Case Presentation #2:
(Authors' Plan of Care)

 A New Paradigm Application

Subjective Infomation:

  • Wanda T. is a 42 y/o female. Presents to your primary care office requesting Meridia to "help stop her yo-yo dieting". States she would like to reach goal weight of 120 lbs to "look great and feel better".
  • Health maintenance: non-smoker, non-drinker, has intermittently participated in aerobic dance classes for weight loss throughout adult life (currently sedentary), wears seat belt. Last physical 6 months ago. States weight 115 lbs with first diet at age 18 (wanted to lose 5 lbs). Repeated weight losses/gains since that time.
  •  Eating pattern frequently alternates between restricted caloric intake (approximately 1000 kcal/day) and periods described as "out of control" with intakes up to 4000 kcal/day. Cycles initially lasted as long as 2-3 weeks, but now occur every few days. Has difficulty recalling specific foods and amounts. Denies purging behaviors and history of eating disorders.
  • Social history: married x 22 years, 1 independent adult child, husband encourages weight loss, works full time as a nurse in a local hospital.
  • Past medial history: C/S (breech) 21 yrs ago, fx L femur in MVA age 30.
  • Family history: father with asthma, maternal grandmother died age 68 Alzheimer's.
  • Medications: ASA or Tylenol 4-5x/mo for HA or pain.
  • NKDA.
  • ROS: unremarkable.

Objective Information:

  • Ht: 64"
  • Wt: 144 lbs
  • BMI: 24
  • BP: 112/68
  • P: 80
  • R: 16
  • HEENT: WNL
  • Lungs: CTAB
  • Heart: RRR without murmur
  • Peripheral vascular: WNL
  • Abdomen: WNL
  • Neuro: WNL
  • MS: WNL

As a provider, what are you concerned about?

  • Weight cycling, possible disordered eating and/or eating disorder
  • Dissatisfaction with body/appearance
  • Sedentary lifestyle
  • Reinforcement of body dislike by husband

What are you reassured by?

  • Apparent open communication with provider
  • Physical exam WNL
  • Medical and family history essentially negative

What other information would be necessary?

  • Detailed assessment for eating disorder
  • Does the client have any psychosocial issues that are contributing to her beliefs and behaviors?
  • What does the client believe your role is?
  • What does she expect of you?

 

Assessment:

What are your primary diagnoses?
  • Body image disturbance r/t dissatisfaction with weight
  • R/O eating disorder
  • Chronic restrained eating
  • Sedentary lifestyle

 

How do you proceed in the formulation of a solid plan of care based on the pew paradigm?

..... First, identify your own beliefs regarding weight-related concerns and prescriptions for weight loss medications. It is the authors' belief that these old paradigm interventions are ineffective and potentially harmful, and as such are inappropriate for use with clients. Next, you should acknowledge the client's frustration with previous failures at weight loss and assist her in understanding why dieting and exercise for weight loss usually fail. Determine whether or not the client is open to interventions other than what she has requested (Meridia). If she is not, the plan should consist of gentle explanation as to why you cannot provide this medication or assist with weight loss efforts. An open invitation for future assistance with improving body image, normalizing eating, and increasing activity should be given.

..... Because this client suffers from chronic restrained eating and possibly firmly entrenched values regarding body size, a team approach may be needed. In addition to you as the primary care provider, the team may consist of a size-friendly nutritionist and therapist. Incorporation of new paradigm principles into lifestyle needs to be a slow, individualized process and may require extended time (years).

..... Notice how the plan of care does not focus on weight loss, but rather emphasizes overall health promotion. Interventions assist with improving body image, normalizing eating, and the incorporation of enjoyable physical activity.

Plan:

What is your plan of care?
· Empower the patient to establish goals, and develop an individualized plan according to her personal priorities (Unit IV Lesson A)

· Assist the client in improving body image and positive self-thoughts (Unit IV Lesson B)

· Focus on the development of healthy, unrestrained eating (Unit IV Lesson C)

and/or

· Promote increased physical activity (Unit IV, Lesson D)

· Consider on-going collaborative relationship with plan evaluation & revision at each visit

 

 

**Notice that the new paradigm is flexible. Care is highly individualized and empowers the patient to make self-paced decisions regarding weight-related concerns. Moving toward size acceptance, healthy, unrestrained eating, and a physically active lifestyle is as much a process as it is a goal.

 

Next 

© Spring 1998