1. A common problem in adults, rarely treated in an inpatient psychiatric setting, can present as a symptom of depressive, manic, or anxiety disorders

2. Sleep consists of two distinct states: REM (rapid eye movement), also called dream sleep, and NREM (non-REM) sleep, which is divided into four stages

3. Sleep is a cyclic phenomenon with restorative qualities

4. Sleep disorders are conditions that repeatedly disrupt the pattern of sleep, leading to diminished performance

1. The sleep cycle evolves throughout the life cycle and decreases with age

2. It is a disorder from which the client usually recovers, because the changes may be reversible and temporary if treated

3. Neuroendocrine arousal system is thought to release corticosteroids by the hypothalamic-pituitary-adrenal axis, as well as stimulate the neurotransmitter system, producing norepinephrine and serotonin

4. Genetic factors show a biologic tendency that may be inherited (e.g., light sleepers in a family); no single gene has been identified

5. Environmental factors are thought to contribute to sleep disturbances, such as jet lag, shift work, fast pace of life, stress, and noise

6. Biologic factors such as cardiovascular, endocrine, psychiatric, infections, cough related to pulmonary disease, pain, use of stimulants including caffeine, and side effects or drug interactions of many medications contribute to sleep-related problems

7. Impaired function results from sleep deprivation

1. Primary

2. Secondary

1. Onset usually in young adulthood; more prevalent with increasing age

2. Difficulty initiating or maintaining sleep, or nonrestorative sleep, for at least 1 month

3. Depression usually associated with fragmented sleep patterns

4. Sleeplessness as a cardinal feature noted in manic disorders; an early sign of impending mania in bipolar disorders

5. Abuse of alcohol or stimulants, heavy smoking, and use of over-the-counter (OTC) cold remedies cause decreased total sleep time

6. Insomnia precipitated by anxiety

1. Relaxation techniques

2. Sleep hygiene practices (interventions that enhance sleep)

3. Sedative/hypnotic agents (see Chapter 16, The Practice of Mental Health/Psychiatric Nursing, Related Pharmacology: Psychotropic Medications, Sedative and Hypnotic Agents; used judiciously, particularly in older adults; used short-term, not long-term

1. History of onset, duration, and sleep patterns

2. Daily routines, night rituals

3. Diet and physical activity

4. Stressors

5. Level of daytime alertness, nap patterns

6. Restless leg movement, snoring

7. Drug, alcohol, caffeine, nicotine use

8. Pharmacologic or herbal remedies

9. Sleep journal

1. Assist with ruling out medical conditions that contribute to sleep-related problems

2. Obtain a diet diary to assess food/liquid intake and caffeine consumption

3. Control physical disturbances at night; provide a private room if necessary

4. Administer prescribed hypnotic

5. Teach sleep hygiene practices

1. Copes with anxiety-producing situations effectively

2. Uses relaxation techniques

3. Limits use of stimulants

4. Reports restorative sleep

5. Reports improved sense of well-being

1. Basic physiologic and safety needs to be met

2. Acceptance

3. Meaningful relationships

4. Limit setting of manipulative behavior

5. Monitoring during and after mealtime

6. An awareness of type, amount, and patterns of food eaten (food diary)

7. Consultation with nutritionist to determine adequate dietary regimen

1. Establish a relationship based on trust

2. Promote self-worth

3. Set limits that are realistic

4. Be consistent in approach and in rules and regulations

5. Support and encourage independence

6. Teach more effective ways of coping

7. Encourage participation in individual and family therapy

1. Decreased levels of norepinephrine, serotonin, and dopamine

2. Combination of genetic, neurochemical, developmental, psychologic, social, cultural, and familial factors cited

3. More common in females

4. Avoidance of food may result from excessive concern with obesity

5. Apparent failure to separate from mother and become autonomous; unconscious fear of maturing

6. Onset usually during adolescence through young adulthood; less common in older adults but is increasing in perimenopausal women

1. Subtypes

2. Weight less than 85% of expected weight; cachexia

3. Distorted self-image; appear fat to themselves even when emaciated

4. Intense fear of becoming fat, even though underweight

6. Usually very manipulative

7. Usually high achiever academically

8. Frequent discord in family relationships, especially with mother

9. Often interested in food and cooking in general; serves as a control strategy

10. Cessation of menses for more than 3 months in females (amenorrhea)

11. Inability to sustain self-starvation may result in bulimic episodes (bingeing of food followed by self-induced vomiting)

