7 Eating Disorders: Anorexia & Bulimia Nervosa Nursing Care Plans

Imbalanced Nutrition: Less Than Body Requirements

Patients with anorexia and bulimia nervosa may use laxatives to control their weight, leading to inadequate nutrient absorption and less than body requirements. Inadequate food intake in anorexia nervosa can also result in nutrient deficiencies and imbalanced nutrition. Both conditions can have significant physical and emotional consequences that require professional treatment.

Nursing Diagnosis

• Imbalanced Nutrition: Less Than Body Requirements

May be related to

• Inadequate food intake; self-induced vomiting
• Chronic/excessive laxative use

Possibly evidenced by

• Body weight 15% (or more) below expected or may be within the normal range (bulimia)
• Pale conjunctiva and mucous membranes; poor skin turgor/muscle tone; edema
• Excessive loss of hair; increased growth of hair on the body (lanugo)
• Amenorrhea
• Hypothermia
• Bradycardia; cardiac irregularities; hypotension

Desired Outcomes

• The client will verbalize understanding of nutritional needs.
• The client will establish a dietary pattern with caloric intake adequate to regain/maintain an appropriate weight.
• The client will demonstrate weight gain toward the individually expected range.

Nursing Assessment/Interventions and Rationales

For Bulimia Nervosa:

1. Identify the patient’s elimination patterns.
To prevent self-induced vomiting.

2. Assess her suicide potential.
Among patients with bulimia nervosa, warning signs include having more co-morbid psychiatric symptoms and reporting a history of sexual abuse.

3. Outline the risks of laxative, emetic, and diuretic abuse for the patient.
Bulimic patients may include abuse laxatives, emetics, and diuretics.

4. Supervise the patient during mealtimes and for a specified period after meals (usually one hour).
Prevents vomiting during or after eating.

For Anorexia Nervosa:

1. Supervise the patient during mealtimes and for a specified period after meals (usually one hour).
To ensure compliance with the dietary treatment program. For a hospitalized patient with anorexia, food is considered a medication.

2. Liquids are more acceptable than solids.
Fluids eliminate the need to choose between foods – something the patient with anorexia may find difficult.

3. Expect weight gain of about 1 lb (0.5 kg) per week.
To see the effectiveness of the treatment regimen.

4. If edema or bloating occurs after the patient has returned to normal eating behavior, reassure her that this phenomenon is temporary.
She may fear that she’s becoming fat and stop complying with the plan of treatment.

For Bulimia and Anorexia:

1. Establish a minimum weight goal and daily nutritional requirements.
Malnutrition is a mood-altering condition, leading to depression and agitation and affecting cognitive function and decision-making. Improved nutritional status enhances thinking ability, allowing initiation of psychological work.

2. Use a consistent approach. Sit with the patient while eating; present and remove food without persuasion and comment. Promote a pleasant environment and record intake.
The patient detects urgency and may react to pressure. Any comment that might be seen as coercion provides a focus on food. When staff responds in a consistent manner, the patient can begin to trust staff responses. The single area in which the patient has exercised power and control is food or eating, and he or she may experience guilt or rebellion if forced to eat. Structuring meals and decreasing discussions about food will decrease power struggles with the patient and avoid manipulative games.

3. Provide smaller meals and supplemental snacks, as appropriate.
Gastric dilation may occur if refeeding is too rapid following a period of starvation dieting. Note: The patient may feel bloated for 3–6 weeks while the body adjusts to food intake.

4. Make a selective menu available, and allow patients to control choices as much as possible.
A patient who gains confidence in self and feels in control of the environment is more likely to eat preferred foods.

5. Be alert to choices of low-calorie foods and beverages; hoard food; dispose of food in various places, such as pockets or wastebaskets.
Patients will try to avoid taking in what is viewed as excessive calories and may go to great lengths to avoid eating.

6. Maintain a regular weighing schedule, such as Monday and Friday before breakfast in the same attire, and graph results.
Provides an accurate ongoing record of weight loss or gain. Also diminishes obsessing about changes in weight.

7. Weigh with back-to-scale (depending on program protocols).
Although some programs prefer the patient to see the results of the weighing, this can force the issue of trust in the patient who usually does not trust others.

