Anorexia nervosa is classified as a psychological disorder (see Chapter 46), but it has serious nutritional consequences. In many contemporary cultures, the emphasis on a slim body has influenced young women’s body image. The patient with anorexia nervosa refuses to eat adequate quantities of food and is in danger of literally starving to death. Although it is a psychiatric disorder, the patient may be admitted to the medical floor for treatment of malnutrition by enteral or parenteral therapy. Diagnosis requires extensive interviewing and treatment—including behavior modification and nutrition support—which may take months to years.

Bulimia Nervosa

Bulimia nervosa is another psychological disorder covered in Chapter 46. The bulimic patient consumes large quantities of food and then induces vomiting to get rid of it so that weight is not gained. Laxatives may be taken to purge the system after an eating binge. Some patients with anorexia nervosa also are bulimic. Some individuals practice bulimia occasionally, without harm. When it is practiced frequently, it can lead to severe fluid and electrolyte imbalances, starvation, and death. Treatment of bulimia includes psychotherapy, antidepressant medication, and behavior modification.

Obesity

Obesity is a worldwide problem, and is particularly prevalent in industrialized nations. Over two thirds of adults in the United States are overweight or obese, and over one third are obese. In the United States, obesity is associated with over 112,000 deaths related to cardiovascular disease, 15,000 deaths due to cancer, and over 35,000 deaths from other causes related to being overweight (Weight-Control Information Network, 2010). Children are showing a trend for increasing obesity. There is an ongoing search to see if there is a genetic predisposition to this disorder. Prevention of obesity and encouraging healthy and nutrition dense foods are goals of Healthy People 2020.

Etiology and Pathophysiology

Several factors must interact for obesity to occur, including genetics, a diet of foods high in calories and fat, lack of exercise, and overconsumption of food. Some medications increase appetite. Known contributors to obesity include readily available high-calorie prepackaged and high-fat fast food, plus “supersized” portions available in restaurants.

For some people overeating is a reaction to stress; for others overeating is a substitute for absent pleasures. Some obese people seem to metabolize nutrients differently than others. The way a person develops fat cells and deposits fat is another factor in obesity. Genetic predisposition is most likely a factor since obesity seems to occur among family members.

Signs and Symptoms

A person is considered obese if he weighs more than 20% above the ideal weight for his height, age, and body type. Approximately 3 million Americans are morbidly obese, defined as 100% over ideal body weight, or having a body mass index over 40.

Obese patients should be counseled to lose weight in order to avoid developing one or more of the many diseases in which obesity is a contributing factor. Complications of obesity include:

• Diabetes mellitus

• Hypertension

• Hyperlipidemia

• Coronary artery disease

• Obstructive sleep apnea

• Cholelithiasis

• Arthritis with back and/or knee problems

• Increased susceptibility to infectious disease and decreased wound healing.

Think Critically

You have a friend who is overweight and she asks your opinion about the effectiveness and safety of over-the-counter “diet” pills. How would you respond?

Diagnosis

To determine whether a patient is obese, the following measurements are used:

• Height and weight chart: if more than 20% above ideal body weight for age and body build, the patient is considered obese.

• Measure the waist and then the hip circumference. Calculate the waist-to-hip ratio (waist measurement divided by the hip measurement). If the ratio is more than 1.0 in men or 0.8 in women, it indicates that the person is overweight. This is a more accurate indicator for obesity in the elderly.

• A body mass index (BMI) of more than 30 indicates obesity.

BMI=Weight(kg)Height(m2)

Thyroid function should be determined to ascertain that hypothyroidism is not a cause of the weight gain.

Treatment

A general health assessment should be conducted before a patient is placed on a weight reduction diet. A physician will usually prescribe a lower-calorie diet and exercise. The patient is taught ways to change thinking about food and weight. Those with a BMI over 40 may have surgery to achieve weight reduction if they meet established criteria. Participation in a support group and behavior modification with some sort of reward for weight loss are part of the total treatment plan. Teaching stress reduction and alternate ways of coping are essential to success. Medications that suppress appetite or block fat absorption may be used on a short-term basis. Sibutramine (Meridia) is the commonly used appetite suppressant. It is a selective serotonin reuptake inhibitor, which enhances the feeling of fullness when eating; sibutramine can be combined with norepinephrine, which increases the metabolic rate, thereby burning more calories. Side effects of sibutramine include dry mouth, insomnia, and constipation. Orlistat (Xenical) inhibits lipase, causing fats to remain partially undigested and unabsorbed. Gastrointestinal side effects of orlistat include diarrhea (sometimes uncontrolled), abdominal cramping, and nausea.

