How to write a Feeding Disorders nursing Case Paper

How to write a Feeding Disorders nursing Case Paper

Summary Statement: Ryan Edwards is a 30-year-old male patient who presents with regurgitations without retching or gagging for the past eight months. He has lost close to 50 pounds during this period and is unable to eat well or perform any physical activity. Additionally, Ryan is struggling with social issues like working appropriately because he fears throwing up in public. His previous diagnoses include GERD and general anxiety disorder that has been managed with Fluoxetine and Buspirone without success. Based on Ryan’s presentation, my primary diagnosis is Rumination disorder with a differential of anorexia nervosa.

Explanation

Eating disorders are one of the significant problems among adolescents, children, and even adults. These disorders are characterized by disturbance in eating habits that may be excessive or insufficient food intake (Murray et al., 2019). If not well-managed, eating disorders can cause nutritional problems and even death. For instance, anorexia nervosa has the highest mortality with about 10% of affected individuals dying within 10 years of disease onset (Murray et al., 2019). Rumination disorder, commonly known as rumination syndrome is a rare behavioral eating problem that affects children and some adults. The disorder causes an automatic regurgitation of recently eaten food whereby individuals can spit it out or re-chew and re-swallow (Bryant-Waugh et al., 2019). It is believed that rumination is unconscious but sometimes voluntary relaxation of the diaphragm is a learned habit that can cause rumination. In anorexia nervosa, individuals usually view themselves as overweight and tend to constantly monitor their weight by avoiding eating certain types of foods. Restricted eating patterns can lead to severe weight loss and nutritional deficiencies among the affected individuals.

Screening Tool for Rumination Disorder

DSM-5 Diagnostic Criteria

Rumination is characterized by voluntary or involuntary regurgitation of food and typically does not involve retching or nausea (Halland et al., 2018). The DSM-5 provides the criteria that can be used to differentiate rumination disorder from other eating disorders.

The diagnosis of the disorder is based on the following findings:

  1. The individual experiences repeated regurgitation of food over a period of at least one month. The food may be re-chewed and re-swallowed or spit out.
  2. Repeated regurgitation is not caused by medical or gastrointestinal problems like GERD or pyloric stenosis among others.
  3. Disturbance in eating does not occur exclusively during the course of other eating disorders like anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant food intake disorder.
  4. Rumination must be severe to warrant independent attention if it occurs within the context of other mental or neurodevelopmental disorders.

PARDI Questionnaire

The Pica, ARFID, and Rumination Disorder Interview (PARDI) is a semi-structured questionnaire that can be used to diagnose eating disorders (Bryant-Waugh et al., 2019). The questionnaire is available in two versions to allow screening for adults aged 14 years and older and the other for young people. During the assessment, YES answers are scored 1 while NO answers get a zero score (Bryant-Waugh et al., 2019). The diagnostic predictors of rumination disorder and other eating disorders are based on different patterns. There are four patterns observed during the questionnaire that includes sensory-based avoidance, lack of interest in food eating, concern about aversive consequences, and rumination disorder severity (Bryant-Waugh et al., 2019). For example, rumination disorder severity contains items scored from 0 to 4 and is used to determine if the individual has rumination disorder. This tool can be relied upon to diagnose eating disorders and aid in the diagnosis of rumination disorder in the patient.

Link: https://doi.org/10.1002/eat.22958

Assessment questions

Rumination syndrome is a disorder that is most frequently missed or misdiagnosed resulting in protracted symptoms and patients not receiving treatment for long. Asking the right questions is the key strategy to the diagnosis of the patient with rumination disorder. The following questions can guide the diagnosis of the disease.

  1. For how long have you been having regurgitation symptoms and how often do they occur?
  2. Has the food material come back into the mouth in a manner that is different from the feeling of being sick or vomiting?
  3. How long after eating does the food material come back to your mouth?
  4. How many times does the food come back up after eating?
  5. Is the regurgitation accompanies by retching?
  6. What does the material taste like?
  7. How do you manage the food material when it comes back? Do you re-chew and swallow it or do you spit?
  8. Does the feeling come voluntarily, involuntarily, or both?

Medication Changes

The main treatment of rumination syndrome does not involve the use of medication but rather behavioral therapy to stop regurgitation (Halland et al., 2018). Diaphragmatic breathing is an evidence-based approach that demonstrates great improvement in patients with rumination syndrome. The exercise operates as a competing response to habitual abdominal wall contraction that occurs after eating. Apart from this behavioral method, I will prescribe baclofen, a muscle relaxer, and an antispasmodic agent. A dose of 10 mg taken three times a day will serve to control postprandial regurgitation observed in the patient (Halland et al., 2018). I will then increase the dosage by 5mg every three days to a maximum of 20mg. I will educate the patient about the drug’s related risk for suicide especially if there are underlying psychiatric conditions. I will also educate the patient on the gradual withdrawal of baclofen to prevent anxiety and paranoia that may result from abrupt withdrawal.

Professional Referrals

I will consider referring Ryan to a behavioral health specialist to help in strengthening his diaphragmatic breathing exercise abilities. Additionally, referral to a mental health professional for psychiatric evaluation and treatment will be another option (Murray et al., 2019). The patient should be treated separately if comorbid disorders like generalized anxiety are diagnosed.

References

Bryant-Waugh, R., Micali, N., Cooke, L., Lawson, E. A., Eddy, K. T., & Thomas, J. J. (2019). Development of the Pica, ARFID, and rumination disorder interview, a multi-informant, semi-structured interview of feeding disorders across the lifespan: A pilot study for ages 10-22. The International Journal of Eating Disorders, 52(4), 378–387. https://doi.org/10.1002/eat.22958

Halland, M., Pandolfino, J., & Barba, E. (2018). Diagnosis and treatment of rumination syndrome. Clinical Gastroenterology and Hepatology : The official Clinical Practice Journal of the American Gastroenterological Association, 16(10), 1549–1555. https://doi.org/10.1016/j.cgh.2018.05.049

Murray, H. B., Juarascio, A. S., Di Lorenzo, C., Drossman, D. A., & Thomas, J. J. (2019). Diagnosis and treatment of rumination syndrome: A critical review. The American Journal of Gastroenterology, 114(4), 562–578.

https://doi.org/10.14309/ajg.0000000000000060

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