use fingers, tooth brushes, eating utensils to induce vomiting
Over time vomiting becomes easier (resulting electrolyte
imbalance may lead to hallucinations & restlessness)
May vow not to binge again (& eat restrictive low calorie
foods between binges), they then binge again because of the
high they experience when binging
May have financial difficulty associated w/ large amount of
food that need to be purchased

BULIMIA NERVOSA
Medical Problems associated w/ disorder
Erosion (dysplasia) & discoloration of teeth enamel
Bruises to palate & posterior pharynx
Loss of anal sphincter from too many enemas &
laxative
Dehydration & electrolyte imbalance
Hypokalemia, hyponatremia, metabolic acidosis,
(associated w/ self induced vomiting)
Mechanical irritation & injury to GI tract ( from abuse
of laxatives & vomiting)
May see calluses on knuckles of fingers from frequent
vomiting induction
Parotid swelling due to repeated vomiting


Nsg Intervention
&TREATMENT
Realistic evaluation of body image
Assist w/ increasing self-esteem
Identify the anxiety producing situations that
trigger the urge to binge & therefore start the
binge purge cycle. Will help to break the cycle
Teach stress reduction techniques such as
relaxation & imagery. Replaces binge eating with
an anxiety reducing activity
Referral to support group
SSRIs-particularly Prozac (Thought to be caused by
excessive Serotonin levels)
Celexa a SSRI positive client responses
Cognitive-behavioral therapy

Compulsive Overeating
Food consumption is out of patients control.
Person feels helpless, & hopeless
Overeating may be Binge like
Overeating causes a release of tension, a
decrease in anxiety for a short time
Do not purge
Very Overweight
Obesity: 15- 20% over normal body weight
for height & age
Chronic obesity from childhood
Nsg Intervention for
compulsive Overeating
Physical problems are a priority:
Type 2 diabetes
Skeletal problems
Heart, kidney problem etc
CHF
Body Image problem
depression
Nsg Diagnosis
Imbalance nutrition: Less or more
than body required
Disturbed body image
Chronic low self esteem
Social isolation
Ineffective health maintenance
Assessment for eating
Disorder
Weight history
Eating & purging experience
Degree of distress/ anxiety
Identify secondary gains for continuing
the eating disorder