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Learning Objectives

By the end of this section, you will be able to:

  • List risk factors associated with bulimia nervosa
  • Plan nursing care for clients in treatment for bulimia nervosa
  • Discuss nursing implications for the therapeutic relationship in care of clients diagnosed with bulimia nervosa

Recurrent episodes of binge eating that are followed by behaviors to prevent weight gain like purging is called bulimia nervosa (APA, 2023b). It occurs most often in adolescent females with an estimated prevalence of 0.5 percent to 1.5 percent in the United States (Jain & Yilanli, 2023). Individuals with bulimia shift from calorie restriction to binge eating where they consume large amounts of food in a short period of time. During binges, there is a loss of control, and the portions are larger than most people would consume in the same time frame. The episodes of binging are followed by recurrent weight control measures that can include extreme exercise, fasting, purging, or abuse of laxatives and diuretics (Jain & Yilanli, 2023). This cycle of out-of-control consumption of large amounts of food in a short period of time followed by methods to prevent weight gain is also known as a binge-purge cycle.

Risk Factors for and Etiology of Bulimia

Though bulimia is seen in females and males, it is significantly more common in females. The median age of the onset of bulimia is around twelve (Jain & Yilanli, 2023). The etiology of bulimia is unknown, but it is thought to include several biological, psychological, environmental, and temperamental factors that can predispose individuals to bulimia. Alterations in the brain structure and function have been found to contribute to binging behaviors (Jain & Yilanli, 2023).

Biological Factors

Biology is thought to play a significant role in the development of bulimia. Puberty and childhood obesity increase the risk for bulimia nervosa, and childhood physical and sexual abuse also lead to an increase in incidence (APA, 2023b). Appetite has been known to be a factor in bulimia. Studies of appetite hormones like ghrelin and leptin in bulimic clients have shown dysregulated levels that may contribute to symptoms seen in bulimia (Presseller et al., 2021).

Addiction is also associated with bulimia. Studies have shown biological similarities between people with bulimia and people with drug addiction; food and illicit drugs both have the same pleasurable effects on neurons in the brain (di Giacomo et al., 2022). The binge eating behaviors seen in bulimia follow a similar pattern to addictive behaviors seen in substance misuse. Substance use disorder may be seen with eating disorders with increased associations reported in individuals with bulimia (Gregorowski et al., 2013).

Real RN Stories

Nurse: Andrea P.
Clinical Setting: Psychiatric unit
Geographic Location: Saskatchewan, Canada

Andrea is a psychiatric nurse in Canada who battled with bulimia nervosa for sixteen years. Andrea’s bulimia began in ninth grade before a trip to Hawaii where she reports that she began starving herself to look better in her bikini. After the trip, her disordered eating persisted and was influenced by a friend who she found in a bathroom purging. She would wake up obsessing over food and would purge after her binges. As her bulimia worsened, she admitted to purging up to ten times a day and hiding her eating behaviors from her spouse. She was consumed with feelings of overwhelming guilt after her binges and reports feeling a loss of control over her eating. Her husband discovered that she had issues with eating after finding a hidden bag of vomit one day, and he encouraged her to get help. She recovered after three admissions to a center for eating disorders, but still has dental complications from her years of purging. She has veneers on four of her teeth from tooth decay and now calls herself a nonactive bulimic.

Social Factors

There are several social factors associated with bulimia. Temperamental factors like low self-esteem, social anxiety, and depressive symptoms can increase the risk for bulimia (APA, 2023b). Individuals with bulimia also tend to engage in their binge eating behaviors in isolation, which could lead to social withdrawal (Hadad & Knackstedt, 2014). The individual with bulimia may experience such strong emotion that they impulsively binge eat to find comfort. The loss of control that individuals with bulimia experience during binge eating and purging episodes demonstrates issues with impulse control (Howard et al., 2020).

Mental Health Comorbidities

Mental health disorders are common in individuals with bulimia. In adolescents, the most frequently seen comorbid mental health conditions were mood and anxiety disorders (Hail & Le Grange, 2018). Adolescents with bulimia also have the highest levels of suicide attempts (Hail & Le Grange, 2018) of all of the eating disorders. The DSM-5 lists depressive disorders, bipolar disorders, borderline personality disorder, and anxiety disorders as mental health conditions that have the highest rates of comorbidity with bulimia; these conditions can either precede the bulimia, occur simultaneously, or can develop shortly after (APA, 2023b). Substances like stimulants may be used to control appetite, and alcohol use is also reported to be higher in individuals with bulimia (APA, 2023b). Individuals with bulimia may use laxatives to promote weight loss; in fact, some studies found laxative abuse in as many as 56 percent of people with eating disorders (Addiction Center, 2023).

