Anorexia nervosa is an eating disorder that causes people to obsess about their weight and the food they eat. People with anorexia nervosa attempt to maintain a weight that’s far below normal for their age and height. To prevent weight gain or to continue losing weight, people with anorexia nervosa may starve themselves or exercise excessively.
Anorexia nervosa is a disease that affects all organ systems, principally the cardiovascular and endocrine systems. However, complications can also involve other systems, including the GI, renal, reproductive, neurologic, orofacial, dermatologic, and hematologic symptoms.
A typical case of anorexia nervosa involves a young person (teenager or young adult) who is mildly overweight or of normal weight and who begins a diet and exercise plan to lose weight. As she loses weight and receives initial positive reinforcement for this behavior (eg, compliments by peers on her appearance), the reward is high and causes an inability to stop this behavior once an ideal weight is achieved.
ETIOLOGICAL THEORIES
Psychodynamics
The individual reflects a developmental arrest in the very early childhood years. The tasks of trust, autonomy, and separation-individuation are unfulfilled, and the individual remains in the dependent position. Ego development is retarded. Symptoms are often associated with a perceived loss of control in some aspect of life and may center on fears of sexual maturity/intimacy. Although these disorders affect women primarily, approximately 5% to 10% of those afflicted are men. Additionally, eating disorders are often associated with depression, anxiety, phobias, and cognitive problems.
Biological
These disorders may be caused by neuroendocrine abnormalities within the hypothalamus. Symptoms are linked to various chemical disturbances normally regulated by the hypothalamus. Furthermore, a physiological defect may make it difficult for the individual to interpret sensations of hunger and fullness.
Family Dynamics
Issues of control become the overriding factors in the family of the client with an eating disorder. These families often consist of a passive father, a domineering mother, and an overly dependent child. There is a high value placed on perfectionism in this family, and the child believes she or he must please others and satisfy these standards.
NURSING PRIORITIES
1. Reestablish adequate/appropriate nutritional intake.
2. Correct fluid and electrolyte imbalance.
3. Assist client to develop realistic body image/improve self-esteem.
4. Provide support/involve SO, if available, in treatment program to client/SO.
5. Coordinate total treatment program with other disciplines.
6. Provide information about disease, prognosis, and treatment.
DISCHARGE GOALS
1. Adequate nutrition and fluid intake maintained.
2. Maladaptive coping behaviors and stressors that precipitate anxiety recognized.
3. Adaptive coping strategies and techniques for anxiety reduction and self-control implemented.
4. Self-esteem increased.
5. Disease process, prognosis, and treatment regimen understood.
6. Plan in place to meet needs after discharge.
Nursing diagnosis of Anorexia Nervosa and Bulimia Nervosa: NUTRITION: altered, less than body requirements may be related to inadequate food intake; self-induced vomiting and chronic/excessive laxative use possibly evidenced by body weight 15% (or more) below expected (anorexia), or may be within normal range (bulimia, binge-eating), pale conjunctiva and mucous membranes; poor skin turgor/muscle tone, edema, excessive loss of hair; increased growth of body hair (lanugo), amenorrhea, hypothermia, bradycardia, cardiac irregularities, hypotension, electrolyte imbalances.
Desired Outcome:
1. Verbalize understanding of nutritional needs.
2. Establish a dietary pattern with caloric intake adequate to regain/maintain appropriate weight.
3. Demonstrate weight gain toward expected goal range.
Nursing intervention with rationale:
1. Establish a minimum weight goal and daily nutritional requirements.
Rationale: Malnutrition is a mood-altering condition leading to depression and agitation and affecting cognitive functioning/decision-making. Improved nutritional status enhances thinking ability, and psychological work can begin.
2. Involve client with team in setting up/carrying out program of behavior modification. Provide reward for weight gain as individually determined; ignore loss.
Rationale: Provides structured eating stimulation while allowing client some control in choices. Behavior modification may be effective only in mild cases or for short-term weight gain. Note: Combination of cognitive-behavioral approach is preferred for treating bulimia.
