All righty, folks. Thanks for popping in. Um, I had intended to post this link uh during class earlier this week, but I totally forgot. Um, I'm going out of town this weekend, so uh I'll try to look at some emails, but Monday I'll be back for sure and I'll be kind of catching back up. Grades are entered. Uh but for now, let's uh talk about tutoring. So, does anyone have um any questions? Any burning questions about the content from this past? I have a question. Yeah, sorry. Go ahead. I have a question. Can you explain to me um I know they're very similar um eating disorders, the bulimia um nervosa and the nurexa nervosa. Um, but what is like the I know one of them is like they look normal and then they vomit like they make themselves vomit and but what is the main reason to be the first sentence the first part you said of you know the main thing is blah blah blah that was it. So sorry can you tell me the difference between the anor anorexia nervosa and the bulimia nervosa? Yeah. Yeah. Is it both of them just fear of gaining weight? No no no. So I'm going to that's so that's what I was telling you was that what you said you actually said it and the main difference is that anorexia comes with that cachexic look or the kachetic look versus bulimia has a relatively normal BMI if not a higher BMI. Okay. And they're both just because of fear of gaining weight, right? Yeah. So the nervosa part has to do with body dysmorphia. So like they think that their value comes from like their I guess attractive value comes from um how they look physically from weight gain. Um it could be it could be rooted in like oh I if I don't eat healthy then like I'm going to be sick and yeah gain weight or yeah not be pretty things like that. Um and then anorexia nervosa is specifically the skinny like a low BMI and then bulimia nervosa is a normal to elevated BMI. Okay. Thank you. Yes. Professor, but with bulimia they also with bulimia they purge, right? But not with anorexia. No, they can both purge. They can both purge. Correct. It's just that anorexia exactly as it is anorexic. You look anorexic, you look ketic is this. But bulimia, that's why it goes unnoticed for so long because this is not the case for those with bulimia. It has everything to do with BMI. Um, and honestly, I don't think our slides even discussed like what a normal BMI looks like or like what the range is. Let's say if I look it up real quick just to provide reference. Um nervosia BMI. So I guess there's like kind of mild, moderate, and severe for thinness related to I mean again anorexia. So anorexia you can just be anorexic and that's it. And that could be for any reason. That could be because of like malnutrition. um like say you're being starved by your caregivers or you're in like a a food poverty type situation. But if you have anorexia nervosa that is related to the body image, body dysmorphia, restricting your food on purpose. So um something that was emphasized I realized in last term but not this one but to add maybe some more context is that um anorexia nervosa and bulimia nervosa these eating disorders are more common in like first world countries um because anorexia is more common in like developing countries where there is a lack of food and there is a lack of nutrition and there's more disease right but in in the United States for example that's not the case as much it's more like choosing to be this way because of body image issues where in a first world country in a capitalistic society skinniness and thinness is like valued. Um, but the BMI uh looks like let's see I guess like 17 but a BMI of like 17 is like the minimum for like a mild and I mean you don't need to know these different you know levels of BMI but I mean if you kind of look it up yourself and see the difference in BMI of someone with anorexia or what would be kind of the cut off for that versus, you know, a normal BMI versus anorexic, then yeah. So anyway, it all boil it all boils down to BMI between the difference. Does that make sense? Yes. Okay. Any other questions? That was a good question. All right, let's see if um if you have anything just let me know obviously and we if things come up as we chat a bit. But um just to reiterate some of the content here um again eating disorders are disruptions and normal eating patterns. So like disordered eating uh and you can have disordered eating alone and if it leads to kind of like physical abnormalities and illnesses like in the way it does with anorexia and bulimia then it's it's a whole it's a full-blown disorder you know to the point where you're not able to retain nutrients and um your vital signs are changing things like that. Um it typically involves anxiety around eating, right? So that kind of goes back to the original question of what exactly you know is it they both have issues with eating and stuff like that. So the nervosa part is what makes it anxiety around eating. So, it could be maybe like people it could be different things like people will feel self-conscious about eating in public or eating at all or it could be like being bullied because people I mean there's always situations where parents are like you shouldn't eat that much, you need to maintain a look or something like that. But obviously a lot of it also surrounds um people's careers like uh especially if they're in physically performing careers, right? to like like athletes, dancers, models, even influencers. Now those kind of performing, physically performing careers or hobbies um can contribute to eating disorders, anxiety around eating because the eating can make them feel like they're gaining weight or maybe it might actually contribute to it and they need to make a certain weight for their sport. Um things like that. And then body dysmorphia, which is this part, altered perception of body shape and weight. So that, you know, the doctor and their friends could tell them, "Dude, like you're, you know, you're you look fine, you look great, like why are you so worried or why are you restricting your food and things like that, but no matter what, this person will look in the mirror and just really genuinely think that they could lose more weight or that it's not enough or something like that, which is body dysmorphia." um more on those just distortions which is what this was. This was a cognitive distortion right here. Um and these are kind of like concepts within that. So just kind of different things the manifestations that come out of eating disorders. Um and the definitions of each of those. So I mean again overgeneralization all or nothing and catastrophizing. They're all pretty much the same definition, but it's like overgeneralizing is kind of when a single event can like like someone with an eating disorder specifically. I mean, this can go for anything. Any mental disorder or any anxiety related situation can make anyone think this for anything, but it's common especially for eating disorders. Um, and it's basically that related to food specifically. So, a single event affects unrelated situations. Meaning, oh, I ate I had like half of a donut last week and now I've I've gained a pound since then and now I'm I'm overweight again or something like that. So, like how eating half a donut is not going to make you gain a pound first of all and it's also not going to make you gain weight like that, you know? So, that's overgeneralization, disordered thinking related to food. uh all or nothing. So, um cat like basically catastrophizing. So, like maybe this person has an eating disorder and they have like really restrictive I mean this isn't I mean this doesn't have to be related to an eating disorder but maybe disordered eating and disordered