Nursing Care Planning

Nurse care planning for individuals with bulimia should focus on restoring metabolic and electrolyte balance, treating any underlying mental health issues, and establishing ordered eating patterns. A sample care plan for a client with bulimia is provided Table 20.2.

CJMM Step Notes
Assessment Hyponatremia
Priority problem Fluid volume deficit related to frequent self-induced vomiting
Outcomes Clients’ electrolytes will return to normal limits
Interventions Daily labs
Electrolyte replacements (oral and IV)
Rationale To ensure that client is adequately hydrated and that client’s electrolyte balance is restored
To assist with healthy eating habits/choices
Evaluation Client’s sodium and potassium levels increased during admission
Table 20.2 Nursing Care Plan for Client with Bulimia

Bulimia Nervosa—Purging Type

Some individuals with bulimia use compensatory measures like purging to prevent weight gain after they binge. Though self-induced vomiting is the most common method used, purging can also include laxative and diuretic overuse (APA, 2023b). These individuals are more at risk for fluid and electrolyte imbalances due to dehydration that can be caused by recurrent purging.

Assessing dental health in clients with bulimia is important because repeated purging can cause complications. Dental erosions are common with chronic vomiting due to the acidity of vomit (Nitsch et al., 2021). Frequent purging can also cause trauma to the oral cavity from coming in contact with acidic vomit or from methods used to induce vomiting like inserting objects in the mouth. It is important for nurses to ask questions related to dental hygiene to assess oral health.

Bulimia Nervosa—Nonpurging Type

There are several nonpurging behaviors that are seen in bulimia to compensate for binge eating. Enemas, thyroid hormone, and excessive exercising are a few nonpurging behaviors that individuals with bulimia may use to control weight gain (APA, 2023b). Individuals who have diabetes mellitus may also manipulate insulin to control weight gain after binges. The client may typically reduce or withhold insulin in an attempt to decrease the metabolism of the excessive food consumed during a binge (APA, 2023b). This can lead to diabetes-related ketoacidosis, which can progress to diabetic coma, and even death from cerebral edema.

Life-Threatening Complications

Bulimia nervosa can lead to life-threatening complications that require immediate nursing intervention. The most common cause of morbidity and mortality seen with bulimia is a result of complications from electrolyte and metabolic disturbances (Nitsch et al., 2021). In addition, other common life-threatening complications of bulimia include:

  • Suicide: Suicide risk is high in clients with bulimia, particularly adolescents.
  • Esophageal rupture: Esophageal rupture can occur from forceful stomach contraction with repeated vomiting. If bleeding is severe, it can lead to death if not promptly treated.
  • Cardiac arrhythmia: Hypokalemia from purging and stimulant abuse can cause prolongation of the QT interval, increasing the risk for life-threatening arrhythmias.

Criteria for Hospitalization

Most individuals with bulimia are normal weight or overweight, making it difficult to detect compared with anorexia and ARFID (Nitsch et al., 2021). Though weight is often not an issue in clients with bulimia, they can have several medical complications. Bulimia has significantly increased mortality rates from these medical complications that can affect many body systems. The complications occur as a result of repeated purging and laxative abuse that cause electrolyte disturbances, metabolic abnormalities, and other physiological complications (Nitsch et al., 2021) (Table 20.3).

Body System Symptom(s)
Integumentary Calluses on dominant hand (also known as Russell sign)
  • Dental erosions
  • Trauma to the oral mucosa (pharynx, soft palate)
  • Subconjunctival hemorrhage
  • Recurrent epistaxis
  • Pharyngitis
  • Parotid gland hypertrophy (sialadenosis)
Gastrointestinal (GI) Upper GI symptoms (seen more in those who purge)
  • Gastrointestinal reflux
  • Barrett’s esophagus
  • Esophageal adenocarcinoma

Lower GI symptoms (seen more in those who abuse stimulant laxatives)
  • Colonic inertia (the inability to pass stool from the colon)
  • Black stool
  • Rectal prolapse
  • Arrhythmias
  • QT prolongation
  • Cardiomyopathy
  • Palpitations
  • Aspiration pneumonia
  • Pneumomediastinum (air in the space between the two lungs)
  • Hypokalemia
  • Hypochloremia
  • Metabolic alkalosis
  • Metabolic acidosis
  • Hyponatremia
  • Irregular menses
Table 20.3 Symptoms of Bulimia (Nitsch et al., 2021)


There are multiple interventions used to manage bulimia. These interventions include stabilizing nutritional status, interrupting maladaptive behaviors, assessing and managing complications, managing medication, and psychotherapy (Nitsch et al., 2021). These interventions involve a collaborative team approach from multiple disciplines in addition to nurses, depending on the needs of the client. For example, a dietitian will work closely with all clients with bulimia, but if the client is having a complication like hypokalemia, a cardiology clinician may manage their cardiac condition. Other examples of nursing interventions that can be used to manage bulimia include:

