Eating disorders are psychiatric mental health conditions in which a persistent disturbance of eating behavior leads to impairment of physical and/or mental health. The eating disorders we'll cover in this article are bulimia nervosa, anorexia nervosa, and binge eating disorder. This series follows along with our Psychiatric Mental Health Nursing Flashcards which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
This information on eating disorders is for nursing students' exams and nursing practice. If you or a loved one have an eating disorder, contact the National Eating Disorders Association Helpline for support, resources, and to hear about treatment options at 1-800-931-2237, Monday through Friday. You can also text “NEDA” to 741741 if you are experiencing a crisis to be contacted by a trained volunteer or visit National Eating Disorders Association (external link) to chat with a trained volunteer online.
Psychiatric Mental Health - Nursing Flashcards
Bulimia nervosa
Bulimia nervosa is an eating disorder, characterized by binge eating, followed by compensation measures to avoid gaining weight, such as vomiting, laxative use, or extreme exercise.
Bulimia risk factors
The main risk factor for bulimia that you need to know for your nursing exams is patient sex (female).
There are other risk factors, like having a parent with bulimia, but they are infrequently tested on in nursing exams. Patient sex (female) being a risk factor for bulimia does not mean that men are not at risk for bulimia, indeed men can and do develop bulimia, but it is statistically less common.
Bulimia signs and symptoms
Bulimia signs and symptoms can include:
- Parotid gland swelling
- Dental erosion
- Russell's sign
- Weight fluctuations
- Dehydration
- Chronic inflamed/sore throat
- Gastrointestinal issues
- Electrolyte imbalances
- Acid-base imbalances
Parotid gland swelling
One symptom of bulimia is parotid gland swelling. The parotid glands produce saliva, and a bulimic patient's frequent vomiting can cause these glands to produce excess saliva. The overstimulation of the parotid glands can cause them to swell.
Dental erosion
Another key symptom of bulimia nervosa is dental erosion. When a patient is vomiting frequently, the stomach acid in the vomit comes in contact with the teeth, and erodes the enamel on the teeth.
Russell's sign
Russell's sign is another important bulimia symptom to know. Russell's sign is callusing on the knuckles. With repetitive self-induced vomiting, the skin on the knuckles comes in contact with the incisor teeth, and this causes abrasions and calluses on the knuckles.
Weight fluctuations
It's important to note that a patient with bulimia nervosa will have weight fluctuations, but they will likely not be underweight. This is different than anorexia nervosa, where the patient may have a dangerously low body weight.
Dehydration
Dehydration is a common side effect of prolonged, or frequent, vomiting, and thus is a symptom of bulimia. Vomiting causes the body to lose fluid. In a patient with bulimia, they may not be replacing lost fluids post-vomiting.
Chronic inflamed/sore throat
Another symptom of bulimia is a chronically inflamed or sore throat. Frequent vomiting means frequent contact of stomach acid with the throat, which can inflame the throat and cause it to become sore.
Gastrointestinal issues
Bulimia can cause gastrointestinal issues. The gastrointestinal system is designed to take in a moderate amount of food and digest it in a predetermined order. When this process is disrupted by frequent intake of large amounts of food (binge eating), and then working in reverse (vomiting), or working in excess via stimulation (laxative use), this can damage the esophagus, stomach, or intestines, which can lead to gastrointestinal issues like acid reflux, constipation, diarrhea, or irritable bowel syndrome.
Electrolyte imbalances
Electrolyte imbalances are an important sign/symptom of bulimia, and in fact are some of the diagnostic criteria used for inpatient hospitalization due to bulimia. Typically, the body derives electrolytes from food and beverage, but when this intake is expelled via vomiting or laxative use, it can deplete the body of electrolytes like potassium and sodium.
Check out these related articles:
- Electrolytes - Calcium, Magnesium, Phosphorus, Potassium, Sodium - Nutrition
- Electrolyte Imbalances - Fundamentals
Acid-base imbalances
Acid base imbalances, specifically metabolic alkalosis, are a sign/symptom of bulimia. A loss of body acids is a key cause of metabolic alkalosis, so any condition that includes prolonged or frequent vomiting (like bulimia) can cause metabolic alkalosis. Symptoms of metabolic alkalosis include tachycardia, dysrhythmias, muscle weakness, and lethargy.