Elder Care Points

The elderly may become obese due to decreased mobility from arthritis or other joint disorders. Cooking and eating are less appealing if the person is living alone, and snacking on junk food may replace meals. Metabolic rate slows with age, and a decreased calorie intake is needed to maintain a normal weight.

Bariatric Surgery

Bariatric surgery reduces gastric capacity. The patient undergoes extensive counseling and assessment. The patient must agree to modify his lifestyle and follow the stringent regimen required to lose weight and keep weight off. Three common types of bariatric surgery are gastric restrictive, malabsorptive, and gastric restrictive combined with malabsorptive surgery.

Restrictive procedures

Laparoscopic adjustable gastric banding is performed by placing an inflatable band around the fundus of the stomach. This procedure may be performed laparoscopically. The band is inflated and deflated via a subcutaneous port to change the size of the stomach as the patient loses weight. For vertical banded gastroplasty, the surgeon creates a small stomach pouch by placing a vertical line of staples. A band is placed to provide an outlet to the small intestine (Figure 29-1).

Figure 29-1 Bariatric surgical procedures.

Malabsorptive and combination procedures

The total gastric bypass procedure causes severe nutritional deficiencies and is no longer recommended. The roux-en-Y gastric bypass (RYGB) limits the stomach size, and the duodenum and part of the jejunum are bypassed. This limits the absorption of calories.

Think Critically

What impact on nutritional status might a roux-en-Y bypass have on an individual? Why? What might be the physical long-term consequences?

Complications

With the RYGB procedure, there is danger of leakage of stomach contents into the abdomen in the early postoperative period. Later, gastric stretching may cause the staple line to break and a leak to occur. Signs and symptoms are tachycardia, dyspnea, or restlessness. An upper gastrointestinal (GI) series or computed tomography scan can diagnose the problem. The band in the vertical banding procedure may erode into the stomach over time and cause leakage. RYGB patients are also at risk for dumping syndrome, which results in nausea, weakness, sweating, and diarrhea. Other complications of major surgery may occur in the respiratory and cardiovascular systems (see Chapter 5 for complications of surgery). There is greater risk of pulmonary dysfunction, thrombus formation, and death, for the obese patient. About a third of patients who undergo bariatric surgery develop gallstones. Urodeoxycholic acid therapy can be used to treat the gallstones, although poor compliance and cost are issues for this therapy (Patel et al., 2009).

All bariatric surgery patients are at risk of nutritional deficiencies. Those with the RYGB procedure are most likely to develop deficiencies of iron, vitamin B₁₂, calcium, and folate. Supplements must be taken for life.

Nursing Management of Obesity

Assessment (Data Collection)

Data collection includes establishing whether there is a family history of obesity, determining contributing factors, and obtaining an accurate record of eating patterns for a 7-day period. Physical assessment includes measuring weight and height, calculating BMI, and taking a skinfold thickness measurement. A general health assessment is performed.

Nursing Diagnosis and Planning

Examples of nursing diagnoses relevant to the care of obese patients include:

• Disturbed body image related to excess weight

• Imbalance nutrition more than body requirements related to high fat diet

• Chronic low self-esteem related to excess weight

Goals should be long term, and expected outcomes might include:

• Patient will make positive statements about decreasing body size.

• Patient will consume less fatty food and more fruit and vegetables.

• Patient will verbalize feelings of self-worth.

Implementation

The diet and exercise plan should be designed according to the patient’s lifestyle and preferences. Encourage the patient to keep an eating and exercise diary. Weekly meetings for counseling and evaluation are important to provide guidance. Offer support by being available to talk about the positive aspects and frustrations of staying on the diet. Discourage fad diets and emphasize the importance of a well-balanced, nutritious, low-calorie diet. Commercial programs are available to assist patients with weight reduction. Weight Watchers and TOPS (Take Off Pounds Sensibly) are two commercial programs that have shown good long-term results with maintenance of normal weight.