thinking related to food. So, um, someone's on a diet maybe and they're on a healthy diet and then suddenly um, yeah, they kind of maybe they're on their period and they cra they caved and they wanted to have something sweet, which you know, everyone deserves that uh, so she had a slice and now she's like, "Wow, my entire diet is failed. I'm a failure. I might as well just eat the whole cake at this point because forget it. Like I screwed up all these things, right?" So all or nothing thinking, you can call it splitting and uh those with eating disorders often have personality disorders and vice versa too. So I mean that kind of goes hand in hand. And then catastrophizing. So consequences are magnified. Oh, I gained a pound over the last week. I never going to lose weight. I'm no one's going to love me. I might as well just forget about it, you know, etc., etc. uh and then taking things personal from other situations. So like in this example, I mean in this example, the parents are fighting and now this kid is blaming herself, right? So in regards to like eating disorders, I mean folks may develop an eating disorder because they think, "Oh, it's my fault that my boyfriend broke up with me because probably because he thinks I'm fat and now I'm just going to starve myself." That's a common one. uh you know taking things personally in that regard um sort of like having an illogical perspective on things like that. There's different reasons that can contribute to disordered eating. Uh emotional reasoning as well. Um this is again this is all just rooted in anxiety um and maybe some like persona disordered personality that could cause like disordered eating or disordered relationships with food. But I wouldn't say that you need to know these in any detail. Just kind of maybe the definition like emotional reasoning is this. That's all. You don't need to really be able to like apply it or anything like that. um different causes of eating disorder. So definitely peer pressure and culture some cultures uh prefer maybe heaviness and so that might lead to disordered like binge eating and then that could be a thing. So but obviously the major one especially again in the western capitalist society it's thinness that's valued and therefore uh we have the the purging and the restricting. Uh stressful life transitions can also cause this. So, you know, I think we've all maybe experienced a time or two when we've lost our appetite or had a heavier appetite than normal for foods that we wouldn't normally eat in excess um in response to stress or to relieve stress. And then maybe the the more that we're continuously exposed to stress in life can lead to worsening of these dietary symptoms, therefore leading to an eating disorder. Could be medications as well. So those on stimulants, those stimulants can lead to eating disorders. Drugs, drug use can lead to eating disorders, things like that. Comorbid anxiety disorder. Okay. So anxiety as a disorder does not cause eating disorders and eating disorders do not cause a diagnosis of anxiety. They coexist. Someone with an anxiety disorder most likely will have or develop one. um or they often co-occur and vice versa. Um participation in activity requiring thinness. So again, that's our our athletes, our ballerinas, our dancers, our models, influencers too, especially trauma of course can change our relationship with food in a lot of different ways, appetite wise and other other ways. Um yeah, and then family issues of course and definitely neurobiological neuroendocrine. So like thyroid, thyroid is always going to cause things like this. Um if it's hyper or hypo, hyper is going to cause like decreased appetite and just weight loss in general. So even if the person's not trying to not eat, but they have hyperyroid, they could become ketic, right? That could just be anorexia. But again, if they're restricting food on purpose because they're worried about looking fat or feeling fat, then that is anorexia nervosa. Um, so yeah. Uh, depression also cause eating what's that? And depression also cause eating disorders. Yep. Anything that can alter basically your appetite. Um, so honestly, yeah, that could be we can add that in here as like a separate. So we could say like altered appetite, which can be related to depression, can be related to trauma, be related to drugs, um, stress. Um yeah, for the most part. So yes, does that answer your question? Yes. Perfect. And then so of course if especially when it comes to anorexia nervosa because of the significant weight loss and the decrease in BMI um all of that can lead to like muscle wasting protein loss um which can like lower just the body's ability to produce and push blood throughout the body. um which can therefore lead to respiratory oxygenation issues, things like that and um potential vomiting and just poor diet in general can lead to electrolyte imbalances, all kinds of issues. So of course at some point anorexia nervosa needs to be stabilized. Um and again depending on how much someone vomits and bulimia, it can also lead to hospitalization. They it might not be kachetic cachexia related like muscle wasting and loss but it could be more so related to like electrolyte imbalances and dehydration right from the vomiting but um but here because the the BMI is significantly decreased that's when we're really seeing lots of lots of lots of lots of issues. So hospital admission criteria for the need for stabilization is discovered when a patient loses 30% of their original weight loss from 6 months ago. So over the course of six months if they've lost 30% of their weight, that's going to be significant um because that could be something that someone could never really recover from on their own or from an outpatient. They need to be stabilized in an urgent eent setting. Um cuz again, if they're being treated in the outpatient setting and they're just not able they're just not able to gain any weight, then that's problematic. then clearly something is up and they're not either compliant with the the treatment regimen or maybe their body is like so far gone that it's just unable to maintain the proper amount of weight and protein without like having a true maybe like without it being like TPN for example to total parental nutrition uh through the IV maybe like direct farm tot if you will um severe hypothermia from that extreme weight loss which is going to lead to lenugo, right? Lenugo development. That's that uh extra peach fuzz hair growth all over the body as the body's way of trying to maintain warmth. Uh heart rate below 40 is going to lead to that. Um systolic blood pressure of less than 70 is going to be concerning and need for hospital admission. Potassium below three because that could lead to some severe cardiac issues that no outpatient clinic can manage. that's might lead to like an emergent cardiac situation. And of course, just EKG changes in general. So, it doesn't have to be all of these at once, right? I mean, all these at once is scary. But really, any one of these, I would say, would warrant that. Um, that's from a medical perspective, right? And medical always trumps psych when it comes to this stuff because you you can't teach anxiety reduction techniques to someone who's barely awake, right? Um hospital admission criteria from a psychiatric perspective. Of course, suicidality, harm of any kind. Um again, I think I mentioned this in class. You know, this isn't necessary, you know, for admission. I guess it depends on how much they're using of these things, how bad it's affecting them. Um because again, these can result in those same changes here and fairly adhere to treatment which is probably seen