13.4 Applying the Nursing Process to Eating Disorders
People with eating disorders may appear healthy even when they are very ill. Additionally, individuals with anorexia nervosa often do not view their behavior as a problem. They are typically only seen in health care settings due to concerned family or friends who encourage them to seek treatment. Conversely, individuals with bulimia nervosa or binge eating disorder may feel shame and sensitivity to the perceptions of others regarding their illness. Therefore, it is vital for the nurse to build a therapeutic nurse-patient relationship with patients with eating disorders and empathize with possible feelings of low self-esteem and lack of control over eating.[1]
This section will apply the nursing process to anorexia nervosa and bulimia nervosa.
Recognizing Cues
When assessing an individual with a potential or diagnosed eating disorder, it is vital to obtain their perception of the problem while assessing for signs and symptoms. Care planning that does not address their perspective will not be effective. As previously mentioned, patients with anorexia nervosa often do not perceive their behaviors as a problem, so specialized therapeutic techniques may be required. Review signs and symptoms associated with various eating disorders in Chapter 13.2.
A complete nursing assessment includes health history, psychosocial assessment, and screening for risk of suicide or self-harm. Nutritional patterns, fluid intake, and daily exercise should also be assessed. If the patient has a binging or purging pattern, the amount of food eaten and/or the frequency of these behaviors should be assessed. Objective assessments include routine weight monitoring and orthostatic vital signs. Common objective assessment findings for individuals with anorexia nervosa and bulimia nervosa are compared in Table 13.3. Patients with binge eating disorder may have obesity and gastrointestinal symptoms but do not typically have other associated abnormal assessment findings.
Table 13.3 Comparison of Assessment Findings in Anorexia Nervosa and Bulimia Nervosa[2]
| Anorexia Nervosa (Restricting Type and Binge Eating/Purging Type) | Bulimia Nervosa (Purging Type and Nonpurging Type) |
|---|---|
| Underweight | Normal to slightly low weight |
| Muscle weakening (from starvation and electrolyte imbalance) | Muscle weakening (from electrolyte imbalance) |
| Peripheral edema (from hypoalbuminemia) | Peripheral edema (from rebound fluids if diuretics are used) |
| Cardiovascular abnormalities (hypotension, bradycardia, heart failure from starvation, and dehydration) | Cardiovascular abnormalities (cardiomyopathy and cardiac dysrhythmias from electrolyte imbalances) |
| Abnormal lab results (hypokalemia and anemia from starvation) | Electrolyte imbalances (hypokalemia and hyponatremia from diuretics, laxatives, or vomiting) |
| Other signs:
Amenorrhea (lack of menstruation) Lanugo (growth of fine hair all over the body) Cold extremities Constipation Impaired renal function Decreased bone density |
Other signs:
Tooth erosion or dental caries (from vomiting reflux over enamel) Parotid swelling (due to increased serum amylase levels) Presence of Russell’s sign: Calluses or scars on hand (from self-induced vomiting) Seizures (purging via self-induced vomiting lowers seizure threshold) |
Diagnostic and Lab Work
Laboratory and diagnostic testing are typically performed to rule out thyroid imbalances and to evaluate for potential physiological complications resulting from starvation, dehydration, and electrolyte imbalances. Laboratory testing may include the following[3]:
- Complete blood count
- Electrolyte levels
- Glucose level
- Thyroid function tests
- Erythrocyte sedimentation rate (ESR)
- Creatine phosphokinase (CPK)
Diagnostic testing may include these tests:
- Electrocardiogram (ECG)
- Dual energy X-ray absorptiometry (DEXA) to measure bone density
Analyzing Cues and Generating Hypotheses
Common nursing concerns for individuals diagnosed with anorexia nervosa or bulimia nervosa include:[4]:
- Imbalanced nutrition: Less than body requirements
- Risk for electrolyte imbalance
- Risk for imbalanced fluid volume
- Impaired body image
- Ineffective coping
- Interrupted family processes
- Chronic low self-esteem
- Powerlessness
- Risk for spiritual distress
Prioritizing Hypotheses and Generating Solutions
These are the typical overall treatment goals for individuals with eating disorders[5]
- Prevent injury to self
- Restoring adequate nutrition
- Bringing weight to a healthy level
- Reducing excessive exercise
- Reducing binge-purge and binge eating behaviors
SMART expected outcomes are individualized for each client based on their established nursing diagnoses and current status. (SMART is an acronym for Specific, Measurable, Attainable/Actionable, Relevant, and Timely.) Examples of SMART outcomes for an individual hospitalized with anorexia nervosa are:
- The patient will maintain a normal sinus heart rhythm with a regular rate during their hospitalization.[6]
- The patient will consume 50% of food at each mealtime during hospitalization.