Bulimia lab values
Lab values typically seen in a patient with bulimia include:
- Hypokalemia: A potassium level that is too low
- Hyponatremia: A sodium level that is too low
- Metabolic alkalosis: A pH that is too high (alkaline) and HCO₃ that is too high (alkaline)
Bulimia inpatient hospitalization criteria
Sometimes patients with bulimia need to be hospitalized. The criteria for inpatient hospitalization for a patient with bulimia includes:
- Inadequate response to outpatient therapy
- Syncope
- Hypothermia
- Severe hypochloremia
- Severe hyperkalemia
- Esophageal tears
- Arrhythmias
- Intractable vomiting
- Hematemesis
- Suicide risk
Inadequate response to outpatient therapy
Patients with bulimia may participate in outpatient therapy. This means they live at home and attend sessions or appointments with their provider(s) at some regular interval. Usually, these patients have been deemed medically stable and able to recover with this balance of care and independence.
Sometimes, a patient's recovery with inpatient treatment is inadequate, and they may need additional care under inpatient hospitalization.
Of course, not all patients with bulimia have participated in outpatient treatment. Some patients with bulimia may directly enter the inpatient hospital setting after their condition leads to an emergency or has become dire.
Syncope
Syncope (pronounced sink-uh-pee; it sounds like Penelope, not antelope) means fainting. Syncope in a patient with bulimia can be caused by electrolyte imbalances, dehydration, or heart arrhythmias. Fainting is dangerous as a patient could fall and hit their head or become seriously injured, or it could be indicative of something life-threatening—this is why it is one of the included criteria for inpatient hospitalization of someone with bulimia.
Hypothermia
The body relies on nutrients to maintain its normal temperature. In eating disorders like bulimia, the body may not be getting adequate nutrients to maintain body temperature, and it is possible that a patient could develop hypothermia (core body temperature below ~95°).
A core body temperature that is too low can impair the function of the heart, nervous system, and other organs. Untreated, hypothermia can lead to heart failure or respiratory failure, so it is a medical emergency—this is why it is one of the included criteria for inpatient hospitalization of someone with bulimia.
Hypochloremia
Chloride is an electrolyte important for maintenance of fluid balance, and it is a component of gastric secretions (digestive juices). The expected range for chloride in the body is 98 - 106 mEq/L. When chloride is too low (under 98 m/EqL), it's known as hypochloremia, and it can lead to weakness, fatigue, dyspnea (difficulty breathing), or confusion.
A body chloride level under 88 mEq/L is dangerously low, which is why it is one of the included criteria for inpatient hospitalization of someone with bulimia.
Hypokalemia
Potassium is an electrolyte important for maintenance of intracellular fluid, and regulation of heart/muscle contractions. The expected range for potassium in the body is 3.5 - 5.0 mEq/L. When potassium is too low (under 3.5 mEq/L), it's known as hypokalemia, and it can lead to dysrhythmias, muscle weakness, constipation/ileus, hypotension, and weak pulses.
A body potassium level under 3.2 mEq/L is dangerously low, which is why it is one of the included criteria for inpatient hospitalization of someone with bulimia.
Esophageal tears
The esophagus connects the mouth to the stomach and passes right between the lungs. Excessive vomiting can lead to an esophageal rupture/tear, causing the esophagus's contents to spill into the chest cavity, which could lead to breathing difficulties or a lung infection. This is very dangerous, which is why it is one of the included criteria for inpatient hospitalization of someone with bulimia.
Arrhythmia
An arrhythmia (or dysrhythmia) is any abnormality of the heart rate or pattern. Cardiac dysrhythmias can be caused by electrolyte imbalances, and have the potential to be very dangerous, which is why they are one of the included criteria for inpatient hospitalization of someone with bulimia.
Intractable vomiting
Intractable vomiting means vomiting that doesn't subside or is uncontrollable. Patients with bulimia tend to induce their own vomiting, but if they have developed uncontrollable vomiting, this can be indicative of a serious complication. Intractable vomiting can, of course, lead to severe dehydration and electrolyte deficiencies which can be life-threatening, which is why it is one of the included criteria for inpatient hospitalization of someone with bulimia.
Hematemesis
Hematemesis means blood in the vomit. This can be indicative of internal bleeding and/or the aforementioned esophageal tear, and it is a sign of a serious complication. Hematemesis is usually considered a medical emergency, which is why it is one of the included criteria for inpatient hospitalization of someone with bulimia.
Tip: If you encountered the word hematemesis and didn't know what it meant, you could easily break the word down into its component parts to determine its meaning. The prefix hemat- means blood, and emesis means vomit, so Hematemesis = blood in the vomit. We created our Medical Terminology flashcards to make breaking down words into their parts easy, so you never have to be confused by an unfamiliar word on an exam!
Suicide risk
Patients at risk of suicide are patients that are considering or planning suicide. One of the risk factors for suicide is mental health disorder(s), which is what bulimia nervosa is. So, having bulimia nervosa increases a patient's risk of suicide.