here, right? So these will lead to the medical stuff anyway, severe depression, even psychosis. So you could become so sick and thin and delirious, right, from the electrolyte imbalances. I mean, low sodium, for example, you immediately kind of start getting confused and delirious and hallucinating and stuff. And I honestly don't even know what that means, so I'm going to delete it. Um, anorexia nervosa. So again, it has everything to do with cachexia and like uh BM well BMI because you can still have a low BMI and not be kachetic per se, but it all has to do with the low BMI. So anorexia nervosa, terrified of gaining weight, always view self as fat no matter what. So just kind of um again those cognitive distortions. They are often found to have like a rigorous exercise regimen and or self-induced vomiting or excessive laxative use. And again, excess laxative use. Just because someone uses laxatives or diuretics is not a problem. It's when you are using it so so so much abnormally way beyond what is recommended. Um, and no person should be using a laxative every single day. I mean, we give a laxative to folks in the hospital because when you're hospitalized and laying down, your gut just significantly slows down. And so we give it as a means of keeping the gut moving. But no regular person, unless they have direction from a physician to do so, should be taking more than one laxative a day. But these folks will take like many, many, many pills of laxatives in a single day or multiple times a day just to keep things out and moving and not ingest or not um absorb any of the fat or anything like that. Um, same with diuretics. I remember when I was in nursing school or no, when was it? When did I learn about this? I I was like starting my It wasn't nursing school. It was um I was in like an undergrad health program and I was learning about this and I on the in the summers I worked at Target and I'll never forget this woman purchased she had like 20 30 boxes of lac laxative that she purchased and that was the only thing that she had gotten. I remember thinking, damn, like this person must have an eating disorder or something like that. It's just it's just not a thing. Um, also there's this preoccupation with food. And I highlighted this and underlined it because um it's definitely something you need to know, but also because this is the one that maybe can be a bit confusing. Like why would you be preoccupied with food if you're scared of gaining weight? And this picture I think summarizes it really well. It's just like preoccupied in the sense that um these people might be like meticulously meticulously counting their calories, meticulously weighing their food uh meticulously reading and obsess obsessing over ingredients and nutrition facts and um serving sizes and and things like that to the point where it's like causing a lot of stress and anxiety. Some of these people might also even be obsessed with like recipes in a way that's a little confusing. Like maybe obsessed with like finding the right recipe that meets all of these different criteria that's going to like make them full but like not make them gain weight but then also be easier to digest or maybe even easier to throw up, things like that. Um, so you might find that these people are preoccupied with food in a lot of different ways that you would not think. But I kind of forgot to bring this up in class. This is something I brought up last term that I thought maybe was helpful to kind of help you understand this a little bit better. Um, well actually I'll bring that up here in a second when I talk about these other few concepts, but so hold that thought. um handles food peculiar peculiarly preoccupied with food. Um higher prevalence than those who perform physically for a living. Not just you know you can perform as a singer and maybe not necessarily like physical performance. Okay. Um and then other things which why isn't it in here so something else that I forgot to mention is that um those with anorexia nervosa tend to also wear baggy clothes. instead of like form fitting clothes. So although these folks are terrified of gaining weight and are terrified of being or looking overweight even when they're not, they will still hide their body anyway. Um, this could be because again they still think that they're they look obese and so they don't want to um show off their body in any way, but they also maybe subconsciously are aware of how they look like how kachetic they look and they don't want and you know people probably already tell them all the time, oh my gosh, you're so skinny like why do you know you need to eat and to get help or whatever and they know that their physical appearance is contributing to that. So they will also wear baggy clothes I think subconsciously because they understand that that they do kind of look like this to others maybe in a way and they just don't want the attention in that respect. So keep that in mind too that they'll wear uh the baggy clothes. And so with that being said, um I mean for those of you on Instagram, there is a girl I follow. Um her name is her her Instagram is called Half Baked Harvest and um she makes really really really amazing recipes and posts them and she's super famous on Instagram now. I actually went to high school with her and um you can kind of scroll through her stuff. She's obviously obsessed with food. She makes really delicious like pretty much like America like truly like European American dishes. But if you take a look at her specifically, you will find that she pretty much fits this this ticket right here, this bill. And I'm I'm fairly certain she's struggling unfortunately. But um she's very very very thin. You can see the gauntness and the cachexia like in her face. There are some spots where you can see like some hairiness. I'm not sure. But um and what else? She wears baggy clothes a lot which goes with that. And then she's I mean her whole thing is she's an influencer who makes food. So she's just a great way unfortunately. I mean I I do suggest following her. Her recipes are great. But um it's a she's kind of like a perfect example of all this to like tie that all together. Um anyway, moving forward. Uh so yeah, anorexia nervosa is going to come with poor circulation. So that could look like what? Low heart rate, right? Low blood pressure. Um it could look like low oxygenation too, right? So it's all in the same realm. Um menstrual disturbances of course. So with that low protein, low low fat, um the body's not going to feel comfortable becoming pregnant and uh harboring and producing like a child. So uh the the period will stop or if they're if they're young and they've never had a period yet, it may never come until they fix their BMI. um all these other things palar palenness right palpitations fainting dizziness all these things cachexia again the lenugo is the hair so don't forget these images with anorexia nervosa so for anorexia nervosa specifically um we really want oh and I don't I mean I'm sure this is a given but lack of energy too low energy especially with the fainting and the dizziness and the poor circulation, right? Just making sure you guys understand that. Um, but uh, vital signs too. Sorry, I keep coming back to this. Um, let me just add it in here. So, low energy should be a given. Um, overall there's going to be low vital signs, but I will say some vital signs can be elevated or fluctuating. I'll say fluctuating maybe like specifically heart rate and respiratory rate because those things are going to be the ones that are going to um comp try to compensate for like a low blood pressure or poor oxygenation from the low blood pressure. respiratory rate