Bulimia Nervosa

• “The Diet-Binge-Purge Disorder”.
• Is a disorder characterized by alternating dieting, binging and purging through vomiting, enema, and laxatives.
• The person engages in episodes of starvation and other methods of controlling weight (diet pills, excessive exercise, enemas, diuretics, laxatives), then engages in uncontrolled and rapid eating for about two hours (over 8000 calories in 2 hours and 50,000 in 1 day) then terminates binging by inducing self to vomit, going to sleep or going to social activities.
• Weight fluctuations are due to alternating fasting and binging.

1. Bulimia means insatiable appetite.
2. Binging means eating an unusually large amount of food over a short period of time.
3. Purging is an attempt to compensate for calories consumed via self-induced vomiting or abuse of laxatives, diuretics, or enemas.

• A chronic disorder that usually manifest first during late adolescence and early adulthood, around the ages 15-24 years. It almost always occurs after a period of dieting.
• The bulimic often belong to a family and society that place great value on external appearance. The person strives to be thin to be accepted because they believe self-worth requires being thin.
• Usually of normal weight or obese, extrovert, reports self loathing, low self-esteem, has symptoms of depression, of fear of losing control, with self-destructive tendencies such as suicide.
• These individuals are known to be perfectionist, achievers scholastically and professionally and highly dependent on the approval of others to maintain self-esteem. They hide their disorder because of fear of rejection.
• Like anorexia, bulimia can kill. Even though bulimics put up a brave front, they are often depressed, lonely, ashamed, and empty inside. Friends may describe them as competent and fun to be with, but underneath, when they hide their guilty secrets, they are hurting. Feeling unworthy, they suffered from great difficulty talking about their feelings, which almost always include anxiety, depression, self-doubt, and deeply buried anger. Impulse control may be a problem like shoplifting, sexual adventurousness, alcohol and drug abuse, and other kinds of risk taking behavior in which the person acts with little consideration of consequences.
• The person is aware that the behavior is abnormal, but is unable to stop because she is immobilized by her fear that she cannot stop her behavior voluntarily. The binge episode usually ends when the person becomes exhausted eating, develops GIT discomfort, runs out of food or is noticed by others.
• After the episode she becomes guilty and depressed that she was unable to control herself, and engages in self-critism. Then she purges her self as a form of cleansing and punishment.

Common Complications Related to the Manner of Purging

• Chronic inflammation of the lining of the esophagus due to induced vomiting, acidic gastric secretions irritates esophageal mucosa.
• Rupture of esophagus and stomach.
• Electrolyte imbalance causing cardiac arrythmias, hypokalemia due to diarrhea,hypochloremia due to vomiting, hyponatremia due to vomiting and diarrhea.
• Dehydration.
• Enlargement of the parotid gland.
• Irritable bowel syndrome.
• Rectal prolapse or abscess.
• Dental erosion.
• Chronic edema.
• Fungal infection of vagina and rectum.

Nursing Diagnosis

• Alterations in health maintenance.
• Altered nutrition: Less than body requirements.
• Altered nutrition: More than body requirements
• Anxiety
• Body image disturbance
• Ineffective family coping; compromised
• Ineffective individual coping
• Self-esteem disturbance

Nursing Interventions

1. Patient with bulimia are aware of their problems and they want to be helped because they feel helpless and unable to control themselves during episodes of binging. But because of their intense desire to please and need to conform they may resort to manipulative behavior and tell half-truths during interview to gain trust and acceptance of nurses. Create an atmosphere of trust. Accept person as worthwhile individual. If they know that no rejection or punishment is forthcoming they disclose their problem, they will be more open and honest.
2. Develop strength to cope with problems. Encourage patient to discuss positive qualities about themselves to increase self-esteem.
3. Help patient identify feelings and situations associated with or that triggers binge eating.
   • Assist to explore alternative and positive ways of coping.
   • Encourage making a journal of incident and feelings before-during and after a binge episode.
   • Make a contract with the patient to approach the nurse when they feel the urge to binge so that feelings and alternative ways of coping can be explored.
4. Encourage adhering to meal and snack schedule of hospital. This decreases the incidence of binging, which is often precipitated by starvation and fasting.
5. Encourage participating in group activities with other persons having the same eating disorder to gain additional support.
6. For young adolescent living at home, encourage family therapy to correct dysfunctional family patterns.
7. Cognitive behavioral therapy is the ideal therapy to help the bulimic understand the problem and explore appropriate behaviors.

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