Preoperative and postoperative care for the bariatric surgery patient depends on the type of surgical procedure performed, but general principles are similar to other types of abdominal or abdominal laparoscopic surgery. Because of the weight and size of the client, lifting apparatus must be available as well as an extra-wide bed and chair. Hospitalization may be for 1 to 5 days depending on the procedure and the patient. If a nasogastric (NG) tube is in place, do not reposition it, as you might disrupt the suture line. Feedings are designed in consultation with a dietitian; you would anticipate feeding progression in the early postoperative period, then onto multiple small meals, a balanced meal plan, and possibly parenteral nutrition (PN) in high-risk patients (National Clearinghouse Guidelines, 2009). For example, feedings begin with 1 ounce of clear liquid at a time, advancing to pureed foods, juice, thinned soups, and milk. The diet is increased in 1-ounce increments taken over 5 minutes until the patient’s appetite is satisfied. The diet is maintained for 6 weeks and then progressed to regular foods. Nausea, vomiting, and discomfort may occur, especially if too many liquids are ingested. The patient remains under medical supervision to monitor for vitamin deficiency or malnutrition.

Evaluation

The patient’s diet and exercise diary should be evaluated each week if possible. Weight is tracked on a graph to show progress in weight loss. If the outcomes are not being met, the plan’s interventions must be reconsidered.

Upper Gastrointestinal Disorders

Stomatitis

Stomatitis is a generalized inflammation of the mucous membranes of the mouth. Causes include trauma from ill-fitting dentures or malocclusions of the teeth, poor oral hygiene, and nutritional deficiencies. Excessive smoking, excessive drinking of alcohol, pathogenic microorganisms, radiation therapy, and drugs (especially those used in chemotherapy for malignancies and anticonvulsants) are other contributors to the problem.

Common symptoms of stomatitis include pain and swelling of the oral mucosa, increased salivation or excessive dryness, severe halitosis, and sometimes fever. Small crater-like aphthous ulcers may appear in the mouth, commonly called “canker sores.”

Treatment of stomatitis is chiefly symptomatic, unless a specific infectious causative agent is identified. Nursing measures to control the symptoms of stomatitis—including special mouth care, artificial saliva, and diet—are discussed in Chapter 8.

Complementary and Alternative Therapies

Lysine for Canker Sores

Many people who develop “canker sores” from food sensitivities or stomach upset often can heal them more quickly by taking the dietary supplement lysine three or four times a day. This often helps cut the time of a “fever blister” on the lips as well (Dugdale, 2009).

Dysphagia

Dysphagia means difficulty in swallowing. It is the most common symptom of disorders of the esophagus and varies from a mild sensation that something is sticking in the throat, to a complete inability to swallow solids or liquids. Tumors, esophageal diverticula, inflammation, or motility disorders from a neurologic disorder may cause swallowing problems. If the patient is experiencing choking or difficulty with swallowing, he is kept on nothing-by-mouth (NPO) status. A modified barium swallow test is ordered to determine the specific cause. Videofluoroscopy is used during the test to visualize the swallowing process.

Treatment and Nursing Management

Have the patient take some “practice swallows” before beginning the meal. Watch to see that the larynx rises with each swallow. Observe the kinds of food the patient can tolerate and the conditions under which difficulties are experienced. Knowing the consistency and temperature of the foods most easily ingested by the patient is helpful. Some patients may strangle on liquids, but will tolerate soft and semisolid foods. Others may have the feeling that high-fiber foods are not moving past a certain point in the esophagus. Measures that may be helpful in relieving dysphagia include instructing the patient to chew the food more thoroughly or to eat semisoft or pureed foods. Drinking liquids throughout the meal may help; however, liquids will cause many patients to choke. If thin liquids are a problem, adding thickener to liquids makes them easier to swallow. Sitting upright with the head forward and the neck flexed with the chin slightly tucked aids in swallowing. Head position may be altered, depending on the particular type of problem present. A speech pathologist should be consulted to design the most effective therapy for the patient.

