COLLABORATIVE

Patients with bulimia generally do not need hospitalization unless they experience severe electrolyte imbalance, dehydration, or rectal bleeding. The bulimia is usually managed with individual behavioral and group therapy, family education and therapy, medication, and nutritional counseling. Work with the interdisciplinary team to coordinate efforts and refer the patient to the physician to evaluate the need for antidepressants and anti-anxiety medication.

Work with the patient to evaluate the effectiveness of antidepressant or anti-anxiety medications as well as to explore ways to identify situations that precede depression and anxiety. Work with the dietitian to ensure that the patient is educated about appropriate nutrition and dietary intake. Encourage the patient to participate in individual, family, and group sessions to help the patient develop ways to express feelings, handle anger, enhance self-esteem, explore career choices, and develop sexual identity and assertiveness skills.

Pharmacologic Highlights

Medication or Drug Class	Dosage	Description	Rationale
Potassium supplements	20–40 mEq PO	Electrolyte replacement	Replace potassium lost through vomiting

Other Drugs: Some experts recommend the use of monoamine oxidase inhibitors (tranylcypromine sulfate, phenelzine sulfate). Drugs that facilitate serotonergic neurotransmission such as fluoxetine, sertraline hydrochloride, and paroxetine may be used. Other drugs may be used such as tricyclic antidepressants, nortriptyline hydrochloride, or desipramine hydrochloride.

INDEPENDENT

Teach the patient to choose correct portion sizes. Encourage the patient to eat slowly and avoid performing other activities such as reading or watching television while eating. Most patients are encouraged not to use diet foods or drinks until a stable body weight is established. Encourage the patient to eat a low-sodium diet to prevent fluid retention. Fluid retention is common until the body readjusts its fluid balance; the patient may need support if she or he experiences edema of the fingers, ankles, and face. As he or she begins to eat and drink normally, support the patient if he or she becomes upset about weight gain and reassure the patient that the weight gain and swelling are temporary. Also encourage the patient to establish a normal exercise routine but to avoid extremes.

The goals of nursing interventions are to enhance self-esteem, facilitate growth in independence, manage separation from the family, develop sexual identity, and make career choices. Explore ways for the patient to identify and express feelings, manage anger and stress, develop assertive communication skills, and control impulses or delay gratification. Help the patient learn ways other than binging and purging to cope with feelings of anxiety and depression. Explore ways to reduce the patient's vomiting, laxative, and diuretic abuse. Some patients respond well to contracting or behavioral management to reduce these behaviors. Educate the family about appropriate nutrition. Explore ways the family can manage conflict, and support the patient's move toward independence.