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EATING DISORDERS
(进食障碍)
Anorexia Nervosa神经性厌食症
Bulimia Nervosa 神经性贪食症
一、Introduction 概念简介
一项关于人们对自我形象（体形）的调查指出：
We are healthier than ever, fitter than ever, but less satisfiedwith how we look.
我们比以往更健康，身体更壮，但是我们却越来越不满意自己的外表。
据报道:
3-5% 女大学生服用泻药 purge, laxatives
56% 25-34岁的女性在节食 on diet
69% 的肥胖人群是由于暴饮暴食造成的binge eating
20% 的肥胖人群死于肥胖带来的疾病
（一） 神经性厌食症：
Anorexia nervosa is an illness ofstarvation related to a severe disturbance紊乱 of body image and amorbid fear of obesity; It is an eating disorder, usually seen inadolescence, when a person is under-weight and emaciated andrefuses to eat. It can result in death due to irreversiblemetabolic process.
是指人不满意自己的外表，惧怕长胖而拒绝正常进食，长期饥饿导致营养缺乏的一种进食障碍，常见于年轻女性，患者体重明显下降，消瘦，拒绝进食， 最终可因不可逆的代谢紊乱导致死亡。
注意：
l排除下丘脑进食中枢病变导致的食欲减退Not due tolack of appetite or problem with appetite center inhypothalamus.
l好发于青年女性：90-95%是女性adolescence
l严重的自我形象的紊乱severe disturbanceof body image
l没有确定的“瘦”的标准 no desiredweight
l惧怕长胖morbid fear ofobesity;
l否认、压抑、强制性的抵制-正常的胃的饥饿感Normalstomach hunger is repressed, denied, depersonalized; no consciousawareness of hunger sensation.
l10-20%神经性厌食症的患者死亡，其中50%死于自杀。Commit suicide
（二）神经性贪食症：
Bulimia nervosa is another type ofeating disorder (binge-purge syndrome) also encountered, primarilyamong older women and younger men.
神经性贪食症是另一种进食障碍，它是一种暴饮暴食狂泻的综合症状，在年轻女性多见，也见于男性。
The person is aware that the behavior is abnormal, fears theinability to stop eating, is self-critical, and may experiencedepression after each episode.
神经性贪食症的患者能够意识到自己的行为是不正常的，他们没有办法让自己停止进食，并因此而担忧、自责，许多人发作后都很沮丧。
The person may stop eating because of abdominal pain.
他们停下来进食可能是由于腹痛。
Repeat attempts are made to lose weight by fasting ordieting;
他们可能反复禁食或节食来减轻体重。
by abusing laxatives, enemas, or diuretics;
by self-induced vomiting;
也可能过量应用泻药、灌肠、利尿剂，或诱发呕吐等方法。
They decrease physical pain of abdominal distention may reducepost-binge anguish, and may provide a method ofself-control.这些方法也可以减轻暴饮暴食后的腹胀和腹痛，也可以减轻患者对暴饮暴食的自责，使患者有自制感。
Bulimia nervosa may develop into a chronic disorder and occurintermittently over several years. Bulimic episodes may occur aspart of anorexia nervosa, but these clients rarely becomeemaciated, and not all have a body-imagedisturbance.神经性贪食可以发展为慢性的进食障碍，或间接发作。神经性厌食症也可以使神经性贪食症的表现之一，但是谭氏症的患者很少表现为消瘦，没有自我形象的紊乱。
二、对神经性厌食症患者的护理评估
（心理、行为、生理三个方面的异常表现）
心理方面：
1、自我形象评价紊乱Body-image disturbance
产生错觉---幻想症delusional
强迫性思维obsessive
e.g., does not see self as thin and is bewildered by others’concern，
2、过分关注食物preoccupied with food
回避食物avoids food
藏觅食物hoards.储藏food
3、担心怀孕Pregnancy fears
错误地认为进食会导致怀孕misconceptions of oral impregnation through food
4、身体感觉迟钝Feels ineffectual
性欲降低low sex drive
批判与性有关的事情Repudiation.批判of sexuality.
5、有自我惩罚的心理和行为Self-punitive behavior
饥饿、压抑自己starvation; suppression of anger.
行为方面：
1、过分关注体重 over concern about weight
计算进食的热量 counting Cal of food
每天称多次体重 weighing oneself several times daily
在意他人的评价 concern about other’s words
在意 外表 personal appearance
frequent mirror gazing; fear unattractiveness, fear obesity
2、进食习惯改变 Loss of appetite
Eat less than one supposed to have
Absent in mealtime
Eat very slowly
Give food to others
Hoard food
Refuse to eat
3、通过各种方式减肥
患者可尝试多种减轻体重的方式：
诱发呕吐induced vomiting
服用泻药 laxatives
灌肠 enemas
利尿剂 diuretic
减肥药 diet pills
过度锻炼 excessive exercise/ hyperactivity (excessive gumchewing)
暴饮暴食狂泻 binge- purge
绝食 refuse to eat
生理变化
1、体重降低 短时间内比以前正常体重下降20%
2、皮肤干燥dry skin，过度角化hyperkeratosis，干瘪 poor turgor浮肿
3、毛发脱落，易折 brittle hair, fall out
4、便秘 constipation
5、月经不调或闭经，第二性征萎缩
Menstrual irregularity; Amenorrhea; second sex organ atrophy
6、低血压、心率，体温 hypotention, bradycardia, hypothermia
7、血液学检查 Blood examinations
白细胞减少Leukopenia
贫血 anemia
低血糖 hypoglycemia
低蛋白hypoproteinemia
低血钾 hypokalemia
低血钠 hyponatremia
低血镁 magnesium
8、ECG：
低电 low voltage
T倒置 T wave inversion
ST压低 ST depression
三、护理诊断
1、营养改变Altered nutrition, ,and
低于机体需求less than body requirements
体液不足fluid volume deficit
与诱发呕吐、过量使用泻药、利尿剂、绝食有关。related to attempts to vomit food aftereating, overuse of laxatives/diuretics and refusal to eat.