The patient may be a candidate for neuromuscular electrical stimulation (NMES). One type of NMES device stimulates muscle at rest, to compensate for muscle wasting. Another NMES device is used for patients who have swallowing issues related to neurologic disorders such as stroke. Some helpful strategies to improve swallowing include licking lollipops to strengthen tongue movements, practicing vowel sounds to stimulate movement, and sucking or blowing through a straw to strengthen the soft palate (Nazarko, 2010). Meals should be served in a relaxing atmosphere with pleasant surroundings and relief from emotional stress.

Nursing diagnoses for patient with swallowing problems are:

• Impaired swallowing

• Risk for imbalanced nutrition: less than body requirements

• Risk for aspiration

Elder Care Points

The older patient may have experienced a stroke that has impaired swallowing ability. Swallowing pills is a frequent difficulty for this age group. Instruct the elderly patient to take a drink of water, swallow, place the pill on the back of the tongue, take another drink of water, tuck the chin down slightly and swallow; follow by drinking at least 6 to 8 ounces of water.

Patients with chronic dysphagia are subject to respiratory problems resulting from the aspiration of food into the respiratory tree. Both acute and chronic dysphagia are likely to produce nutritional deficiencies and electrolyte imbalances. If the dysphagia is such that the patient cannot swallow sufficient amounts of food for adequate nutrition, tube feeding may be indicated. This sometimes is necessary when the dysphagia is the result of cerebral damage, as in cerebrovascular accident.

Clinical Cues

When your patient has a swallowing problem, the oral suction equipment should always be readily available. Aspiration of food or mucus can occur quickly. The patient or family should be taught how to quickly use the oral suction apparatus (Yankauer).

If the patient cannot swallow anything because of a neurologic condition (see Chapters 22 and 24), or if the esophagus is obstructed and cannot be corrected surgically, the patient must have a gastrostomy. An opening in the wall of the stomach is created, and a permanent feeding tube is sutured in place. Nursing interventions for feeding tubes are discussed later in this chapter.

Cancer of the Oral Cavity

Etiology, Pathophysiology, and Signs and Symptoms

In May 2010, there were approximately 25,800 new cases of oral cancer in the United States (American Cancer Society, 2010). Although the specific cause is unknown, oral or throat cancer is curable if discovered early. Cell mutation occurs until an area of cells becomes neoplastic. A genetic factor is most likely present. Oral and pharyngeal cancer risks are cigarette smoking, use of smokeless tobacco, pipe smoking, and heavy alcohol use. The human papillomavirus is another risk factor. Leukoplakia, a precancerous lesion, may occur on the tongue or mucosa. Dental examinations should include inspection for this lesion. Sores or discolorations on the lips or in the mouth that do not heal within 2 weeks should be checked by a physician.

Diagnosis and Treatment

Diagnosis is made by physical examination and biopsy. Oral cancer treatment varies depending on the structures involved. Radiation, chemotherapy, and surgery are treatment options. Mandibulectomy (removal of the mandible), hemiglossectomy (removal of half of the tongue), or glossectomy (removal of the tongue) with resection of other parts of the mouth may be necessary. If the cancer has spread to the cervical lymph nodes, radical or modified neck dissection is performed. This surgery involves wide excision of the primary tumor with removal of the regional lymph nodes, the deep cervical lymph nodes, and lymph channels. A tracheostomy accompanies these procedures to protect the airway (see Chapter 14). A drain is placed to prevent fluid accumulation. Tube feedings are used as long as swallowing is difficult.

Nursing Management

Postoperative care includes close monitoring of respiratory status, airway, and oxygenation. Cold packs and elevation of the head are used to prevent excessive swelling in the neck that might compress the airway, circulation, and nerves. Aseptic wound care and tracheostomy care are provided. Nutritional support is an ongoing concern and is very important in the healing process. Many of these patients are malnourished before surgery. See Chapter 8 for the specific care of the cancer patient undergoing radiation and/or chemotherapy.

Think Critically

You are caring for a young woman who was recently informed that she would need surgery and radiation treatment for oral cancer. What are the implications for her sense of body image and psychological well-being?