- The patient will demonstrate use of one coping technique when experiencing anxiety during shift.
Planning depends on the acuity of the patient’s situation. As previously discussed, patients are hospitalized for stabilization. Common criteria for hospitalization include extreme electrolyte imbalance, unstable vital signs, weight below 75% of healthy body weight, cardiac disturbances and arrhythmias, hypotension, temperature less than 98 degrees Fahrenheit, a failure of previous outpatient treatment, or risk for suicide.[7] After a patient is medically stable, the treatment plan includes a combination of psychotherapy, medications, and nutritional counseling. Review Chapter 13.2 for more details. EatingDisordersCareGuideline.pdf (choc.org) Because anxiety and disturbances in mood are comorbid conditions with eating disorders, it is important to review pertinent information in previous chapters when planning care.
Taking Action
Nurses individualize interventions based on the patient’s current clinical status and their phase of treatment. Interventions can be categorized based on the American Psychiatric Nursing Association (APNA) standard for Implementation that includes Coordination of Care; Health Teaching and Health Promotion; Pharmacological, Biological, and Integrative Therapies; Milieu Therapy; and Therapeutic Relationship and Counseling. (Review information about these subcategories in the “Taking Action” section of Chapter 3.) See Table 13.4 for selected nursing interventions for clients with eating disorders categorized by APNA categories. Previous chapters on stress and coping (see Chapter 2), anxiety (see Chapter 9), and depression (see Chapter 7) also discuss pertinent interventions.
Table 13.4 Examples of Nursing Interventions by APNA Subcategories[8],[9]
| Subcategory of the APNA Standard of Implementation | The Nurse Will … | Rationale |
|---|---|---|
| Coordination of Care | Communicate patient trends with interprofessional team members, such as risk for suicide and target weight. A target weight and daily caloric intake are set in collaboration with the dietician and the provider.
Refer to community resources and outpatient treatment. |
All team members providing care must be aware of the patient’s suicide risk to maintain a safe environment. A combination of treatments is used to achieve the patient’s goal weight and promote recovery.
Discharge planning is a vital component of treatment and should include the patient’s family or loved ones. |
| Health Teaching and Health Promotion | Promote health by teaching adaptive coping strategies such as journaling. Support basic skills such as learning how to create meal plans, shopping at the grocery store, and navigating family or social eating situations. | Nurses encourage resilience by promoting healthy coping strategies, communication, and problem-solving skills. |
| Pharmacological, Biological, and Integrative Therapies | Deliver patient education about antidepressants or other medications with expected time frames for improvement. | Patient understanding of their medications and potential side effects can increase medication adherence. |
| Milieu Therapy | Provide a pleasant, calm atmosphere at mealtimes. Emphasize the social nature of eating. Encourage conversations during mealtimes that do not involve the topics of eating or exercise.
Observe patients during meals to prevent hiding or throwing away food and at least one hour after eating to prevent purging. Encourage the patient to make their own menu choices as they approach their goal weight. |
The milieu of an eating disorder specialty unit is purposefully organized to assist the patient in establishing healthy eating patterns and normalization of eating. The highly structured environment provides precise mealtimes, adherence to the meal plan, close observation of bathroom trips, and monitoring potential access to laxatives or diuretics. Mealtimes can cause episodes of high anxiety. The patient should feel accepted and safe from judgmental evaluations in the milieu with a focus on eating behaviors and underlying feelings of anxiety, dysphoria, low self-esteem, and a lack of control.[10] |
| Therapeutic Relationship and Counseling | Provide 1:1 therapeutic communication to encourage the patient to develop adaptive coping strategies, use stress management techniques, develop supportive relationships, and seek spiritual resources.
