I am in desperate need of opinions as to what your priority in this case would be.

[dietsprite]

Hi,

I'm sorry for reposting this from the assitance forum, but no one is replying over there. And it's really important.

I am in desperate need of your opinions as to what your priority in this case would be. I have a hypothetical case study of an adolescent who comes into a school nurses office (I am the nurse) referred to by another teacher who is worried about her recent weight loss.

She is in denial as to the fact that she has a problem which is clearly anorexia nervosa (BMI below 18, loss of menstrual cycle, has lost significant weight recently, self perception of being overweight, etc). However, the client claims she is eating well and does not have a problem.

I have to create a comprehensive careplan with sever diagnoses (actual and risk). The two primary actual diagnoses I have chosen are Ineffective Denial and Imbalanced Nutrition: Less than Body Requirements. I am not including the entire diagnosis (3 part) for purposes of academic integrity - should you need more information, you may message me privately.

My question is whether I should intervene first with the client's denial of the situation instead of her nutritional status since this is an outpatient setting and she is not in immediate risk of death or serious harm. I believe that any interventions related to nutrition will be ineffective until I at least tackle the fact that there is denial of an underlying problem. Then, I can slowly educate her on nutrition and show her how her own symptoms correspond to a poor nutritional intake.

In conclusion, I have two questions:

1. Is it always necessary to address the goal of establishing nutritional balance before a goal lower on the hierarchy, or only if the status is severe?

2. In this particular case, would you address the client's denial prior to to addressing their nutrition? Or do you believe that it will not make a difference in terms of success?

[woman_king]

Is there a place on your care plan where you can include your rationale for prioritizing the Maslow physiological need lower? I'd think if your rationale is well-written and well-thought-out, your nursing instructors shouldn't have much of a problem with it.

I personally like the way you've thought about and prioritized the diagnoses.

[FLmomof5]

Maslow tells you that her nutritional imbalance is the highest priority. While it is true you cannot "cure" the situation without addressing her emotional deficit, the reality is that she is a risk for serious metabolic alterations that can result in terminal cardiac arrhythmias if her nutritional status is not corrected.Think about it this way, do you take a heroin addict's heroin away first or do you address his addiction first?

[dietsprite]

How would I realistically intervene on a nutritional level as a school nurse without having any prior sort of a relationship with her? In other words, I could provide information to her about diet and help her set nutrient goals, but realistically if she is in denial that a problem exists would she accept the interventions?

Any ideas on interventions that would work? I already included as an initial intervention, a family conference which would include referrals to professionals as part of the Ineffective Denial - due to the severity of the situation and her age (she is a minor).

Should I just move those interventions instead to Imbalanced Nutrition along with the educational sessions, keeping a diary of intake, and weighing her on a weekly basis?

Or do you think that if I contact the family and offer them professional referrals as part of Ineffective Denial, I can implement the teaching part of Imbalanced Nutrition later?

[FLmomof5]

Something you also need to consider....

Anorexia is a medical diagnosis that has not been made. You cannot make that diagnosis (even though it seems "obvious"). We only utilize a Nursing Diagnosis. Yes, you show objective data that points to anorexia, but that requires an MD to actually do that. What you *do* have is a student that appears to have an issue that appears to need intervention.

The true root of anorexia is control, not body image. If she is truly anorexic, a medical diagnosis will need to be made, treatment plan outlined and counseling begun. You, as a school nurse, can help monitor, but your job is not to fix.

I will point out something.....

I have a daughter that is 5'5" and 105 lbs at 17 yo. That is a 17.5 BMI. She eats like a horse (and her friends hate her for it! LOL). She was 115 lbs a couple of months ago. She lost 10 lbs.

Sounds like it could be your student, right? The difference? Her swimming training started up again. She had been fairly idle through the winter months.

She is not anorexic. My oldest was 5'2" and 97 lbs when she enlisted in the Army. Second (son) was 5'10" and 120 lbs. My middle child was 6'1" and 130! When my fourth graduated HS, she was 5'3" and 105. (soccer) I am 5'4" and until perimenopause, I was 110 in the summer, 115 in the winter.

If you had asked any of my kids if they were eating well, they would say yes. (My monthly grocery bill topped $240/week!) They wouldn't be in denial.

This is why we don't do medical diagnosis'. My children were "Constitutional Short Stature".

It also doesn't mean that teachers and schools didn't make referrals....they did. Trust me when I say....social workers are not my most favorite people!

[dietsprite]

Thanks for your insight about being quick to rush into making a medical diagnosis.

When we were given the case study in class, our teacher said she was what would be later would be diagnosed as someone suffering from Anorexia Nervosa, and I unfortunately forgot that while writing diagnoses at this stage (prior to making the referral) I cannot say secondary to: anorexia nervosa. I went back and changed it everywhere in the care plan. Kudos for reminding me that medical problems are for the doctors to diagnose.

However, the case of your children is a little different. I doubt that your children would say when interviewed that they "believe they need to continue to lose weight because they are still fat" and that their recent weight loss is due to a diet that they plan to continue because they are still fat - yet claim to eat well despite being on a diet that has produced drastic weight loss.

I also should have mentioned that the client showed visible signs of nutirient deficiency: skin and conjunctival sac pale, hair dull.

So this case is a clear one for referral and I am still going to vote for denial since a person who is underweight with a BMI of 17 who claims they are fat and need to lose weight and continue dieting yet eats well seems to be in denial in my opinion.

Your children on the other hand are like one of my best friends who eats like a horse and gets called anorexic by those who don't know that her metabolism and constitution are naturally just that way. However, she has never once told me I'm fat, I need to diet.

Thanks for your help. If you have more suggestions, let me know.

[dietsprite]

PS : If anyone else has an opinion, please share.

[jacksonvillelpn]

Ok, as my name tells all, I may not be in the right ball park here, but I did just pass nutrition this spring, and I've raised 2 teenagers, so here goes:

Since you can't officially diagnose as having anorexia, and you don't have an existing relationship with her, you need to establish some sort of ground you can work from. Since she's sure she's fat and insists on continuing to diet, could you suggest the use of supplements to improve her nutrition. They have no calories, but they would help address the dull hair and other symptoms of malnutrition. You could also suggest that she make an appointment with her family doctor to establish a "healthy diet plan". That would help to satisfy Maslow as well as put yourself in a positive light with the girl by being "on her side" and help you develop a caring relationship with her. Then go to her parents, discuss counseling, etc.