Anorexia nervosa is an illness of starvation related to a severe disturbance of body image and a morbid fear of obesity; it is an eating disorder, usually seen in adolescence, when a person is underweight and emaciated and refuses to eat. It can result in death due to irreversible metabolic processes.

Bulimia nervosa is another type of eating disorder (bingepurge syndrome) also encountered primarily in late adolescence or early adulthood. It is characterized by at least two binge-eating episodes of large quantities of high-calorie food over a couple of hours followed by disparaging self-criticism and depression. Self-induced vomiting, abuse of laxatives, and abuse of diuretics are commonly associated because they decrease physical pain of abdominal distention, may reduce postbinge anguish, and may provide a method of self-control. Bulimic episodes may occur as part of anorexia nervosa, but these clients rarely become emaciated, and not all have a body image disturbance Table 10-11. Comparison: Anorexia and Bulimia .

1. CONCEPTS AND PRINCIPLES RELATED TO ANOREXIA NERVOSA:
1. Not due to lack of appetite or problem with appetite center in hypothalamus.
2. Normal stomach hunger is repressed, denied, depersonalized; no conscious awareness of hunger sensation.
2. ASSESSMENT OF ANOREXIA NERVOSA:
1. Body image disturbance—delusional, obsessive (e.g., does not see self as thin and is bewildered by others' concern).
2. Usually preoccupied with food, yet dreads gaining too much weight. Ambivalence: avoids food, hoards food.
3. Feels ineffectual, with low sex drive. Repudiation of sexuality.
4. Pregnancy fears, including misconceptions of oral impregnation through food.
5. Self-punitive behavior leading to starvation; suppression of anger.
6. Physical signs and symptoms:
1. Weight loss (20% of previous "normal" body weight).
2. Amenorrhea and secondary sex organ atrophy.
3. Hyperactivity; compulsiveness; excessive gum chewing.
4. Constipation.
5. Hypotension, bradycardia, hypothermia.
6. Skin: hyperkeratosis, poor turgor, dry.
7. Blood: leukopenia, anemia, hypoglycemia, hypoproteinemia, hypocholesteremia, hypokalemia, hyponatremia, decreased magnesium, decreased chloride, increased BUN; ECG: T-wave inversion
3. ANALYSIS/NURSING DIAGNOSIS:
1. Imbalanced nutrition, less than body requirements, and fluid volume deficit related to attempts to vomit food after eating, overuse of laxatives/diuretics, and refusal to eat, related to need to demonstrate control.
2. Risk for altered physical regulation processes/risk for or actual fluid volume deficit: amenorrhea related to starvation; hypotension, bradycardia; metabolic alkalosis.
3. Risk for self-inflicted injury related to starvation from refusal to eat or ambivalence about food.
4. Altered eating related to altered thought processes: binge-purge syndrome.
5. Body-image disturbance/chronic low self-esteem related to anxiety over assuming an adult role and concern with sexual identity; unmet dependency needs, personal vulnerability; perceived loss of control in some aspect of life; dysfunctional family system.
6. Compulsive behaviors related to need to maintain control of self, represented by losing weight.
4. NURSING CARE PLAN/IMPLEMENTATION:
1. Help reestablish connections between body sensations (hunger) and responses (eating). Use stimulus-response conditioning methods to set up eating regimen.
1. Weigh regularly, at same time and with same amount of clothing, with back to scale.
2. Make sure water drinking is avoided before weighing.
3. Give one-to-one supervision during and 30 minutes after mealtimes to prevent attempts to vomit food.
4. Monitor exercise program and set limits on physical activity.
2. Monitor physiological signs and symptoms (amenorrhea, constipation, hypoproteinemia, hypoglycemia, anemia, eroded tooth enamel, inflamed buccal cavity, brittle nails, dull hair, secondary sexual organ atrophy, hypothermia, hypotension, leg cramps and other signs of hypokalemia).
3. Health teaching:
1. Explain normal sexual growth and development to improve knowledge deficit and confront sexual fears.
2. Use behavior modification to reestablish awareness of hunger sensation and to relate it to the clock and regular mealtimes.
3. Teach parents skills in communication related to dependence/independence needs of adolescent; allow client to assume control in areas other than dieting, weight loss (e.g., management of daily activities, work, leisure choices).
5. EVALUATION/OUTCOME CRITERIA:
1. Attains and maintains minimal normal weight for age and height.
2. Eats regular meal (standard nutritional diet).
3. No incidence of self-induced vomiting, bulimia, or compulsive physical activity.
4. Acts on increased internal emotional awareness and recognition of body sensation of hunger (i.e., talks about being hungry and feeling hunger pangs).
5. Relates increased sense of effectiveness with less need to control food intake.