3. Use a consistent approach. Sit with client while eating; present and remove food without persuasion and/or comment. Promote pleasant environment and record intake.
Rationale: Client detects urgency and reacts to pressure. Any comment that might be seen as coercion provides focus on food. When staff member responds consistently, client can begin to trust her or his responses. The single area in which client has exercised power and control is food/eating, and she or he may experience guilt or rebellion if forced to eat. Structuring meals and decreasing discussions about food will decrease power struggles with client and avoid manipulative games.
4. Provide smaller meals and supplemental snacks, as appropriate.
Rationale: Gastric dilation may occur if refeeding is too rapid following a period of starvation dieting. Note: Client may feel bloated for 3–6 weeks while body readjusts to food intake.
5. Make selective menu available and allow client to control choices, as much as possible.
Rationale: Client who gains self-confidence and feels in control of environment is more likely to eat preferred foods.
6. Be alert to choices of low-calorie foods/beverages; hoarding food; disposing of food in various places such as pockets or wastebaskets.
Rationale: Client will try to avoid taking in what is viewed as excessive calories and may go to great lengths to avoid eating.
7. Maintain a regular weighing schedule, such as Monday/Friday before breakfast in same attire, on same scale, and graph results.
Rationale: Provides accurate ongoing record of weight loss/gain. Also diminishes obsessing about changes in weight.
8. Weigh with back to scale (depending on program protocols).
Rationale: Although some programs prefer client to see the results of weighing, this approach can force the issue of trust in client who usually does not trust others.
9. Consult with dietitian/nutritional therapy team.
Rationale: Helpful in determining individual dietary needs and appropriate sources. Note: Insufficient calorie and protein intake can lower resistance to infection and cause constipation, hallucinations, and liver damage.
10. Transfer to acute medical setting for nutritional therapy, when condition is life-threatening.
Rationale: The underlying problem cannot be cured 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 client from SO(s) and provides exposure to others with the same problem, creating an atmosphere for sharing.
Nursing Diagnoses
1. Imbalanced Nutrition: Less Than Body Requirements
| Common Related Factors | Defining Characteristics |
Severe fear of obesity Severely distorted self-concept, self-esteem, and/or body image
Absence of physical conditions that would explain weight loss or prevent weight gain | Body weight 15% to 29% or more below ideal weight for height Self-restricted calorie intake despite hunger
Obsession with food, calories, weight, and control issues |
Common Expected Outcomes Patient stops losing weight.
Patient begins to gain weight.
Patient recognizes eating disorder. | NOC Outcomes Nutritional Status: Food and Fluid Intake; Weight Control
NIC Interventions
Eating Disorders Management; Weight Gain Assistance; Nutritional Therapy |
Ongoing Assessment
| Actions/Interventions | Rationale |
| Record the patient’s weight and height on intake. Weigh regularly, maintaining standard conditions (i.e., same scale, same time of day, patient wearing similar clothes). | This ensures accurate record of weight changes. |
| Weigh the patient in a matter-of-fact manner without discussion. | This reduces risk of acting-out behaviors. Weight gain is only one aspect of the total therapeutic program; other critical factors include nutritional adequacy, behaviors related to eating, appropriate use of exercise, and development of a healthy body image. |
| Obtain weight history, including initial motivation for weight loss or food restrictions. | Clinical anorexia can follow ordinary weight loss dieting. |
| Conduct a nutritional assessment: | It is critical that the health care provider openly discuss and have an understanding of the complex food and weight-related behaviors of the patient so that appropriate supports can be integrated into the treatment plan. |
- Assess the patient’s beliefs and fears about food and weight gain
| Excessive focus on food and weight can be a maladaptive method of coping with stress. |
- Knowledge about nutrition and sources of information
| This information provides the basis for an individualized teaching plan about maintaining adequate nutritional intake. |
- Behaviors used to reduce calorie intake (dieting), to increase energy output (exercising), and generally to lose weight (vomiting, purging, and laxative abuse)
