4/14/2017. Female still primary, but there is a growing number of males. Peaks at ages and 17-18

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1 Identify those at risk or with an active eating disorder Stephanie Macon MS, RD, CD Carli Hill RD, CD Central Washington Hospital Correctly treat and set up appropriate referrals and follow up as outpatient, refer to higher level of care if appropriate Help avoid medical complications Help decrease readmission rates Highest mortality rate of any psychiatric diagnosis Female still primary, but there is a growing number of males Peaks at ages and Hx of DM type I, cystic fibrosis, mood/anxiety disorders, substance abuse, trauma, severe illness with weight loss Family Hx of obesity, mental disorders, substance abuse, eating disorders Refusal to maintain body weight at or above 85% Subtypes: restrictive or binge/purge Fatigue/weakness, infections Dysphagia Depression Abdominal pain, constipation, bloating/fullness with eating Dry skin, brittle hair/nails, lanugo hair, cold and cyanotic hands/feet, cold intolerance Hypothermia/hypotension/bradycardia Cardiac murmur Amenorrhea Erosion of dental enamel and dental caries 10-20% will die from cardiac arrest, suicide, starvation, or other medical complications 1

2 Recurrent episodes of binge eating & inappropriate compensatory behavior to prevent weight gain Palpitations, cardiac arrhythmias Acid reflux, dental erosion/caries, mouth ulcers, sore throat Salivary gland hypertrophy, swollen cheeks Constipation/diarrhea, abdominal bloating Edema Fatigue/weakness Calluses on back of hand 2 bingeing episodes per week NICE GUIDELINES Either the patient has one or more of the following: Body mass index (kg/m 2 ) <16 Unintentional weight loss >15% in the past three to six months Little or no nutritional intake for >10 days Low levels of potassium, phosphate, or magnesium before feeding Or the patient has two or more of the following: Body mass index <18.5 Unintentional weight loss >10% in the past three to six months Little or no nutritional intake for >5 days History of alcohol misuse or drugs, including insulin, chemotherapy, antacids, or diuretics 2

3 Start low and go slow method challenged. Underfeeding can lead to further weight loss, worse prognosis, possibly death in severely malnourished patients Start at kcal/day and increase by kcal every 2-3 days until goal is achieved Close medical monitoring of labs and vitals Weight gain of 2-4 lb/week is goal. Most patients require kcal/day to achieve consistent weight gain once past initial stages of refeeding Meals based on diabetic exchange. Helps to decrease focus on calories Set menu cycles developed for 1400, 1800, 2200, 2600, and 2900 calories. May need to provide higher calories if prolonged LOS. Usually three meals, three snacks Supplement with Boost Plus if unable to finish meal/snack to make up the calories 3

4 Lower sodium. Lower fiber if delayed gastric emptying Vegetarian ok, but no other restrictions unless for a documented medical reason. Allowed 3 dislikes 30-39kg Weight (KG) Total fluid at each meal/snack in oz (6x/day) 10 oz Caffeinated beverages limited. No gum 40-49kg 11 oz No sugar free, light, or low fat foods. No bad foods 50-59kg 12 oz Lower carbohydrate enteral formulas preferred initially. TPN avoided unless gut is not functioning 60kg+ 13 oz CMP+Mg+Phos CBC with auto diff Pre-albumin Ionized calcium TSH EKG Echo if BMI is <14 Urinalysis Bulimia Pseudo-Bartter s Syndrome chronic volume depletion from purging causes upregulation of aldosterone Prophylactic spironolactone 25-50mg daily for 1-2 weeks recommended to block action of aldosterone if at risk Aggressive volume resuscitation may lead to congestive heart failure or severe edema NS w/20kcl at 50mls/hr if purging 4

