Anorexia nervosa is a serious eating disorder that is potentially life-threatening if not recognized and treated appropriately. It is characterized by a very low body weight, an intense fear of gaining weight, and extreme habits to prevent weight gain.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Disturbed Body Image
- Imbalanced Nutrition: Less Than Body Requirements
- Ineffective Adolescent Eating Dynamics
- Risk for Impaired Skin Integrity
Overview
Anorexias nervosa is a recognized psychiatric disorder by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Anorexia frequently co-occurs with other mental health conditions such as anxiety, depression, and substance abuse.
Anorexia is generally divided into two subtypes:
- Restricting type involves severe calorie restriction without binging or purging behavior, though the patient may participate in excessive exercise.
- Binging/purging type involves binge eating and then purging by inducing vomiting or misusing laxatives, diuretics, or enemas.
Anorexia has the potential to affect every organ system due to malnutrition from the patient starving their body of nutrients. Early treatment is crucial in preventing long-term health problems such as heart failure, kidney issues, and osteoporosis.
Anorexia nervosa carries a high risk of mortality and a low rate of remission. It is difficult to treat because the patient may not recognize or accept that they have an eating disorder. The goals of treatment focus on stabilizing and restoring weight, eliminating restricting or compensatory behaviors, treating psychological issues, and developing long-term changes.
Nursing Process
Nurses in medical settings may care for patients with anorexia when they are admitted for electrolyte imbalances, heart arrhythmias, and severe malnutrition. Psychiatric nurses may also care for patients with anorexia in instances of suicide attempts, depression, and anxiety. These patients require monitoring and management of complications, cautious refeeding treatment, and intense psychological therapy.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to anorexia.
Review of Health History
1. Interview the patient and the people surrounding them.
Ask questions that may reveal signs and symptoms of disordered eating. Many patients with anorexia are in denial about their condition or do not realize the severity of it. Patients often receive medical attention due to concerns from family members.
2. Assess for complaints observed with anorexia.
The patient may report findings, such as:
- Difficulty concentrating
- Headaches
- Irritability
- Constipation
- Dizziness
- Fatigue
- Amenorrhea
3. Track the patient’s weight history.
Anorexia is characterized by a very low body weight, an intense fear of gaining weight, and a distorted perception of weight. Note any significant weight changes.
4. Allow the patient or family to describe eating behaviors.
Patients with anorexia may form habits around food and may obsessively count calories, hoard or conceal food, or refuse to eat certain foods or food groups. Family members or friends may notice behaviors like spending time in the bathroom immediately after eating, lying about how much or when they’ve eaten, or finding laxatives or diuretics in their possession.
5. Ask about activities to lose weight.
Patients may attempt to reduce weight through:
- Fasting or extreme calorie restriction
- Excessive exercise
- Self-inflicted vomiting (purging)
- Use of laxatives, enemas, diet supplements, appetite suppressants, or herbal remedies
6. Ask the patient about their beliefs and perceptions about their appearance.
Patients with anorexia often perceive themselves as overweight even when they are not. They may feel that certain areas of their body carry excess fat and continue to seek ways to lose weight despite reassurances from others.
7. Check the presence of peer pressure in children and adolescents.
Peer pressure may be a powerful influence, especially for young people. Teenagers may wish to control their weight as a way to fit in. Social media platforms also play a role in what is perceived as attractive and may include thinness, dieting, and excessive exercise.
8. Note any personal or family history of mental illness.
There is a genetic component to anorexia. Patients with a female relative who had anorexia are at a greater risk for the condition. Many patients also exhibit other psychiatric illnesses or have a family history of mental illness. Monitor for the presence of anxiety disorders, major depression, or obsessive-compulsive disorder.
9. Assess for trauma.
Physical, emotional, or sexual abuse can play a role in the development of body image issues and eating disorders in certain individuals. Disordered eating may result as a coping mechanism.
10. Assess the patient’s emotions.
Patients with anorexia are often very self-critical and need to feel in control. They may withdraw from friends and family. The nurse should assess for thoughts of suicide as this is the second leading cause of death for patients with anorexia.
11. Look for a history of disordered eating.
Anorexia nervosa shares similarities with other eating disorders. Avoidant/Restrictive food intake disorder, for example, can occur in children and causes extreme pickiness or disinterest in eating, which could worsen into anorexia. Other eating disorders may include:
- Bulimia nervosa
- Binge eating disorder
- Pica
- Rumination disorder
12. Identify predisposing factors.
Anorexia nervosa is more common in:
- Females
- Adolescents (onset between 13 and 18 years of age)
- Caucasians (> 95%)
- Those with a perfectionistic personality
- Patients who have difficulty communicating emotions
- Patients who have difficulty with conflict resolution
- Patients with low self-esteem
- Patients whose mothers encourage weight loss
- Athletes in sports like gymnastics, dancing, or running
Physical Assessment
1. Perform a thorough physical assessment.
Anorexia can cause complications that may affect every body system. Some signs of anorexia include:
- Thinning, brittle hair and nails
- Lanugo (fine hair covering the body)
- Edema
- Stomach pain or bloating
- Cold hands and feet
- Breast atrophy
- Loss of muscle mass
- Arrhythmias
2. Observe for signs of purging.
The following are physical signs of purging that the nurse may observe:
- Dental enamel erosion
- Parotid gland enlargement
- Esophagitis
- GI bleeding
- Russell’s sign (calluses on the knuckles)
3. Monitor vital signs.
Patients with anorexia may exhibit orthostatic hypotension, bradycardia, and hypothermia due to inadequate caloric intake.
