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Case Study 5

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Rachel McCubbin

on 29 September 2014

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Transcript of Case Study 5

Case Study Group 5
Amy ordway, caleb darby, kindril Stefanski, and rachel McCubbin
Case Study 128
J.M., a 23-year-old woman, was admitted to the psychiatric unit last night after assessment and treatment at a local hospital emergency department (ED) for "blacking out at school." She has been given a preliminary diagnosis of anorexia nervosa. As you begin to assess her, you notice that she has very loose clothing and is wrapped in a blanket. She tells you, "I don't know why I'm here. They're making a big deal about nothing." She appears to be extremely thin and pale, with dry and brittle hair, and she constantly complains about being cold. As you ask questions pertaining to weight and nutrition, she becomes defensive and vague, but she does admit to losing "some" weight after an appendectomy 2 years ago. She tells you that she used to be fat, but after her surgery she didn't feel like eating for a while. She informs you that she is eating lots now, even though everyone keeps "bugging me about my weight and how much I eat." She eventually admits to a weight loss of "about 40 pounds and I'm still fat."
Question #1:

How is the diagnosis of anorexia nervosa determined?
Question #2:
What are the clinical symptoms of anorexia nervosa? Identify eight symptoms.
Syncope r/t possible hypotension/bradycardia
Gross distortion of body image: states “I’m still fat” despite being underweight.
Marked weight loss: 40 lbs.
Patient complains of hypothermia
Appears extremely thin and pale
Dry brittle hair r/t lack of nutrition. States she voluntary stopped eating after receiving positive feedback regarding initial weight loss post appendectomy
Question #1 Answer:
Actual weight less than 85% of expected weight
Hypothermia
Bradycardia
Hypotension
Edema
Lanugo
Metabolic changes
Amenorrhea
Other symptoms:
Morbid fear of obesity
Gross distortion of body image
Preoccupation with food
Refusal to eat
Question #2 Answer:
Question #3:
What are concomitant disorders associated with anorexia nervosa?
Obsessive-compulsive behavior
Depression
Question #3 Answer:
Question #4:
Name behaviors that J.M. may engage in other than self-starvation
Excessive exercise
Fasting
Binge-eating
Purging behaviors such as:
Self-induced vomiting
Laxative abuse
Use of diuretics
Enemas

Question #4 Answer:
Question #5:
What are common family dynamics with anorexia nervosa?
Question #5 Answer:
Conflict avoidance - Anorexia is reinforced by parents that use the sick child as a reason to avoid spousal conflict. Parents are able to define the sick child as the family problem (even though there is the underlying conflict between the spouses). In these families the members try at all costs to maintain “appearances” to the outside world.

Elements of power and control - The families of a child with an eating disorder such as anorexia often involve a passive father, domineering mother, and an overly dependent child. This family will spend an inordinate amount of time on perfection and the child feels like they must meet these expectations. The parents will pressure the child to meet these standards and the child will continue to gain love and affection through these efforts. The child eventually starts to feel helpless and starts to care less about the parent’s wishes. In adolescence the eating disorder may be an effort to rebel against the parents. The symptoms are often triggered by the perceived sense of control loss in their lives.

Question #6:
What are the clinical symptoms that should have the highest priority? Why?
Question #7:
In general, the care plans for patients with anorexia are detailed and include many psychologic aspects. What are they? You should be able to name at least 10.
Question #8:
What will you and the RN discuss with the primary care provider (PCP) before any further discharge teaching or plans?
Question #9:
You report J.M.'s statements to the PCP. How will the treatment plan be altered?
Question #10:
What medications would be indicated for J.M. to assist with resolution of both her anorexia nervosa and major depression?
Question #11:
What would indicate successful treatment with J.M.?
Question #6 Answer:
The biggest concern would be the lack of nutrition that leads to other manifestations such as hypothermia, bradycardia, hypotension, edema, lanugo (downy hair that covers the body), metabolic changes, amenorrhea, depression, anxiety, compulsive behaviors.
The client is in danger if they do not eat and that will lead to consequences such as those listed above.

Question #7 Answer:
Imbalanced Nutrition – less than body requirements
Fluid Volume Deficit
Disturbed Body Image
Low Self-Esteem
Activity Intolerance r/t fatigue and weakness
Chronic Low Self Esteem
Ineffective Denial
Ineffective family coping
Risk for infection: malnutrition resulting in depressed immune system
Risk for spiritual distress: Risk factor: low self esteem

Question #8 Answer:
The RN’s first priority to discuss with the PCP is J.M.’s comment about not wanting to live, which could indicate suicidal ideation.
Question #9 Answer:
J.M.’s statement would change the trajectory of her discharge and her treatment plan may include a psychiatric evaluation to determine if J.M. is serious about committing suicide and possible admittance to a psychiatric hospital.
Question #10 Answer:
Class: Selective Serotonin Reuptake Inhibitors (SSRI)
Drug: Fluoxetine (Prozac)

Class: Tricyclic antidepressants (TCA)
Drugs: Clomipramine (Anafranil)

Class: Atypical antipsychotics
Drugs: Olanzapine (Zyprexa)

Class: First generation antipsychotics
Drug: Chlorpromazine (Thorazine)

Question #11 Answer:
Steadily gain 2-3 pounds per week to at least 80% of body weight for her age and size
Remain free of signs and symptoms of malnutrition and dehydration
Consume adequate calories as determined by a dietitian
Be willing to discuss the real issues concerning family roles, sexuality, dependence/independence, and the need for achievement
Acknowledge that the perception of her body image as “fat” is incorrect
Regular attendance of Anorexia Nervosa and Associated Disorders (ANAD) support group meetings

References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to

planning care (10th ed.). Maryland Heights, MO: Elsevier Saunders.

Townsend, M. C. (2012). Psychiatric and mental health nursing: Concepts of care in

evidence-based practice (7th ed.). Philadelphia, PA: F. A. Davis Company.

Venes, D. (2013). Taber's cyclopedic medical dictionary (22nd ed.). Philadelphia, PA: F. A. Davis
Company.

Case Study Progress:

J.M. is ready for discharge teaching and you are assisting the RN. J.M. states, "I'll be so glad to get out of this place. I'm so fat and ugly. I need to lose 10 pounds. I bet I can do it in just a couple of days. I don't want to live anymore."
Full transcript