might increase to compensate for that or heart rate might increase to compensate for those same things. Right? So that's again application based should already know this based on how the body works but I wanted to re-emphasize that and um so that with that being said that leads us to kind of like the outcomes that we are looking for right and that is um in general just an we want to see an increase in body weight while they're hospitalized especially the first the very beginning of their hospitalization. So increase in body weight Um also we want to see normal labs. So labs that are within normal range. We want to see of course um ultimately normal vital signs. Just so within exactly what normal range is. So make sure you know your normals for your vitals. And that's going to be really important just for pretty much everything that we learn moving forward. Um and for the rest of your the rest of your classes. Um and then uh of course normal diagnostics, right? So like uh we talked about how there's EKG changes associated with the electrolyte imbalances. So making sure that that's coming back normal as well. That's what we want to see for anorexia nervosa specifically. Um, and other things we want to do is of course we want to weigh the patient regularly depending on what the orders are, usually daily because if someone is really kachetic and really skinny, um, they're going to probably be gaining weight almost every day if they're being fed properly in the hospital. And then of course if it's I mean bulimia related, well actually well it doesn't matter both of them. Both of them we want to observe patients while they eat. If it's bulimia nervosa, which we're going to talk about, if bulimia nervosa, monitor for monitor after, long story short, um, we want to observe the anorexic patient while they eat because we want to make sure they're not pocketing food, that they're not throwing any food away, things like that. Um, actually, sorry, really, you should be monitoring afterward. I don't know why they wrote it like this. you should be monitoring after for both because they both can result in vomiting. Um I just think that bulimia nervosa results in more frequent choice of vomiting because they're still going to be binge eating, right? Uh but in anorexia they're more often restricting. That's why we want to monitor during as well. Um we want to give them structure around eating. Get a nutrition nutritionist involved. U monitor of course for all the different things stabilize and of course therapy is going to be really important. Medications are good as well specifically prozac and zyprea are going to be good for those for anorexia. Now, bulimia nervosa characterized as a normal to somewhat elevated BMI because of the binging because of the binging and um there's not really you you can technically restrict. Yeah, it's just I mean there's it's more you're more likely to be binging in bulimia. Let's just say that you're more likely to be binging in bulimia nervosa, hence the BMI. But that's what characterizes it as bulimia nervosa is the normal BMI. But more things that are more related to bulimia again the binge eating. So that's basically the shoveling of large amounts of like high caloric, highfat foods. Typically hiding that from friends and family. So like taking food and like going into your room or the bathroom and like you know just shoving um eating lots of food very fast too. Um and then typically followed by that compensatory behavior, the purging, excess uh exercise, laxatives, diuretics, things like that. Oftentimes they can have a history of anorexia nervosa. The binging will occur after or um I'm not even going to mention this. It's just going to confuse you guys. I'll just cross it out and leave it. But um sometimes these folks can fast. Again, it's kind of confusing because there's a lot of overlap between anorexia nervosa and bulimia nervosa. The real difference is the BMI because of the higher likelihood of engaging in this in the binging. Anyway, comorbid with depression, anxiety, compulsive behaviors with the shoveling of the food. Other issues per usual. Um, other things to keep in mind, binging and purging, these acts don't necessarily create any emotional high for the patient. It's not like they're getting a fix of any kind. Both of these actually cause like a significant amount of distress for the patient. Um, so, you know, these folks could be just really upset, depressed, crying while they binge insane with the purging. Um, but it's just something they feel like they have to do. Have to do. It's compulsive behavior. Um, and then of course again, bulimia can go undetected for a very, very, very long time because of that normal BMI. And I'm honestly shocked that it wasn't on this. I don't know if it's on a different slide, but I'm just going to add it. Typically normal BMI. Normal or elevated BMI. Yeah. Okay. And again the parotted glands can um become compromised because the excess vomiting just the parotted glands uh going going into overdrive and saliva production and acid exposure dental erosion because the acid exposure again at or above ideal body weight so normal or elevated BMI with bulimia nervosa again we want to medically stabilize just because they're not anorexic or kaetic doesn't mean they might not need medical stabilization. The excess vomiting, the excess uh laxative and diuretic use can still cause medical destabilization. We want everything else to look normal as well. Labs, EKGs, you know, diagnostics. We want to assess whatever meds that they're on or using a full psyche evalu they could be having hallucinations that are telling them to do that, too. So um again psychiatric lots of different comorbid psychiatric conditions and of course a suicide risk is could always be at play. Same thing same thing. So again regular weight uh weight evaluations we want to observe the patient while they eat and after for the for that compensatory behavior the purging specifically. I think this goes for uh anorexia as well, but the main difference is that BMI uh and a lot of the low body weight problems as well, the low heart rate, the low uh blood pressure, the you know, all those things. So, kind of like the hospital admission criteria, it's a lot more associated with anorexia nervosa than anything else. And therapy is always going to help. Prozac again is going to help as well from a psychiatric standpoint. Now, binge eating disorder, remember? Oh, any questions about what we just what I just talked about. Um, and then let's see, let me look at something real quick. Um, okay. Um, something else I wanted to emphasize going back to this like physical exam lab findings for both anorexia and uh, bulimia nervosa is that just like when it comes to the medical stabilization piece of all this, I emphasized this in the past, but I'm going to emphasize it again. Do not forget about how you were to prioritize a patient, how you're going to prioritize medical stabilization. A B C's airway, breathing, circulation in that order too. Okay, so circulation that's associated with blood pressure, low blood pressure, right? Breathing that's going to be like lung function of course still, but that's also oxygenation. So if someone's O2 is low, right, we need to address that for sure. Um, if it's low while on oxygen, that's problematic, right? Like, so think regular meds surge still in this setting. Just because there's stuff in the question about bulimia and anorexia and this that and the other thing, don't forget that you're a med surge nurse at the end of the day with psych capabilities and with a psych priority as well. Airway, breathing, circulation for your medical