4. Note height and weight.
The nurse must obtain a current height and weight to evaluate treatment effectiveness. Patients with anorexia often display a very low BMI.
5. Utilize the SCOFF questionnaire.
This screening tool assesses for the likelihood of anorexia by asking these questions:
- Do you make yourself Sick because you are full?
- Do you worry about losing Control over how much you eat?
- Have you lost more than One stone (14 lbs or 6.35 kg) in three months?
- Do you believe you are Fat when others say you are thin?
- Would you say Food dominates your life?
Diagnostic Procedures
1. Send blood for testing.
Lab tests evaluate for complications of starvation to guide treatment and may include:
- Complete blood count
- Complete metabolic profile
- Urinalysis
- Renal function panel
- Liver function tests
- Thyroid-stimulating hormone
- Hormone tests (such as testosterone levels)
2. Assess the cardiovascular status.
Anorexia is associated with cardiovascular complications, which are the leading cause of morbidity and mortality associated with the disorder. Obtain an ECG to detect potentially fatal arrhythmias.
3. Initiate further testing as ordered.
Further testing may be necessary to analyze other complications. Tests include:
- Drug testing for illegal and prescription drugs
- Chest X-ray to assess for damage from vomiting
- Bone density tests
- Serum vitamin D
- Fecal occult blood test to assess for trauma from laxative abuse
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions related to anorexia.
1. Anticipate inpatient care.
Patients with anorexia nervosa who are severely malnourished or psychologically at risk require treatment in an inpatient facility. The following are indications for hospital admission:
- Significant weight loss
- Lack of any weight gain
- Significant edema
- Vital sign alterations
- Severe electrolyte imbalance
- Cardiac disturbances
- Acute medical disorders
- Altered mental status
- Psychosis
- High risk of suicide
- Lack of a support system
- Limited access to outpatient treatment
- Nonadherence or continued purging behaviors
2. Monitor vital signs, lab values, and more.
In the inpatient setting, the nurse must closely monitor the client’s vital signs for orthostatic changes or hypothermia, ECG changes for arrhythmias, lab values for electrolyte disturbances, and intake and output for hydration or kidney issues.
3. Consider medications if necessary.
Olanzapine is the first drug of choice for patients who do not improve with early care. Selective serotonin reuptake inhibitors (SSRIs) may be prescribed for co-morbid conditions like an anxiety disorder or major depressive disorder.
Note: Tricyclic antidepressants (TCAs) are less favorable because of the potential for cardiotoxicity, particularly in individuals who are malnourished. Bupropion is not recommended for people with eating disorders due to the elevated risk of seizures.
4. Begin refeeding.
An essential component of treating anorexia is nutrition. Refeeding involves providing a set number of calories per day to achieve a goal weight. Refeeding must be administered gradually and with caution to prevent refeeding syndrome. If refeeding occurs too quickly in a malnourished body, it can cause serious and potentially deadly fluid and metabolic shifts. The nurse should collaborate closely with the dietician. Oral feedings are recommended, though tube feedings are necessary for severely underweight patients.
5. Prevent bone disorders.
Encourage the patient to take calcium-containing vitamin supplements. Estrogen replacement therapy (such as oral contraceptives) may also treat osteopenia.
6. Implement safety precautions.
Patients with anorexia may have mental health disorders that can increase the risk of self-injury and suicide. Implement safety precautions to prevent the patient from harming themselves.
7. Initiate psychotherapy.
Psychotherapy is vital to treating eating disorders and is recommended to continue on an outpatient basis for at least a year once the patient’s weight has been restored. Cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) are common forms of psychotherapy, and family-based therapy is essential for adolescents. Other forms of therapy may be added on an individualized basis.
8. Limit activities.
Limit the patient from excessive exercise and activities to reduce energy expenditure and ensure weight gain. Keep in mind that this may affect the patient’s coping strategies, and the nurse can offer other activities like journaling or creative outlets.
9. Closely monitor progress.
Surveillance is necessary to ensure that the patient’s weight and health are maintained and that the patient doesn’t develop unhealthy eating habits.
10. Provide support for the patient and their family.
The nurse should use active listening and empathy when communicating with the patient and family. The nurse must not make comments, good or bad, about the patient’s weight or appearance and should instead focus on other qualities.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for anorexia, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for anorexia.
Deficient Fluid Volume
To prevent weight gain and encourage weight loss, patients with anorexia severely restrict their intake and may also resort to purging behaviors leading to dehydration.