Obviously, this does not mean that all patients with a mental health disorder (e.g. bulimia) are suicidal. This just means that out of the people who die by suicide, it is more common that they have a comorbid mental health disorder (e.g. bulimia) than not.
Suicide risk is one of the included criteria for inpatient hospitalization of someone with bulimia.
See article: Sexual Assault and Suicidal Patients - Mental Health
This information on bulimia and suicide is for your nursing exams and nursing practice. If you (or someone you know) are thinking of harming yourself or attempting suicide, tell someone who can help right away. Call the toll-free, 24-hour hotline of the National Suicide Prevention Lifeline (external link) at 1-800-273-TALK (8255) to be connected to a trained counselor.
Anorexia nervosa
Anorexia nervosa is an eating disorder characterized by restriction of calorie intake that results in a dangerously low body weight.
Anorexia nervosa vs. anorexia terminology
The word anorexia by itself means "without appetite." The Greek prefix An- means without (e.g., Anemia = lack of red blood cells), and the Greek suffix -orexia means appetite.
The word nervosa means nervous, which can be understood two ways: nervous meaning psychiatric-related (e.g. the outdated terminology "a nervous condition" or the non-medical slang "nervous breakdown"), or nervous from the direct Latin translation a fear of (e.g., a fear of weight gain).
The word anorexia by itself (lack of appetite) can actually be a symptom of other disorders that are unrelated to eating disorders, e.g., nephrotic syndrome.
This can be slightly confusing at first, because in everyday conversation, using the word anorexia usually is in reference to the eating disorder anorexia nervosa. In fact, you usually see "loss of appetite" or "lack of appetite" used in regular writing (e.g. on a medication side effect on a TV commercial, or on WebMD) because the use of anorexia in that context would be confusing for a regular audience.
But, when you are studying for your nursing exams, and you see the term anorexia by itself, you will know that it doesn't necessarily mean an eating disorder.
Anorexia nervosa risk factors
The main anorexia nervosa risk factors you need to know for your nursing exams are patient sex (female), patient age (adolescence, early adulthood), and other psychiatric disorders.
Anorexia nervosa signs and symptoms
Signs and symptoms of anorexia nervosa include:
- Extreme thinness
- Amenorrhea
- Lanugo
- Cold intolerance
- Brittle hair and nails
- Severe constipation
- Lethargy
- Decreased heart rate
- Decreased blood pressure
- Decreased respiratory rate
Extreme thinness
Extreme thinness is a patient weighing less than 75% of their ideal body weight, or having a body fat percentage less than 10%.
See article: Body Mass Index (BMI) - Fundamentals
Amenorrhea
Amenorrhea is the lack of menstruation in a patient that would otherwise be menstruating. Technically, primary amenorrhea is when menstruation has not happened by age 15 or within 5 years after the first signs of puberty, and secondary amenorrhea is when menstruation stops for a minimum length of time in someone that has previously menstruated. So the amenorrhea we're talking about, in the context of an anorexia nervosa symptom, is secondary amenorrhea.
Amenorrhea can occur for these two reasons specifically with anorexia nervosa: poor nutrition or extreme exercise. In layman's terms, when the body is under starvation, it will begin to "shut down" "non essential" processes in order to stay alive. Essentially, the body will put reproductive processes on pause to prioritize more important things for immediate survival, like the heart beating.
Note: Amenorrhea can also occur from birth control, pregnancy, menopause, medications, or stress.
Lanugo
Lanugo is downy hair growth on the body that works as a protective mechanism. During pregnancy, fetuses grow lanugo as a protective coating (usually it is shed before birth). Lanugo can also grow in cases of malnutrition—in the absence of fat, lanugo serves as insulation to try to help preserve the core body temperature. This is why lanugo can happen in patients with anorexia nervosa.
Cold intolerance
The body relies on nutrients to maintain its normal temperature. In a cold environment, the body thus uses more nutrients to do the work of maintaining its temperature. With eating disorders like anorexia nervosa, the body may not be getting adequate nutrients to maintain body temperature, and the patient may be intolerant to cold.
Brittle hair and nails
The body requires nutrients to maintain hair and nails as part of the integumentary system. Without adequate nutrients, the body can't maintain healthy hair and nails, which is why brittle hair and nails may be found in a patient with anorexia nervosa.
Severe constipation
Constipation is infrequent bowel movements and/or difficult bowel movements, and it can be caused by many things, but one cause is undereating. Bowel movements are caused by the digestion of food, without adequate food, bowel movements will become infrequent.
