University of Technology, Jamaica

College of Health Sciences

Caribbean School of Nursing

Presented To

Lecturer:

Submitted by

Paulette Simms ID#:1000764

.
 Case Study 128

Scenario
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 whay 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 and
everybody started commenting on how good she was beginning to look, so she just quit
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."

1. How is the diagnosis of anorexia nervosa determined?

Anorexia nervosa can be a difficult disorder to diagnose, since individuals with anorexia often
attempt to hide the disorder. Denial and secrecy frequently accompany other symptoms. The
DSM-IV-TR Diagnostic Criteria for anorexia nervosa: 1.) refusal to maintain body weight at or
above a minimum normal weight for age and height 2.) Intense fear of gaining weight or
becoming fat, although significantly underweight 3.)Disturbance in the way in which one's body
weight or shape is experienced, overvaluing of shape or weight, or denial of seriousness of low
weight or weight loss 4.) In women and female adolescents, the absence of at least 3 consecutive
menstal cycles.
(Keltner pg.399)

2. What are the clinical symptoms of anorexia nervosa? Identify eight symptoms.

1.) extreme weight loss 2.) dehydrartion 3.) thin appearence 4.) hair that thins, breaks, or fall out
5.) intolerance of cold 6.) fatigue 7.)dental problems 8.) low blood pressure
www.mayoclinic.com/health/anorexia/.../DSECTION=symptomsCached - Similar

3. What are concomitant disorders associated with anorexia nervosa?

Hypotension, bradycardia, and hypothermia are common.

Scenario

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 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'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 and everybody started commenting on how good she was

beginning to look, so she just quit 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."

Anorexia nervosa can be a difficult disorder to diagnose, since individuals with anorexia often

attempt to hide the disorder. Denial and secrecy frequently accompany other symptoms. The

DSM-IV-TR Diagnostic Criteria for anorexia nervosa: 1.) refusal to maintain body weight at or

above a minimum normal weight for age and height 2.) Intense fear of gaining weight or

becoming fat, although significantly underweight 3.)Disturbance in the way in which one's body

weight or shape is experienced, overvaluing of shape or weight, or denial of seriousness of low

weight or weight loss 4.) In women and female adolescents, the absence of at least 3 consecutive

menstal cycles.

(Keltner pg.399)

. What are the clinical symptoms of anorexia nervosa? Identify eight symptoms

2.

1.) extreme weight loss 2.) dehydrartion 3.) thin appearence 4.) hair that thins, breaks, or fall out
5.) intolerance of cold 6.) fatigue 7.)dental problems 8.) low blood pressure

www.mayoclinic.com/health/anorexia/.../DSECTION=symptoms Cached - Similar

3. What are concomitant disorders associated with anorexia nervosa?

Hypotension, bradycardia, and hypothermia are common.

Depression, lessened sex drive, and obsessional symptoms are also concomitant disorders with
anorexia nervosa.

(Keltner pg. 400)

4. Name five behaviors that J.M. may engage in other than starvation?

Suicide, prostitution, psychological problems, obsession with food, addictions, perfectionist.

5. what are common family dynamics with anorexia nervosa?

Anorexia tends to affect the middle and upper socioeconomic classes and Caucasians more

often than less advantaged classes and ethnic minorities

Underlying dissatisfaction and tension is often present within the parental dyad. It has been

suggested that parents of anorexic offspring put high expectations on their children to over-

compensate for the lack of love in their own marriage. The anorexic is then capable of using

the illness to unite his/her parents.

The family dynamics of patients with anorexia nervosa: enmeshment, over protectiveness,

rigidity, and avoidance of conflict and lack of conflict resolution. These four transactional

characteristics provide the context for the anorexic child to use his/her illness as a means for

communicating avoided messages as well as family and parental conflict. According to

Blinder, Chaitin & Goldstein, 1988.

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.

1.monitor daily caloric intake and electrolyte status while in hospital.

2.monitor activity level and encourage appropriate levels of activity.

4. Encourage use of therapies or support groups.

5. Promote positive self-control and perception of body, as well as interaction with others.

6 .Be honest: patient enter tx distrustful of everyone, honesty is essential to develop a trusting

relationship.

7. Convey warmth and sincerity. Patient must believe that the nurse genuinely understands and

cares about their concerns.

8. Assist patient to identify their positive qualities.

9. Model and teach appropriate social skills.

9 .Set appropriate behavioral limits.

10.Listen with empathy.

11.Promote pt decision making concerning issues other than food.(keltner407)

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 ulgy. 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."

8. What will you and the RN discuss with the primary care provider (PCP) before any further

discharge teaching or plans?

First I would address the fact that she stated she dont want to live anymore with her physician

and her healthcare team. I would express my concerns that she was not ready to be discharged to

home ,due to fact she might cause harm to herself and the fact she still has not resolved her
primary issue for being admitted to the hospital(anorexia nervosa)

9. You report J.M.'s statements to the PCP. How will the treatment plan be altered?

- J.M.'s statement "I don't want to live anymore" indicates suicidal ideation. She would be

considered a level 1 precaution, which would include frequent observation (every 10 minutes),

and monitoring of drug taking, eating utensils, shaving gear, and other potentially dangerous

devices in the environment.

- She will be assessed for depression.

- She will be encouraged to attend group therapy sessions.

(Keltner pgs. 95, 408)

10. What medications would be indicated for J.M. to assist with resolution of both her

anorexia nervosa and major depression?

Currently, no psychopharmacologic agent is approved specifically for anorexia nervosa.

Treatment with antidepressants, especially the SSRI antidepressants, have shown to have a

positive effect on associated mood disturbances and preoccupation with shape and weight. Some

examples of SSRIs include fluoxetine (Prozac) , escitalopram (Lexapro), paroxetine (Paxil), and

sertraline (Zoloft).

(Keltner pg. 184-185, 407)

11. What would indicate successful treatment with J.M.?

present