stuff. Um, okay. Anyway, um, other things with eating disorders that I wanted to mention, I'm just going to maybe add them to this slide here. Just want to make sure that all this stuff is emphasized appropriately for your understanding of the content. Um, so going back to the excess laxative use, the excess diuretic use on top of being medically unstable, there's going to be some issues with our organs. All right, we talked about the parotted gland of course. Um, but there's another major organ based off what I just said that can be impacted significantly. Can you guys think of what that organ is? Based on what I just talked about, what's a big organ that could be impacted from everything that we just talked about? Low blood pressure, diuretics, laxatives, your heart. Yes, the heart. Absolutely. So, EKGs, right? We're worried about that. We're worried about long-term issues of the heart. What else? Kidneys. What' you say? Kidneys. Yes, absolutely. Thank you. Kidneys. So, um we want to check out kidney function, right? Low blood pressure, uh you know, low filtration can lead to kidney issues. Low dehydration can lead to kidney issues, right? If you have excess salt or not enough salt, right? Sodium, things like that. Um diuretic use, so overdriv the kidneys. um the laxatives, anything that you're taking that the kidneys have to like process out. Um so we want to look at kidney function in in these situations. We want to know, we need to remember what kind of labs are associated with that. Do we remember bun kryton? What was the first one? B I I I can't hear you. Can you hear me now? Yeah, a little bit. Just so it sounds a little muffled. Bun. Bun. Okay. And then what else? Creatin. Mhm. Creatinine. Okay. So, these are our kidney labs. Our classic kidney labs. B1 and creatinate. um you know, you don't need to know the normals, but you need to just know that these are our kidney labs and that our kidneys are, you know, impacted significantly in situations like these because of those reasons that we just discussed. Um yeah, so just keep that in mind as well. I think that's that's something I missed in kind of emphasizing and I definitely want you to know that again the electrolyte issues all those things when we think electrolytes and we think of diuretics we should absolutely be thinking of kidneys and kidney function um and of course like vomiting too the excess vomiting with the parotted glands maybe your esophagus is going to get damaged as well dental right um and of course cardiac again also with electrolytes and um low blood pressure. Uh but especially the you know the low um I mean in the this first slide the hospital criteria admission criteria we talked about uh low potassium right which can lead to cardiac issues well mainly EKG issues less cardiac and more EKG. So cardiac conductivity conductivity just keeping that stuff in mind and um let's see okay um so yeah outcomes more outcomes we want to see stable stabilized vitals, stabilized normal electrolytes, refraining from these behaviors, free from self harm, things like that. Uh, again, I think I already went over that slide, therapy, meds. Um, now binge eating disorder. Now, this is binging. It's similar to bulimia nervosa except um there's no compensatory behavior. There's no vomiting, there's no diuretic use, there's no um laxative use or anything like that. just binging and eating lots of foods, high calorie, high fat really, really fast to the point of like being so full and sick after, but feeling super guilty and bad about yourself and low self-esteem, super depressed afterward. Um, you know, like like out of like out of the norm, like it was just very very very low after that. um just helping kind of like set limits on certain things, education, all that stuff. Um, another thing I wanted to emphasize about eating disorders in general is that um uh our our priority I think I I think maybe I already did emphasize this a little bit ago, but our priority in these things, especially if they're in the hospital now, right, because we're again we're hospital nurses. at when we finish school. Um we're we're seeing these folks because they are medically unstable. Well, they're not here to see us to have their uh eating disorder treated from a psychiatric standpoint or at least not yet. At least not at first, right? When they come into the hospital because they are medically unstable. So, our goal is to first stabilize them medically. Um and uh and then followed by psychiatric well psychiatric stabilization of course if there's like suicidality or um like self harm or homicidality involved of course but the whole point of like like improving their self-image and um providing structure and learning around like their habits and all these different things including like giving them more and more freedoms, right? Because we're over here observing them and watching them and putting time limits on their eating and all these different things. Um, where was the other slide about that? Um, we want them to eventually be able to not have to be observed while they eat, right? um see and then consult nutritionist for choice of foods. This ba this is basically saying that the patient can't really choose their own foods, right? In a normal situation, we would allow the patient to choose what they want to eat and we want that for them. But because of this situation, once they are stabilized after all this, then we can start giving them those freedoms of choosing what they want to eat and when and how they eat it and things like that. But that's going to be later once we've stabilized them medically and psychiatrically. The rest of this giving them these increased freedoms back to normaly learning how to eat have a better relationship with food on their own is going to come later toward the latter half of their hospitalization. Okay, please keep that in mind. Now, uh neurocognitive disorders. Um hopefully I can fly through the rest of this. This might be a little longer than normal. I apologize but um uh you know some of the stuff you should be able to read on your own. Obviously neurokcognitive disorders are impacted in the following ways because of because it's the brain, right? These different parts of our ability to function in society and to communicate and to understand are all related to what parts of the function of the brain that they contribute to. So when those parts are damaged, these these are damaged as well. Um first and foremost, delirium. Again, please I'm emphasizing be able to recognize the difference between delirium and dementia. Delirium is the quick onset neurokcognitive like decline situation from hospitalization or from infection or from drug use or um lack of sleep. for the most part, it's always secondary to something else from the same things I just listed and it's extremely reversible. So once the insult or the threat that's contributing to the delarium is removed or treated or mitigated, the delirium will then go away as well. Um the elderly are at greatest risk because of all the coorbidities that they already have, especially if they're again hospitalized. You can become delirious outside of hospitalization again from infection things like that especially in older folks but risk factors for delirium again meds infections comorbidities substances and alcohol so drugs extreme unreieved pain of course older you are the more likely and the more the worse it can get existing cognitive impairment existing mental health disorders sleep issues so again lack of cluster care in the hospital uh symptoms develop rapidly, very quick onset and they can fluctuate meaning they can go between hyperactive, hypoactive or mix. So that hyperactive delirium can