Slow gastrointestinal motility is also the body's adaptation to malnutrition—if food moves through the body more slowly, it gives the intestines more time to absorb nutrients.
Note: If you've ever seen the reality TV show Alone, where participants go into the wilderness and try to live off the land alone, you'll remember these people often have trouble with constipation — they aren't eating much, so they can't go. Obviously this is very different than anorexia nervosa, but it might help you remember constipation as a side effect of malnutrition/undereating.
Lethargy
Lethargy is a lack of energy, and you may remember that lethargic is step #2 on Levels of Consciousness.
The body gets energy from calories, and in cases of anorexia nervosa, the body may not be getting enough calories to provide a normal level of energy.
Decreased heart rate
Everything the body does, including beat the heart, requires calories. In cases of malnutrition due to anorexia nervosa, the body will slow its heart rate to preserve energy.
Decreased blood pressure
If a heart has become weakened from prolonged malnutrition due to anorexia nervosa, it will struggle to pump blood throughout the body, resulting in low blood pressure.
Decreased respiratory rate
Again: everything the body does requires calories. That includes breathing. In the case of malnutrition due to anorexia nervosa, the body may slow the respiratory rate to preserve energy.
Anorexia nervosa hospitalization criteria
The criteria for hospitalizing a patient with anorexia nervosa includes:
- Inadequate response to outpatient therapy
- Electrolyte abnormalities
- Daytime heart rate under 50 bpm
- Systolic blood pressure under 90 mmHg
- Arrhythmias
- Body temperature under 96°
- Body weight under 75% of ideal
- Body fat under 10%
- Refusal to eat
Inadequate response to outpatient therapy
Patients with anorexia nervosa may participate in outpatient therapy. This means they live at home and attend sessions or appointments with their provider(s) at some regular interval. Usually, these patients have been deemed medically stable and able to recover with this balance of care and independence.
Sometimes, a patient's recovery with inpatient treatment is inadequate, and they may need additional care under inpatient hospitalization.
Of course, not all patients with anorexia nervosa have participated in outpatient treatment. Some patients with anorexia nervosa may directly enter the inpatient hospital setting after their condition leads to an emergency or has become dire.
Electrolyte abnormalities & arrhythmias
Electrolyte abnormalities resulting from anorexia nervosa can include hypokalemia and hyponatremia.
An arrhythmia (or dysrhythmia) is any abnormality of the heart rate or pattern. Cardiac dysrhythmias can be caused by these electrolyte imbalances, and have the potential to be very dangerous, which is why they are one of the included criteria for inpatient hospitalization of someone with anorexia nervosa.
Body temperature under 96°
The body relies on nutrients to maintain its normal temperature. With anorexia nervosa, the body may not be getting adequate nutrients to maintain body temperature, and it is possible that a patient could develop a body temperature that is dangerously low.
A core body temperature that is too low can impair the function of the heart, nervous system, and other organs. Untreated, hypothermia can lead to heart failure or respiratory failure, so it is a medical emergency—this is why it is one of the included criteria for inpatient hospitalization of someone with anorexia nervosa.
Body weight and body fat percentage
When a patient has anorexia nervosa and their body weight is less than 75% of normal, and/or their body fat percentage is under 10%, this can be one of the criteria for inpatient hospitalization.
Refusal to eat
If a patient with anorexia nervosa is refusing to eat, this can be one of the criteria for inpatient hospitalization.
Bulimia & anorexia nervosa treatment & care
Although bulimia and anorexia nervosa are different disorders, the treatment and monitoring that RNs need to know for nursing exams are the same between the two disorders.
Bulimia & anorexia treatments
Treatment for bulimia and anorexia nervosa can include:
- Individual, group, or family talk therapy
- Cognitive behavioral therapy
- Nutritional counseling
- Medications for comorbid psychiatric conditions
Therapies
Therapies indicated for treatment of bulimia and anorexia nervosa can include individual, group, or family talk therapy, as well as cognitive behavioral therapy.
Talk therapy is a broad term for different kinds of psychotherapy. Individual is when the patient is by themselves, group therapy occurs in a group setting, and family therapy is when the patient's family is involved.
Cognitive behavioral therapy (CBT) is a type of talk therapy that aims to modify the patient’s patterns of thinking and behavior. The goals of CBT are to replace negative, distorted thoughts with positive, rational ones.
Nutritional counseling
Nutritional counseling is a very important component of treatment for bulimia and anorexia nervosa. In nutritional counseling, a patient works directly with a nutritional counselor (e.g., a Registered Dietician) on nutritional topics, like correcting inaccurate nutritional knowledge, eating behaviors, and making sure a patient's food plan covers their unique needs and cultural considerations.