Acknowledge the emotional and physical difficulty the patient is experiencing. Use motivational interviewing and contract with the patient to increase their ownership of treatment goals. Weigh the patient daily in their underwear for the first week and then three times a week. Do not allow oral intake before the morning weigh-in. It is permissible for the patient to not view the scale during the weigh-in. Administer liquid supplements as prescribed. Be empathetic with the patient’s struggle to give up control of their eating and weight as they are expected to regain weight. Encourage the clients to verbalize or use a journal to record their feelings surrounding eating disorder behaviors. Confront irrational thoughts and beliefs to promote healthy eating behaviors. Monitor physical activity and individualize the patient’s plans for exercise. Focus on the patient’s strengths, including their work on normalizing weight and eating behaviors. Reinforce the knowledge and skills gained from individual, family, and group therapy sessions. |
Effective therapeutic techniques for patients with depression can promote hope and positive self-esteem.
The first priority is to establish a trusting relationship. The patient’s extreme symptoms can be used to engage cooperation in the treatment plan. Motivational interviewing is a collaborative, goal-oriented style of communication. It is designed to strengthen personal motivation and commitment to specific goals by eliciting and exploring the person’s reasons for change within an atmosphere of acceptance and compassion.[11] Accurate weight taking and monitoring are vital. The patient may try to control and sabotage the weight monitoring. The patient is typically expected to gain 0.5 pound on a specific schedule. However, weight gain of more than five pounds in one week can cause pulmonary edema. The particulars of how patients should be weighed (i.e., open vs. blind weighed) is a point of debate in the field. Because viewing the scale can cause anxiety, blind weighing is typically used during the acute stage of treatment, whereas open weighing may be suitable at later stages of recovery.[12] Oral or enteral supplements may be prescribed based on the patient’s status. However, be alert for refeeding syndrome in severely malnourished patients. External control is required initially to promote good nutrition and a healthy weight. Cognitive and behavioral changes will occur gradually. The patient often experiences a strong drive to exercise. Nurses can assist in planning a reasonable amount of exercise. Acknowledge milestones and encourage other sources of gratification other than eating. |
Inpatient Care
The emphasis in an inpatient program of care is on achieving physiologic stability and initiating nutritional intake. As discussed above, patients are at risk for complications related to malnutrition, including cardiac and fluid and electrolyte abnormalities. Patients often exhibit instability in mood, anxiety, and functioning. If the patient is exhibiting risk for suicide, a safety plan should be immediately implemented. Review nursing care for patients with risk for suicide in Chapter 2.
Severely malnourished patients may require therapeutic enteral nutrition. Any patient with negligible food intake for more than five days is at risk of developing a potentially fatal complication called refeeding syndrome. The hallmark feature of refeeding syndrome is hypophosphatemia but may also involve serious sodium and fluid imbalances; changes in glucose, protein, and fat metabolism; thiamine deficiency; hypokalemia; and hypomagnesaemia. To avoid this syndrome, a thorough nutritional assessment must be performed followed by the slow reintroduction of nutrients and fluids according to evidence-based guidelines.[13]
After resolving acute symptoms, patients with anorexia begin a weight restoration program for incremental weight gain with a treatment goal set for 90% of ideal body weight. Specially trained dieticians assist in developing daily meal plans and caloric intake, and clients are generally weighed two or three times a week to gauge progress.[14] Of high importance is careful observation of eating behaviors during mealtimes. Patients must be observed for attempts to hide food or purge. Generally patients must stay in the open areas of the unit for one hour after eating.