Nursing Diagnosis: Deficient Fluid Volume
Related to:
- Purging behaviors (self-induced vomiting, laxative use, diuretic use)
- Insufficient fluid intake
- Extreme fluid and food restriction
As evidenced by:
- Altered skin turgor
- Decreased blood pressure
- Decreased urine output
- Dry skin
- Dry mucous membranes
- Thirst
- Weakness
- Tachycardia
- Increased hematocrit
Expected outcomes:
- Patient will maintain blood pressure, temperature, and heart rate within normal limits.
- Patient will not experience dry skin, poor skin turgor, or dry mucous membranes.
Assessment:
1. Assess hydration status.
Anorexia can involve behaviors of excessive calorie restriction and purging behaviors which can lead to dehydration and electrolyte imbalances. Review the patient’s hematocrit, electrolyte panel, urinalysis, and kidney function for signs of deficient fluid volume.
2. Assess and monitor the patient’s vital signs and capillary refill.
Decreased blood pressure, tachycardia, bradycardia, and abnormal capillary refill can indicate decreased circulating volume and dehydration.
3. Assess for purging behaviors.
The binging/purging form of anorexia includes behaviors such as self-induced vomiting or the misuse of laxatives, diuretics, or enemas in an attempt to encourage weight loss. These behaviors instead only remove water from the body, causing potentially life-threatening hypovolemia, kidney damage, and electrolyte imbalances.
4. Inquire about symptoms of deficient fluid volume.
Patients may report symptoms of headache, dizziness, fatigue, and difficulty concentrating, which can alert the nurse to hypovolemia.
Interventions:
1. Monitor the patient’s intake and output.
In the inpatient setting, strict I&O monitoring is crucial to assess the patient’s hydration status and ensure adherence to the treatment plan.
2. Prevent purging behaviors.
Attempt to educate the patient that purging behaviors only cause a temporary weight reduction due to the loss of water, not fat. In the outpatient setting, parents may need to remain vigilant to prevent these harmful behaviors by monitoring the patient in the bathroom and searching their belongings for diuretics or laxatives.
3. Administer intravenous fluids and electrolytes as indicated.
Administering IV fluids and electrolytes corrects fluid and electrolyte imbalances and reduces the risk of other complications.
4. Monitor for orthostatic hypotension.
Orthostatic hypotension often results from hypovolemia. The nurse can take the patient’s blood pressure lying, sitting, and standing, to assess for a drop in blood pressure of 20 mm Hg or more systolic or 10 mm Hg or more diastolic.
Disturbed Body Image
Patients who suffer from anorexia restrict themselves from eating because they have a distorted view of their outward appearance.
Nursing Diagnosis: Disturbed Body Image
Related to:
- Mental health disorder
- Eating disorder
As evidenced by:
- Seeing themselves as fat even when they are not
- Fear of rejection or reaction by others
- Negative feelings about their body
- Feelings of hopelessness or powerlessness
- Self-harm
- Frequently looking at self in the mirror
- Obsessive weight checking
- Not eating in public
Expected outcomes:
- Patient will verbalize positive feelings about their body.
- Patient will eat meals in the presence of others.
- Patient will participate in therapy and psychological counseling.
Assessment:
1. Have the patient describe themselves.
Documenting how they see themselves and how they think others see them will help in determining the extent of their body image distortion.
2. Listen to the patient’s comments and responses.
Assess for comments of negative self-talk in general conversation.
3. Observe their behavior concerning their appearance and body.
Ritualistic behaviors such as body-checking or concealment of their appearance provide insight into how the patient feels about themselves.
Interventions:
1. Encourage cognitive-behavioral therapy.
This form of therapy helps improve body image by modifying dysfunctional thoughts, feelings, and behaviors.
2. Establish a therapeutic nurse-patient relationship.
Developing an unbiased relationship with the patient will help build trust, which is necessary to treat a chronic eating disorder.
3. Consider underlying mental disorders.
Patients with eating disorders often suffer from personality disorders, severe depression, substance abuse, and more. Treatment of these conditions, along with anorexia, is paramount for long-term success.
4. Make distinctions between beauty in the media.
Adolescents with anorexia may be influenced by TV, magazines, and social media or even by parents or family members. They may feel pressured to appear a certain way. Patients may need to unlearn what they have been taught about unrealistic beauty standards.
5. Closely monitor for suicidal ideation and behavior.
Suicidal thoughts may occur when the patient is experiencing severe anxiety, depression, or hopelessness regarding weight and appearance. Recognition and safety is a priority.
Imbalanced Nutrition: Less Than Body Requirements
Nutritional imbalances can occur in patients suffering from anorexia due to an abnormally low level of nutrients due to a limitation of dietary intake or purging.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related to:
- Eating disorder
- Limited food intake
- Malnourishment
- Induced purging
- Excessive exercise
As evidenced by:
- Excessive weight loss
- Fatigue
- Hair loss
- Brittle nails
- Dry skin
- Electrolyte imbalances
- Anemia
- Loss of menses
Expected outcomes:
- Patient will verbalize an understanding of their nutritional needs.
- Patient will display improvement of weight as evidenced by a BMI of at least 19.
- Patient will demonstrate adherence to dietary interventions and treatment.
Assessment:
1. