NCP Anorexia Nervosa

Anorexia Nervosa

Eating Disorder

Anorexia nervosa is a disorder characterized by an intense fear of obesity or weight gain and the inability or refusal to maintain body weight at 85% minimum expected for height. It is generally considered to be a disorder of young women that begins in adolescence or young adulthood. It is becoming more common in males. Anorexia nervosa is marked by severely restricted calorie intake, despite hunger, which leads to malnourishment and serious weight loss. The patient with anorexia nervosa achieves and maintains massive weight loss by calorie restriction; self-induced vomiting; abuse of cathartics, laxatives, or enemas; and/or excessive exercising. Many patients have severe disturbances in self-concept, self-esteem, and body image and may benefit from a therapeutic approach that involves nutritional consults, individual and family therapy, and medical management of the complicated organ system imbalances that this order brings about. Patients may be hospitalized briefly during the initial acute phase of treatment, when medical problems require intensive monitoring and complicated therapies. The initial aim of treatment is to stabilize the patient medically and stop weight loss. When medically stable, the patient can be managed in outpatient day treatment or partial hospitalization programs.

Nursing Diagnosis

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.

Nursing Diagnosis

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.

Nursing Diagnosis

Interrupted Family Processes

Common Related Factor	Defining Characteristics
Developmental attachment and separation crisis and the necessity for family restructuring	Family members unable to relate to each other for mutual growth and maturation Family system unable to meet the emotional needs of all family members Rigid family functions and roles Family does not tolerate individuality and autonomy for all members Family fails to accomplish critical developmental tasks
Common Expected Outcomes Family members develop effective methods of communication. Family members express understanding of shared and individual problems. Family members identify new resources for problem solving.	NOC Outcomes Family Coping; Family Functioning NIC Interventions Family Integrity Promotion; Family Therapy

Ongoing Assessment

Actions/Interventions	Rationale
Assess interactional patterns used by family:
·     Enmeshment	This is a lack of boundaries between family members.
·     Overprotectiveness	This is exaggerated concern for the welfare of family members.
·     Rigidity	This is an excessive need to maintain status quo.
·     Dysfunctional conflict resolution	Child becomes symptomatic in response to unresolved parental conflict.
Explore family views on recurring problems.	It is important to de-emphasize the family’s view of the patient as the family problem.
Explore effects of family members’ behaviors on one another. Identify interaction patterns.	This demonstrates how patterns produce dependence on family cues for regulation rather than fostering self-regulation.
Enroll the patient and family in counseling.	The family’s willingness to participate in the therapeutic process is a strong indicator of how successful the patient will be in reducing symptoms and behavior.
Acknowledge and give feedback to the family’s concerns and feelings.	This encourages direct expression of personal feelings.
Assist the adolescent or young adult patient in individuating self from parents. Encourage autonomy as is appropriate for age.	Patients with anorexia and their families may struggle with issues of dependence and independence, as well as control issues.