2、有生理规律改变的危险/有体液不足的危险Risk foraltered physical regulation processes/risk for or actual fluidvolume deficit:
饥饿导致闭经amenorrhea related to starvation;
与低血压、心率慢、代谢性硷中毒有关hypotension, bradycardia; metabolicalkalosis.
3、有自我伤害的危险Risk forself-inflicted injury
与拒绝进食和对食物的看法有关related to starvation from refusal to eat orambivalence about food
4、饮食（形态）改变Altered eating
与有暴饮暴食狂泻有关related to altered thought processes: binge-purgesyndrome.
5、自我形象紊乱/长期自卑Body-imagedisturbance/chronic low self-esteem
对成熟性别形象的焦虑related to anxiety over assuming an adult role andconcern with sexual identity
依赖感未得到满足unmet dependency needs
个性脆弱personal vulnerability
对生活的某些方面缺少信心perceived loss of control in some aspect or life;
家庭不完善dysfunctional family system
6、强迫行为Compulsivebehaviors
有想要控制自己的需要related to need to maintain control of self, representedby losing weight.
四、护理计划及实施
A、帮助患者建立条件反射
即建立饥饿和进食之间的反射
采用条件反射的饮食疗法
Help reestablish connections between body sensation(hunger) andresponses(eating). Use stimulus-response conditioning methods toset up eating regimen.
1、Weigh regularly, at same time and with same amount of clothing,with back to scale.定期测体重（在同一时间穿着同样的衣服，面对着称）
2、Make sure water drinking is avoided before weighing称重前不能饮水
3、Give one-to-one supervision during and 30 min after mealtimes toprevent
attempts to vomit food.进食过程中，和30分钟内进行一对一监督防止呕吐
4、Monitor exercise program and set limits in physicalactivity.监测患者的锻炼计划，限制运动量
B、监测症状、体征Monitor physiologicalsigns and symptoms
(amenorrhea, constipation, hypoproteinemia, hypoglycemia, anemia,eroded tooth enamel, inflamed buccal cavity, brittle hails, dullhair, secondary sexual organ atrophy, hypothermia, hypotension, legcramps and other signs ofhypokalemia)月经、便秘、低血压、贫血、龋齿、口腔溃疡，头发有，低体温、低血压、痉孪等低血钾的症状。
C、健康教育Health teaching:
l解释正常的性别发育Explain normal sexualgrowth and development to improve knowledge deficit and confrontsexual fears.
l应用行为疗法建立起饥饿与时间及进食的规律Usebehavior modification to reestablish awareness of hunger sensationand to relate it to the clock and regular meal times.
l教育家长与患者的问题方法，满足其依赖或独立的心理需求，让病人关注节食、减肥以外的方面自我调节（日常生活、工作、休闲等）Teachparents skills in communication related to dependence/independenceneeds of adolescent; allow patient to assume control in areas otherthan dieting, weight loss (e.g., management of daily activities,work, leisure choices).
临床护理中，面对患者时须注意的几点：
The nurse plays an important role in the care of individuals witheating disorders. The nurse needs to adjust 调节readily to moodswings 情绪波动and changes of behavior.
lBeing friendly and casual ifthe patient is withdrawn性格内向 or sullen闷闷不乐(not happy, little bitanger，);
lRemaining uninvolved when thepatient is indecisive or ambivalent;
lAvoiding confrontation whenthe patient exhibits hostility反对，反抗 or anger;
lStating that eating 3nutritional meals a day is necessary to maintain a healthybody;
lAvoiding long discussions orexplanations about food or the body; 注意力
lAllowing the patient tomaintain some control, eg in decision making.
五、护理效果评价标准
A、达到维持与身高、年龄相应的最低体重
Attains and maintains minimal normal weight for age andheight.
B、饮食规律（符合营养标准的）
Eats regular meal (standard nutritional diet).
C、无自己诱导呕吐、贪食及强迫行为发生
No incidence of self-induced vomiting, bulimia, or compulsivephysical activity.
D、自我内心情绪意识增强，能够承饥饿（自诉自己饿，饿得心慌、痛）等
Acts on increased internal emotional awareness and recognition ofbody sensation of hunger (i.e., talks about being hungry andfeeling hunger pangs).
E、叙述不断增强的“不去控制食物摄入的”感觉
Relates increased sense of effectiveness with less need to controlfood intake.