look like confusion, irritation, agitation, maybe even violence and aggression. It can also look hypoactive. So it can look uh uptunded, nearly comeos or flat affect or poverty of speech, things like that. So keep that in mind with delirium. Where did I go? Oh, so it can fluctuate. So it can be different throughout the day, could be different in the morning versus at night. It can fluctuate with maybe the administration of pain meds or um you know, things like that. Other ways that delirium looks, memory impairment, definitely again these folks when they're delirious, the reason they get agitated and irritated is really because they're because they're confused in that moment. It's literally just like confusion. Um, and because of that, they become scared, confused. They don't know who you are, what's going on, what you're doing to them, where they're at. For all they know in that moment, like they're being detained or something like that, or there's like, you know, something like that going on. So, a way to help this, one way to help this, um, of course, besides treating the original insult, so the infection or the lack of sleep, all these different things, there's ways to help kind of mitigate the delirium, and that is reorientation because they're going to be disoriented, right? Right here, they're decrease orientation. Um, so we want to help reorient them like, "No, no, no. You're, you know, you're at the hospital. You're safe. I'm a nurse. I'm here to take care of you. You had a stroke, sir. Everything is fine." You know, things like that. And then also, um, having frequent visitation from family, frequent visitation and interaction from family. So, aka familiar faces. So the um familiar and safe familiar slashs safe faces and voices that's going to be very very very helpful. And then finally also um of course promoting rest and there's one other thing I wanted to say I thought oh and just like um keeping familiar things with them keeping familiar objects within reach. So that might be like um this could be like maybe pictures of family. This could be like their gl I mean this could even just be their glasses too. If they can't hear or see that's not going to help. Um, it could be their their cardigan that they used to wear every day at home, something like that. Um, just something to keep in mind. Increasing familiarity and comfort and safety is going to be really helpful. Um, [Music] and let's see, let's see. So, okay, moving forward. Uh, more delirium behaviors, restlessness, anxiety, motor agitation. So that's physical irritation and aggression things like that change in you know change in mood and emotions and stuff. Delirium can result in hallucinations and illusions of course and I believe I showed you guys this in class but delirium again altered mental status typically an acute change in that mental status. It's a medical emergency always. That means there's something very severe and significant going on in the body. um especially if they're if this is happening outside of the hospital setting. Disoriented change in level of alertness as well is going to happen and change in vital signs can occur as well. rapid onset and but equally rapid uh um treatment if it's treated properly and it's reversible of course as we mentioned it more interventions again safe provide a safe space but also a therapeutic environment and low stimula a low stimulated environment so low light soft noises um again uh cluster care allowing them to rest things like that and now we've switched gears so I'm going to put a nice little pause in here and say um now we're talking about dementia. Now we moved on to demented disorders. Dementia. Now dementia can be classified as a mild or a major neurocognitive disorder. Mild neurokcognitive disorders are have just very modest impairments. So these folks might still need cues to comp to perform their ADLs, mild physical impairments, but ultimately the symptoms do not interfere with their dayto-day functioning. Again, a mocha assessment. That's the one with the pictures of the animals and the clock drawing, the thing that Trump did that he aced, right? That is something that you can do. Go online and you can do a certification in that so you can give it to folks in the hospital. And then there's major neurokcognitive disorders where there are substantial impairment and sub and symptoms significantly interfere with their independence, their ability to do to complete day-to-day functioning and and decision-m on their own. Again, this is the Mocha assessment for mild mild cognitive impairment detection, major neurokcognitive disorder um once again in general. So, dementia disorders are gradual and progressive impairment, insidious onset as opposed to delirium, that's a rapid onset. major neurokcognitive disorders, dementia have a slow gradual onset over time. So, it starts with like little bit of forgetfulness here and there and then it turns into like major forgetfulness and then full-blown lack of decision-m and then really just inability to keep yourself even up and take care of yourself at all. There's there could be primary and secondary. Um the greatest risk the greatest greatest risk for dementia for Alzheimer's for neur major neurokcognitive disorders is age. Age is the greatest risk factor out of everything. Um women are at a greater risk over men but it is not the greatest risk factor that contributes to dementia. Please understand that genetics the dementia is typically rooted in genetics. You are more likely to develop dementia if you have an immediate family member who developed dementia. However, age is still the greatest risk factor. Please understand that um another diagnostic assessment is MMS. Uh more neurokcognitive disorder. So defense mechanisms um seen in those with neurocognitive disorders are typically going to be more primitive because dementia forces the individual to become more primitive even from a physical and neurokcognitive standpoint right especially seen in Alzheimer's disease and endstage there's going to be that lack of ability to make decisions for yourself lack of ability to clean yourself feed yourself things like that basically going into baby mode as as the dementia becomes more and more severe so same with the defense mechanisms lots of deny lots of making stuff up, lots of fixations on things and avoidance too because they just simply can't remember things or or maybe they only can remember a single thing about something so they'll proceverate on it or they just simply won't believe that they're really becoming demented like that. Um or because of the dementia they have the the lack of ability to even understand that that's happening. Um, other cognitive impairment issues related to executive function. Well, there's going to be disturbances related to executive functioning, but other cognitive impairment that we'll see because the brain plays a big role in how we perceive our environment, how we see it, how we smell it, things like that. Um, these things are going to be a thing. So, amnesia is going to be memory loss, right? Aphasia is going to be inability to speak slashexpress self. A praxia is going to be difficulty with purposeful movement. So I gave the example in class of like trying to hug someone else but going and hugging yourself instead and not really understanding why you're doing that. Not like knowing what you're trying to do but it's coming out wrong. Uh agnosia. A nausea. and loss of ability to identify objects and people. But an nausemia is partial or complete loss of sense of smell. So make sure you know the difference between these. I would do flash cards for these. Go over and repeat and repeat and repeat and repeat to the point that you should be able to see the word and know the definition by heart without having to flip the card. And then you flip the card and realize you're right. That should that should be how you know these. Um, now it's one thing to know the definition of anosmia, but it's another thing to apply it. So, how are you going to help someone with dementia with anosmia be able to function at home? That could look like um putting like labels on their foods. um you know this is maybe they might not be able to differentiate between certain liquids at home that they have or again something is spoiled or something like that right so we want to make sure we're doing that and then dementia again these different things are often associated with dementia neglect cognition decline medical issues some common dementia disorders Alzheimer's again that's the genetic one that is usually results in like like protein deposits in the brain that cause like just neurokcognitive decline and degradation and things like that. Um, Pix is similar. It's more rapid than Alzheimer's. Louisibody dementia is similar with the Louisbody deposits. Uh, vascular dementia is related to strokes like frequent strokes, TAS where there's like constant insults to the brain and therefore those parts of the brain lose function. And then Parkinson's as you know it is like that degradation of just neurological functioning of dopamine production and therefore uh loss of control of muscular body movements. Please understand the stages of Alzheimer's the very beginning the mild stages are going to be forgetfulness and then moderate is going to be just straight up bouts of confusion. This is when you might see something called or start to see something called sundowning. I don't know if I mentioned this in class, but you're going to see it a lot a lot a lot a lot in the hospital with your patients if you work night shift. Um, sundowning, it's going to make your job so much more difficult. I don't know if I told you all this story very brief, but when I was a I used to be a CNA. I used to work night shift on a step down oncology unit and I had a patient who was sund downing of course at the start of my shift and I had to get vital signs on them and I I told him I said hey sir it's me I'm just here to get I'm here to take your vital signs and he said how dare you you can't just take someone's vital signs those are my vitals you think you're just going to like steal my vitals and he was very confused and he was very defensive And um he was starting to get a little violent with me. He was the cutest thing though in the entire world. Um but yeah, and he was so he was sundowning. He just straight up got confused and didn't understand the concept of taking someone's vital signs. I was like, "No, no, sir. You don't understand. I just need to like take your blood pressure." He's like, "No, you can't do that. That's my blood pressure." So, um that's sundowning anyway. Uh and that is very just much associated with nighttime sleepiness. the body's natural production of like melatonin for rest and relaxation. So, it's nighttime confusion. It it you know it occurs like late afternoon even or um at night time. So, I mean that was 7:00 at the start of the hour to get my my vital signs. But anyway, that is sundowning. That's what you're going to see in dementia. You can see it in other things too. brain tumors, brain cancer, but um moderate to severe stage three of Alzheimer's dementia is ambulatory dementia. So, a lot of this is the primary experience. Decision- making might be pretty much out the window at this point, but physical abilities are mostly intact. So, you know, with Q's could probably bathe themselves, can walk and talk, go up and down the stairs, definitely not drive, but other things like that like hygiene, ADLs, um, still might need help in cues, but physically physically they are capable of of moving. Now, late end stage terminal, this is also called terminal. Um, this is really at the point where they've lost all of their physical capabilities as well. So, unable to maintain their uh bowel and bladder habits. So, they might need to be cleaned up. They might need to be bathed. They are going to need to be fed. Uh, they might not even be able to hold themselves up. So, they might be in a wheelchair. Um, things like that. I, you know, for a lack of better words, just for the sake of your uh ability to understand is it's just far more baby like at this point. Okay. So, Benjamin Button, honestly, it's like a it's a Benjamin Button disease. You could call it think Benjamin Button for the stages of Alzheimer's disease. Um, any questions on all of that stuff that I just went over? All right. Um, outcomes for dementia, they're going to remain safe. So, with dementia, with delirium, there could be some aggression, violence, or possibly just lack of safe activities. So, like getting up out of bed, thinking that they are um off to go do something, off to go to work or something, but they're in the hospital and, you know, they're confused if they're sundowning, things like that. Um, another story I forgot to mention. Um, uh, we had a patient once at the hospital. This was a story that someone told to me at my hospital, but there was a patient that they had that was sun son Downing, had dementia, and they couldn't find him for the night shift, and he was missing. It was a hospitalwide thing. They looked everywhere. They couldn't find him. They're like, "How could he have gotten that far?" Until they heard some sounds in the room, and uh, they found him underneath the bed. working on the bed like he was under a car because he used to be a mechanic. So when he was sundowning and he must have gotten out of bed which is very unsafe, right? Um so that it would be considered a fall unfortunately but he was under the bed working on it like it was a car. Super cute. But um so remaining safe in other words making sure that they're staying safe. Least restrictive first. least restrictive implementation for safety first. So these folks could be getting up out of bed, running around, walking around when they're physically not able to as much as they think that they are, but also um they could be tugging and pulling like at their catheter or their IV things like that. So least restrictive measures first. So that could look like first and foremost onetoone observation, right? followed by if that's not enough, we might need to add introduce a a sedative medication or just we'll just say medication. Sometimes we give antisycchotics um and maybe keep the onetoone observation. Then finally, if none of those things work and they're still being violent and aggressive and very harmful, then we might need restraints. Okay. Um, short close-ended questions with those with dementia and delirium are going to be key. And, uh, what else? Yeah, that's pretty much the the name of that. Um, dementia. So, uh, another way to help those with dementia, same thing as mentioned before with the delirium. We're going to help reorient them. We're going to help make sure that family is visiting them often. You know, familiar faces, familiar voices. That's going to help them feel safe and calm. It's going to help them remember who they are, what they're there for. Um, and also reminiscence therapy. So, this is more like say you're in like a long-term care facility at this point. We are going to want to encourage group therapy for this. Get them together with other patients with dementia or not. um to basically bring up and talk about the past. Uh reminisce therapy specifically is sharing positive and negative things about the past not only to promote cognitive stimulation um