12. Fatigue or hyperactivity

13. Gastrointestinal (GI) disturbances (e.g., feeling of fullness after small intake, nausea, and constipation)

14. Hypotension; bradycardia

15. Fluid and electrolyte disturbances; dependent edema

16. Low blood glucose level

17. Anemia

18. Sensitivity to cold

19. Erosion of tooth enamel (if vomiting)

20. Lanugo (fine, brittle body hair); dry skin

1. Unified team approach

2. Behavior modification techniques that focus on client’s responsibility for weight gain

3. Time limit on meals; monitor client after meals

4. Use of enteral feedings if weight loss is so great or fluid and electrolyte imbalance is so severe that it causes a threat to life

5. Limit on excessive physical activity

6. Psychotherapy focusing on self-image

7. Group and cognitive therapy

8. Family therapy with all members of family involved

9. Gradual increase in calories and protein under guidance of nutritionist

10. Antidepressants are helpful especially with comorbid depression

1. Complete physical and dental examination to rule out associated medical complications of eating disorder; involved systems: central nervous system (CNS), renal, hematologic, GI, endocrine, cardiovascular, and integumentary

2. Weight and height

3. Signs of fluid and electrolyte imbalance

4. History of amenorrhea

5. Indulgence in excessive exercise

6. Behavior reflecting obsessiveness with food

7. History of stringent control of food intake

8. Depressive mood

9. Motivation to change maladaptive eating patterns

10. Heart rate and rhythm

1. See General Nursing Care of Clients with Eating Disorders

2. Develop a therapeutic environment

3. Establish a behavior modification program

4. Help client identify feelings

5. Briefly discuss dietary modification in a nonthreatening manner

6. Provide diet high in nutrient-dense foods

7. Avoid focusing on eating or weight loss

1. Maintains dietary intake adequate to meet daily caloric requirements

2. Reaches and maintains appropriate body weight

3. Develops realistic body image

4. Identifies and verbalizes feelings

5. Accepts age-appropriate role

6. Resolves separation and individuation issues

1. Most common in adolescent through 30-year-old population

2. More common in females but seen in males who need to maintain low weights (e.g., jockeys, wrestlers, gymnasts, ice skaters)

3. Obesity frequently found in parents or siblings

4. Predisposition to depression

5. Discord in family relationships

6. Obsession with food results from morbid fear of obesity and the pathologic need to binge

7. Purging is an attempt to regain control after binge eating

1. Subtypes

2. Compulsive eating binges characterized by rapid consumption of excessive amounts of high-caloric foods in brief periods; followed by induced purging (e.g., vomiting, enemas, laxatives, diuretics) in the purging subtype

3. Periods of severe dieting or fasting between binges

4. Sporadic vigorous exercising between binges

5. Weight may be within expected range with frequent fluctuations above or below expected range because of alternating binges and fasts

6. Lack of control over eating during episode

7. Depression and self-deprecating thoughts follow binges

8. Extroverted

9. Possible intermittent substance abuse

10. Very concerned with body image and appearance

11. Repeated attempts to control or lose weight

1. See Therapeutic interventions under Anorexia Nervosa, except for the use of an enteral feeding tube

2. Treatment of depression, which is the most frequently observed psychologic concomitant condition associated with bulimia

1. Behavior indicative of purging such as self-induced vomiting and use of enemas, laxatives, and/or diuretics

2. Obsession with excessive exercise

3. Pattern and duration of bingeing

4. Undue concern with body weight and shape

5. Physiologic changes such as dental caries, chipped teeth, enlarged parotid glands, calluses or scars on knuckles from induced vomiting

6. Signs of fluid and electrolyte imbalances

7. Weight and height

8. History of consuming tremendous amounts of calories in a short period of time

9. Symptoms of depression or obsessive-compulsive behaviors

10. Substance abuse (drug[s], pattern, duration)

1. See General Nursing Care of Clients with Eating Disorders

2. Provide a nonjudgmental, accepting environment

3. Set realistic limits; keep under close observation to prevent purging

4. Encourage verbalization of feelings

5. Help to identify feelings associated with bingeing and purging

6. Shift focus from food, eating, and exercise to emotional issues

7. Encourage journaling to identify situational and emotional triggers to bingeing

1. Limits dietary intake to caloric requirements

2. Reduces episodes of bingeing

3. Reduces episodes of purging

4. Identifies feelings

5. Verbalizes emotions and needs

6. Reports no depressive symptoms

7. Develops a healthy lifestyle balancing eating and exercise