8. Avoid room checks and other control devices whenever possible.
External control reinforces feelings of powerlessness and therefore is usually not helpful.

9. Provide one-to-one supervision and have a patient with bulimia remain in the day room area with no bathroom privileges for a specified period (2 hr) following eating, if contracting is unsuccessful.
Prevents vomiting during and after eating. The patient may desire food and use a binge-purge syndrome to maintain weight. Note: The patient may purge for the first time in response to the establishment of a weight gain program.

10. Monitor the exercise program and set limits on physical activities. Chart activity and level of work (pacing and so on).
Moderate exercise helps in maintaining muscle tone, and weight and combating depression; however, patients may exercise excessively to burn calories.

11. Maintain a matter-of-fact, nonjudgmental attitude if giving tube feedings, hyperalimentation, and so on.
Perception of punishment is counterproductive to the patient’s self-confidence and faith in their own ability to control destiny.

12. Be alert to the possibility of the patient disconnecting the tube and emptying hyperalimentation if used. Check measurements, and tape tubing snugly.
Sabotage behavior is common in an attempt to prevent weight gain.

13. Provide nutritional therapy within a hospital treatment program as indicated when the condition is life-threatening.
Cure of the underlying problem cannot happen without improved nutritional status. Hospitalization provides a controlled environment in which food intake, vomiting, elimination, medications, and activities can be monitored. It also separates the patient from SO (who may be contributing factors) and provides exposure to others with the same problem, creating an atmosphere for sharing.

14. Involve the patient in setting up or carrying out a program of behavior modification. Provide a reward for weight gain as individually determined; ignore the loss.
Provides structured eating situation while allowing the patient some control over choices. Behavior modification may be effective in mild cases or for short-term weight gain.

15. Provide diet and snacks with substitutions of preferred foods when available.
Having a variety of foods available enables the patient to have a choice of potentially enjoyable foods.

16. Administer liquid diet, tube feedings, and hyperalimentation if needed.
When caloric intake is insufficient to sustain metabolic needs, nutritional support can be used to prevent malnutrition and death while therapy is continuing. High-calorie liquid feedings may be given as medication, at preset times separate from meals, as an alternative means of increasing caloric intake.

17. Blenderize and tube-feed anything left on the tray after a given period of time if indicated.
May be used as part of a behavior modification program to provide a total intake of needed calories.

18. Administer supplemental nutrition as appropriate.
Total parenteral nutrition (TPN) may be required for life-threatening situations; however, enteral feedings are preferred because they preserve gastrointestinal (GI) function and reduce atrophy of the gut.

19. Avoid giving laxatives.
Use is counterproductive because it may be used by the patient to rid the body of food and calories.

20. Administer medication as indicated:

• 20.1. Cyproheptadine (Periactin)
  A serotonin and histamine antagonist may be used in high doses to stimulate the appetite, decrease preoccupation with food, and combat depression. Does not appear to have serious side effects, although decreased mental alertness may occur.

• 20.2. Tricyclic antidepressants: amitriptyline (Elavil), imipramine (Tofranil), desipramine (Norpramin)
  Lifts depression and stimulates the appetite.

• 20.3. selective serotonin reuptake inhibitors (SSRIs): fluoxetine (Prozac)
  SSRIs reduce binge-purge cycles and may also be helpful in treating anorexia. Note: Use must be closely monitored because of potential side effects, although side effects from SSRIs are less significant than those associated with tricyclics.

• 20.4. Antianxiety agents: alprazolam (Xanax)
  Reduces tension, anxiety, and nervousness and may help the patient to participate in treatment.

• 20.5. Antipsychotic drugs: chlorpromazine (Thorazine)
  Promotes weight gain and cooperation with the psychotherapeutic program; however, used only when absolutely necessary because of the possibility of extrapyramidal side effects.

• 20.6. Monoamine oxidase inhibitors (MAOIs): tranylcypromine sulfate (Parnate)
  May be used to treat depression when other drug therapy is ineffective; decreases the urge to binge in bulimia.

21. Assist with electroconvulsive therapy (ECT) if indicated. Discuss reasons for use and help the patient understand this is not punishment.
In rare and difficult cases in which malnutrition is severe and life-threatening, a short-term ECT series may enable the patient to begin eating and become accessible to psychotherapy.