  • monitoring meals and ensuring that purging behaviors are not performed one hour after meals
  • providing small frequent meals
  • teaching coping skills to help manage emotions related to bulimia
  • identifying the clients’ strengths to help increase their self-esteem


Cognitive behavioral therapy and interpersonal psychotherapy are two psychotherapeutic modalities that have demonstrated efficacy for bulimia (Jain & Yilanli, 2023). Cognitive behavioral therapy is used to help change maladaptive thinking patterns and behaviors that can help with disrupted eating patterns. Interpersonal therapy aims to improve interpersonal and social factors that may contribute to the behaviors seen with bulimia.

Clinical Safety and Procedures (QSEN)

Competencies and Interventions for Bulimia

The six QSEN competencies developed for nursing programs are important to consider when working with individuals with bulimia.

QSEN Competency Examples of Nursing Interventions
Client-centered care Assess the client’s vital signs and labs to evaluate for physiological complications.
Educate the client on healthy eating behaviors.
Teamwork & collaboration Collaborate with other disciplines involved in the client’s plan of care, like dietitians and psychiatrists.
Delegate appropriate tasks to other personnel. For example, a nurse’s assistant can help check vitals.
Evidence-based practice (EBP) Provide evidence-based resources to clients to educate them on bulimia.
Attend continuing education nursing activities on bulimia to stay up to date on the latest evidence-based practices.
Quality improvement Assess processes in place related to caring for clients with bulimia and help to create solutions to improve client care.
Safety Assess clients with bulimia for suicidal thoughts using screening tools.
Implement needed precautions for clients at high risk for suicide, like one-on-one supervision.
Informatics Use clinical tools to help monitor the clients’ vitals and document them in the electronic medical record.


Pharmacological interventions have been well-studied with bulimia and have proven to be effective in managing symptoms of individuals with bulimia (Davis & Attia, 2017). The two most common classes of medications used are antidepressants and antiepileptic medications. Fluoxetine is the most commonly prescribed antidepressant and the only one approved by the FDA for bulimia nervosa (Davis & Attia, 2017). It has been found to significantly help reduce binging and purging episodes. There are several other antidepressants that are also used for bulimia off-label, or they may be used to manage any comorbid depression or anxiety. It is important to note that bupropion, a common antidepressant used to manage depression, is specifically contraindicated in treating bulimia due to its seizure risks. Antidepressants also carry a warning related to increased suicide risk in adolescents, so it is important to monitor clients on antidepressants closely (Davis & Attia, 2017).

Antiepileptic medications are used in the treatment of bulimia due to their effect on binging and purging (Davis & Attia, 2017). Topiramate is a common antiepileptic medication that helps reduce binging and purging episodes. It must be used with caution with clients who have low body weight because it can also cause significant weight loss (Davis & Attia, 2017).

Client’s Self-Help

Self-help can be effective in bulimia treatment. There is a known treatment gap in those diagnosed with bulimia and those being treated routinely for the disorder (Hartmann et al., 2022). Clients may prefer to access resources on their own to help manage their eating disorder. Other factors like stigma, shame, guilt, and poor motivation have also been found to be barriers to individuals with bulimia seeking care (Hartmann et al., 2022). Studies have shown that web-based self-help interventions can effectively help reduce symptoms seen in bulimia. These interventions often incorporate cognitive behavioral therapies in an online format.

Nursing Implications

Nurses will encounter clients with bulimia who require intervention. Assessing these clients for disordered eating habits and any purging behaviors is important. It is also imperative to screen for suicide. Physical assessment will include height, weight, and vital signs along with labs measuring metabolic and electrolyte abnormalities. These clients may have other nursing assessments that reveal ineffective coping or chronic low self-esteem that will require care planning to achieve treatment goals.

Therapeutic Relationship

Individuals with bulimia can have feelings of shame and guilt related to their disorder. They may have issues with self-esteem, depression, and impulse control that may cause them to be reluctant to seek care. It is important to show compassion for these clients and build a therapeutic relationship to facilitate their recovery.

Nurses’ reactions to clients with bulimia will vary. Disordered eating and purging behaviors may seem very abnormal to nurses caring for them. Some clients may report purging several times a day or taking very large quantities of laxatives to prevent weight gain. It is important for nurses to show empathy and to be nonjudgmental in their interactions with these clients to help facilitate a therapeutic relationship.

Safe Environment

Like anorexia, clients with bulimia are also at high risk for suicide. It is essential to provide a safe environment for these clients and to screen for suicide risk. For clients at high risk, implement safety interventions to prevent self-harm and provide crisis information. Hospitalization can provide opportunities for group work and behavior modification therapies in a supportive environment.


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