See article: Nutrition, part 33: Nutritional Guidance for Eating Disorders
Medications for comorbid psychiatric conditions
Oftentimes, disorders like bulimia and anorexia nervosa can be comorbid with other psychiatric conditions like depression or anxiety. These conditions can be treated with psychiatric medications which can in turn help eating disorder recovery.
Check out these related articles for psychiatric medications:
- Psychiatric Mental Health, part 22: Therapies - Bipolar Disorder Medications
- Psychiatric Mental Health, part 21: Therapies - Atypical Antidepressants
- Psychiatric Mental Health, part 20: Therapies - MAOIs Monoamine Oxidase Inhibitors
- Psychiatric Mental Health, part 19: Therapies - Tricyclic Antidepressants
- Psychiatric Mental Health, part 18: Therapies - SSRIs & SSNRIs
- Psychiatric Mental Health, part 17: Therapies - Benzodiazepines & Atypical Anxiolytics
- Psychiatric Mental Health, part 16: Therapies - Neurotransmitters & Patient Teaching for Psych Meds
These medications are also covered in our Pharmacology - Nursing Flashcards.
Bulimia & anorexia nursing care
Nursing care you need to know for bulimia and anorexia nervosa include:
- Maintaining strict inputs & outputs
- Weighing procedures
- Mealtime monitoring
- Privileges
- Activity restriction
- Refeeding syndrome monitoring
Maintaining strict inputs & outputs
When charting a patient's inputs and outputs (Is and Os), it's always important to maintain accurate records. However, with an eating disorder patient, it becomes even more important as the patient's weight changes are closely monitored to understand treatment progress.
Weighing procedures
When you have a patient with bulimia or anorexia nervosa, the weighing procedures that you need to follow are important because their weight changes are very important to understanding treatment's progress. The patient should be weighed first thing in the morning after waking up, so that their weight is not affected by the day's food consumption. The same scale should always be used to weigh the patient, so weight changes due to differently calibrated scales aren't misattributed to the patient's weight actually changing.
Mealtime monitoring
When you have a patient with bulimia or anorexia nervosa, they will need to be monitored closely during mealtime, to ensure they are actually eating and not doing something else with the food (e.g., throwing it away, hiding it). The patient should also be monitored for over 1 hour after mealtime, to ensure they don't engage in compensatory behaviors like purging or overexercising.
Privileges
Privileges can be offered to patients for treatment compliance and weight gain. These privileges usually are directly related to restricted substances or activities.
For example, an eating disorder patient may be restricted from consuming coffee. Maybe after following their meal plan for the week, they gain back the privilege of having coffee with their breakfast.
Another example of a privilege might be allowing the patient to go on a walk, or allowing more alone time.
Follow provider's orders.
Activity restriction
When you have a patient with bulimia or anorexia nervosa, one of the nursing care steps you may need to take is restricting strenuous activity—this can help prevent compensatory overexercising.
Refeeding syndrome monitoring
Refeeding syndrome can occur if nutrition is introduced too rapidly after prolonged starvation. Signs and symptoms of refeeding syndrome include severe electrolyte imbalances, arrhythmias, and seizures. Part of your nursing care of a patient with bulimia or anorexia nervosa will be monitoring for refeeding syndrome.
Binge eating disorder
Binge eating disorder is the most common eating disorder in the United States, and it's characterized by recurrent episodes of eating large amounts of food (bingeing). Someone with binge eating disorder will eat large amounts of food even though they are not physically hungry, and afterwards, they may feel intense guilt or shame.
Binge eating disorder risk factors
The binge eating disorder risk factors you need to know for your nursing exams are patient sex (female), patient age (young adulthood), and other mental health disorders.
Binge eating disorder signs and symptoms
The signs and symptoms of binge eating disorder include eating larger-than-normal amounts of food, weekly, for a greater period of time than 3 months , weight fluctuations, concerns about body weight or body image, low self-esteem, feelings of shame after bingeing, and abdominal cramps or pain.
Binge eating disorder treatment
Treatment of binge eating disorder includes cognitive behavioral therapy (CBT), as well as dialectical behavioral therapy (DBT). DBT is a specific form of CBT that helps the patient to regulate their emotions and helps to reduce self-destructive behavior. Medications such as SSRIs can also be helpful.
Another treatment option that is sometimes used is bariatric surgery.
Binge eating disorder nursing care
Nursing care of a patient with binge eating disorder includes encouraging the patient to keep a food diary, working with the patient to establish realistic weight goals, and providing referrals to support groups.