and help like further remember like memories that maybe they had forgotten but also to promote resolution. Okay. Um and also just like just the group therapy aspect of it promotes socialization, cognitive stimulation, um sense of belonging, things like that. Music therapy, sensory, so having familiar objects too with the patient. I think I mentioned this a earlier, but I'm going to say it again. Familiar objects near a patient. Again, that could be Yeah. they used to maybe they an old Walkman or um music they used to listen to or their familiar cardigan things like that. Uh pharmacological things. So denazil is our main player here. It's a common one for treating Alzheimer's. Again, it doesn't treat it, it doesn't reverse it, but it slows the progression down over time. And it's better for mild to moderate levels of Alzheimer's, not late stage. At that point, it's too late, but you can kind of catch it a little early and just slow it down. Um, other things to know about uh donazil and just treatments related to azimer. So, I'm going to add dpazil to the slide. Donapazil, if I spelled it right, something like that. There we go. Okay. um that can result in dizziness. It can result in um oh gosh, sorry. I should just make a separate slide for this. Um so here we go. I'm going to add a slide. Donapazil donazil. Um, so keep in mind that this is a Alzheimer's disease treatment to slow progression of disease in early to moderate stages only. Okay. And dinepazil um can also uh keep in mind too that these medications will uh do not improve memory. Okay, again it just slows down the progression of the disease and that's that nothing can make you remember anything. Um also keep in mind that it can cause basically low vital signs. So that can lead to like brady cardia that can lead to dizziness. That can lead to like fainting even fainting or syncopy. a word that you guys should already know, but I know some of these not so common words um we tend to maybe forget. Um and then uh because of these low vital signs, that can also lead to like just basically sedation. So, it's going to be, you know, you're going to want to give it like at night just because it can cause these things. You don't want these people to be up and awake during the day and having these side effects from the medications, right? If anything, that's going to help promote sleep and rest, which is going to be great for those with Alzheimer's. Um, but also this drug can cause side effects. Um, I don't know if you remember anything about like a colonergic crisis or what anticolinergic side effects look like, but side effects look like the body kind of purges. So like sweating, um, excess or like just like urination or like frequency of urination, then like diarrhea, things like that. Um, so keep that in mind. And I'll uh blow this up, I guess, a little bit here. Okay, and that is it. Any questions or concerns for me about this sturf? Um, okay. So, I did uh I took the quiz myself to see just to really make sure that the questions made sense, that the answers made sense. And this one is a good one. This one was really well done, I think, because of the last two. And, you know, like I said, I've been communicating with leadership. Um, and so this quiz is is really wellm made. And um if if you just really follow this tutoring session and follow the slides um clarify anything that you're not familiar with or have struggle wrapping your head around, that's really going to be your ticket. Again, memorization is not a bad thing, especially when it comes to um especially when it comes to like just words that you aren't very familiar with. Go through it. If there's words that like that you don't see on a daily basis that like maybe you kind of know, like just go out of your way to like review that vocab in different contexts. Like watch a video about it or um read examples about it. Um learn about it in more detail just to help make the word make more sense in your head so you can therefore apply it to other questions when they come up. like syncopy for example or um I know one word that came up in the past was ideology in the last quiz. Um just to reemphasize because it could come up in future questions but the ideology of something is like basically the the story behind the condition like what causes it? What's the prevalence of it? Um basically the statistics behind a condition. Um, something else I want to emphasize again is just like when it comes to the NextGen questions, all of those different tabs and stuff, just make sure you're looking at all the tabs. Make sure you're looking at the changes in vital signs and changes in diagnostics, looking for improvements and worsening of things, and looking for what stayed the same. that's going to give you clues on to things and things that have improved or declined or like gotten worse doesn't mean that they've gotten the numbers have gotten higher or gotten lower, right? Because that could be different for different things. So, um if my respiratory rate has increased, that doesn't mean it's improved. That means it's declined, right? Because an increased respiratory rate means that something bad is going on in the body and my respiratory rate is trying to make up for that. Now, it depends on what it went up from, right? If I went from a heart a respiratory rate of eight, which is abnormal, to a respiratory rate of 12, that's a good increase. That's an improvement. Say I had I came in with a respiratory rate of eight because I had overdose on a narcotic. And then I was treated with an antidote and now my now my vital signs have improved from a respiratory rate of eight to a respiratory rate of 12. That's an improvement. Now, if I had a respiratory rate of uh 24 and I now have oxygen and now it went down to a respiratory rate of 20, that's an improvement. I went from an abnormal number to a normal number. Um or if it's if I'm on oxygen and my oxygen is too low below normal, that's a concern, right? So you need to be able to look at the numbers beyond just your typical what is normal and what isn't. Like be able to apply the changes. Look at the improvement. What does it really look like? I was going to say another example of that for the opposite side of it. If I took yeah like a stimulant and my heart my respiratory rate went from 20 to 24. If it went up that's not an improvement. That's that's not a good sign. That's a sign that yeah, there's drugs involved or something like that. Right. So again, just be able to look at what is what does a real improvement mean? What does a real worsening mean? And then of course, if there's no change between vitals or diagnostics between two different assessments, be able to recognize that as a non-improvement. Or if there's no change between a normal diagnostic and a normal diagnostic later, that's good. If there's no change from an abnormal diagnostic or vital sign and then no change and it's still abnormal the next time, that's a non-improvement. So, that's just my final piece of advice. Any questions on that stuff or of anything else? Okay. Um, take practice questions on ATI, read the rationale, practice nextgens, go out of your way to find nextgen questions and practice those because I think that's where we're all struggling the most. And um, just repeat repetition, repetition, repetition. Try to memorize those notes as much as you can. Of course, application is going to matter, but you can't really apply it if you don't remember the details of the content, right? And otherwise, uh, thank you so much for tuning in and I'll see you guys on Tuesday. Have a good, uh, holiday weekend. Uh, email me if you need anything. Okay. Thank you. Yeah. Thank you. Thanks, guys.