5 Anorexia NS at 25-50mls/hr for dehydration Aggressive D5 IVF administration may send anorexia patient into refeeding Hypoglycemia may use D5NS at 50mls/hr to maintain serum glucose above 70 Administer thiamine prior to giving dextrose to avoid precipitating Wernicke s encephalopathy Do not treat low BP with dextrose-containing fluids Spironolactone for bulimia. Lasix not recommended Laxative abuse: risk of cathartic colon. Cease all bowel meds, start on Miralax day one Reglan: start on Reglan 2.5mg prior to meals for anorexics for delayed gastric emptying/gastroparesis Unstable vital signs Bradycardia <30 bpm Bradycardia <40 bpm & hypotension Orthostatic increase in pulse (>20 bpm) or decrease in systolic BP (>20 bpm) or diastolic BP (>10 bpm) Hypothermia (<35 C or 95 F) Cardiac dysrhythmia Weight <70% of IBW or BMI <16 Marked dehydration Acute medical complications of malnutrition Moderate to severe refeeding syndrome: marked edema, serum phos <2mg/dL 1) Do you make yourself Sick because you feel uncomfortably full? 2) Do you worry you have lost Control over how much you eat? 3) Have you recently lost over One stone (14 pounds) in a three month period? 4) Do you believe yourself to be Fat when others say you are too thin? 5) Would you say Food dominates your life? Ask all patients years old in high risk groups One point for every yes answer Score of > 2 likely anorexia or bulimia 5

6 Supervised meals. Patients have 30 minutes to finish their meal. Otherwise receive supplementation with Boost Plus Watch for eating very slowly, cutting food into tiny pieces, picking at food, wiping food into napkin, hiding food No outside foods or beverages can be provided. Patients are not allowed to choose any of their food/fluids Calorie count, kept out of sight Blinded weights If patient refuses to eat, consider placing SBFT for enteral feeds Monitor for purging behaviors: Supervised bathroom visits - no bathroom for 1 hour postmeal Self-induced vomiting after meals Unnecessary movement, fidgeting to burn calories Exercising in room, especially at night Monitor for fluid overloading Closely monitor all intake and output and document Document if rigid rules surrounding food is observed, and for increased irritability around meals/snacks At CWH: Consult to dietitian Outpatient dietitian referral Case Management and Social Work to set up outpatient appointments SLP atrophied esophageal muscles can cause dysphagia MHP/Behavioral Medicine If someone is hospitalized for ED-associated health issues, they likely need admission to eating disorder facility Refer to specialized treatment program for assessment/intake 13 yr old male patient, I.V. Presented to CWH January 2015 with nausea, abdominal pain, weight loss of 65lbs since June Wt on admit 108lbs. IBW 142lbs. 76% of IBW Developed pubertal gynecomastia when overweight at 173lbs Bullied, began eating calories daily to lose weight High anxiety, depression, anger, mood swings Dx with anorexia nervosa and SMA syndrome 6

7 Calorie count during admit, patient supplemented with Boost for meals/snacks left unfinished Difficulty tolerating meals, but was up to 2400kcal by discharge after 11 days As outpatient, recommended DEXA scan, but not done Had low fasting glucose several times as outpatient. Also low BUN & creatinine Concern for persistent hypoglycemia, inability to gain weight discussed with MD Presented to ED after threats of self-harm Pt transferred to Children s Hospital in March 2015 I.V. failed to gain sufficient weight as outpatient via p.o. intake. Children s Hospital placed NJ tube for nocturnal feeds By May 2015, SMA resolved but tube remained in place because of continued poor po Mother caught patient turning off TF at night Complains of chronic constipation despite daily Miralax Strange food behaviors Flushing food in toilet observed Pt slowly improved with tube feeds, more supervision, home schooling with tutors, weekly therapy sessions Started playing soccer again with friends Restraining order placed against bully June 2015 NJ tube fell out and was not replaced. Wt was 124lbs at that time Improved mood, eating more variety of foods Highest wt 146lbs in June

8 Fast forward to March 2017 Admitted to hospital with bradycardia, orthostatic hypotension Wt down to 107.5lbs Transferred to Children s Hospital again, but mother & patient left AMA Re-admitted later in March, wt 105lbs, now 74% of IBW Other than low K, labs wnl Bradycardia, dizziness worse, continues to complain of chronic abdominal pain Eating Disorder Protocol initiated Nursing re-educated. Calorie counts, supervised meals Still noted to be flushing food on occasion when mother alone was supervising At first refused to eat unless family was present Feeding tube if pt is unable to finish Constipation still an issue Pt admitted for medical stabilization for a little over 2 weeks, up to 3300kcal daily Continued to lose weight 104lbs, but HR and BP improved Placement was difficult, finally able to place at inpatient treatment facility Developing nursing-specific protocol Identified nurse champion in charge of eating disorder protocol binder Developing handout for patients and parents to sign, explaining what to expect while inpatient Develop menus for higher calories Goal continues to be to medically stabilize until we are able to place patient at inpatient eating disorder facility 8

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