Nurses should be aware that patients with bulimia nervosa typically establish a therapeutic nurse-patient relationship more quickly than patients with anorexia nervosa. As previously discussed in this chapter, patients with anorexia nervosa often do not view their condition as a disorder and value their obsessive-compulsive behaviors with eating as a way to feel safe and secure and avoid negative feelings. Conversely, patients with bulimia nervosa view their behaviors as problematic and desire help.[15]
Outpatient Care
Outpatient programs and residential treatment are options for patients who have been medically stabilized. In this setting, patients are engaged in a variety of treatment modalities aimed at continued normalization of eating behaviors and addressing underlying psychiatric disorders. Emphasis is on learning skills to manage symptoms and return to functioning in the community. Outpatient treatment continues if the client maintains a contracted weight, vital signs are within a normal range, and there is an absence of disordered eating behaviors.[16]
A significant part of the recovery process includes rebuilding relationships with family. Family members or significant others often feel frustrated, powerless, and hopeless because the strategies they previously attempted, such as forcing the patient to eat or begging the patient to eat, were not successful. The nurse helps with this recovery process by providing education to the patient and their loved ones about the illness, treatment, and meal planning. Adaptive coping skills to address disordered thoughts should be reinforced.[17]
Resources
Nurses refer patients and their loved ones to resources as part of discharge planning. Review examples of community resources in the following box.
Resources for Individuals With Eating Disorders
National Eating Disorders Association: Support, resources, and treatment options
Eating Disorders Resource Group: Resources including treatment apps
ANAD: Eating disorder peer support groups
Evaluation
Evaluation is a continuous process of reviewing a patient’s progress towards their individualized goals and SMART outcomes. Interventions are continually evaluated and modified based on their success in meeting these short-term goals. Patients with eating disorders are at risk for relapsing, necessitating reformulation of outcomes and revising care.
- Halter, M. (2022). Varcarolis’ foundations of psychiatric-mental health nursing (9th ed.). Saunders. ↵
- Halter, M. (2022). Varcarolis’ foundations of psychiatric-mental health nursing (9th ed.). Saunders. ↵
- Halter, M. (2022). Varcarolis’ foundations of psychiatric-mental health nursing (9th ed.). Saunders. ↵
- Halter, M. (2022). Varcarolis’ foundations of psychiatric-mental health nursing (9th ed.). Saunders. ↵
- Balasundaram, P. & Santhanam, P. (2023, June 26). Eating disorders. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK567717/ ↵
- Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
- Halter, M. (2022). Varcarolis’ foundations of psychiatric-mental health nursing (9th ed.). Saunders. ↵
- Halter, M. (2022). Varcarolis’ foundations of psychiatric-mental health nursing (9th ed.). Saunders. ↵
- American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). ↵
- Halter, M. (2022). Varcarolis’ foundations of psychiatric-mental health nursing (9th ed.). Saunders. ↵
- Miller, W. R., & Rollnick, S. (2013) Motivational Interviewing: Helping people to change (3rd ed.). Guilford Press. ↵
- Froreich, F. V., Ratcliffe, S. E., & Vartanian, L. R. (2020). Blind versus open weighing from an eating disorder patient perspective. Journal of Eating Disorders 8, 39. https://doi.org/10.1186/s40337-020-00316-1 ↵
- Persaud-Sharma, D., Saha, S., & Trippensee, A.W.(2022, November 17). Refeeding Syndrome. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK564513/ ↵
- Halter, M. (2022). Varcarolis’ foundations of psychiatric-mental health nursing (9th ed.). Saunders. ↵
- Halter, M. (2022). Varcarolis’ foundations of psychiatric-mental health nursing (9th ed.). Saunders. ↵
- Halter, M. (2022). Varcarolis’ foundations of psychiatric-mental health nursing (9th ed.). Saunders. ↵
- Halter, M. (2022). Varcarolis’ foundations of psychiatric-mental health nursing (9th ed.). Saunders. ↵
A syndrome in which individuals exhibit hypophosphatemia, sodium and fluid imbalances; changes in glucose, protein, and fat metabolism; thiamine deficiency; hypokalemia; and hypomagnesaemia.