| This provides data on patient thinking and thought distortions. |
| Assess cardiovascular, metabolic, renal, gastric, hematological, and endocrine system functioning. | Assessment provides data on the severity of malnutrition. |
| Monitor intake (i.e., daily food plans that track eating trends along with emotional states and triggering events). Record intake and output for the hospitalized patient. | These data help determine the patient’s actual caloric intake and eating behaviors. |
Therapeutic Interventions
| Actions/Interventions | Rationale |
| Prescribe appropriate nutrition and total calories per day to relieve acute starvation. | A gradual refeeding prescription ensures steady weight gain and reduces risk of medical complications. |
| Supervise all activities immediately before and after meals; maintain supervision consistency. | This decreases opportunity to engage in compensatory activities to reduce calorie intake. |
| Provide food and meals without comment. | This helps separate emotional behaviors from eating behaviors. |
| Set limits on all exercise but allow daily activity. | Preventing all forms of exercise may induce severe anxiety. |
| Assure the patient that treatment is not designed to produce obesity. | Patients have an overwhelming fear of weight gain and obesity. |
| Acknowledge any anger, sadness, or feeling of loss that the patient may have toward treatment. | This helps provide external emotional controls that have not yet been internalized by the patient. |
| Provide supplemental feedings and nutrition as indicated. | Nutritional supplements may be necessary if the patient is malnourished. Tube or parenteral feedings may be necessary if the patient is unable to allow herself or himself oral feedings. |
2. Disturbed Body Image
| Common Related Factors | Defining Characteristics |
Difficulty coping with development and maturation Inability to achieve unreasonable personal goals
Alexithymia (channeling uncomfortable feelings into behaviors such as self-starvation) | Distorted views of one’s body weight and shape for age Negative feelings about self and body
Self-loathing (impulsive or obsessive)
Intense fear of gaining or not being able to lose weight |
Common Expected Outcomes Patient identifies positive thoughts and feelings regarding body and self.
Patient identifies a direct means of coping with problems. | NOC Outcome Body Image
NIC Interventions
Self-Awareness Enhancement; Body Image Enhancement |
Ongoing Assessment
| Actions/Interventions | Rationale |
| Explore the patient’s understanding of his or her physical body, especially as it relates to maturation. Assess to what degree the patient’s negative body image and negative self-concept are related to overwhelming anxiety. | Patients with anorexia have a distorted body image. |
| Assess to what degree culture, religion, race, and gender influence the patient’s negative views of self. | Cultural and social norms about body size and shape may influence the patient’s thinking and feelings about his or her body image. |
| Determine the family or patient’s perceptions regarding psychological and physical changes brought about by anorexia. | These data need to be compared to the patient’s thinking prior to the onset of anorexia. |
| Obtain the patient’s assessment of personal strengths and weaknesses. | Patients learn they have the ability to handle day-to-day stress. |
| Assess the patient’s ability to identify “here and now” emotional states and precipitating events that trigger negative behaviors. | The patient may not be aware of the relationship between feelings and eating behaviors. |
Therapeutic Interventions
Actions/Interventions | Rationale |
| Encourage reexamination of positive and negative self-perceptions. | The patient needs to develop a realistic understanding of his or her body image. |
| Encourage the patient to identify the differences between “real people” and celebrities. | Patients often use media reports of celebrities as a guide for their eating behaviors. |
| Encourage recognition, expression, and acceptance of unpleasant feelings. | Patients with anorexia have a need for control in multiple areas of their lives. Mastery over food may have become a method for reducing tensions. |
| Help the patient develop a realistic, acceptable perception of body image and food. | Patients must understand the complex health problems associated with anorexia. |
| Refer the patient to individual counseling and a support group for eating disorders. | Multiple approaches are needed to achieve long-term changes in behavior. Groups that come together for mutual support and guidance can provide long-term assistance. |
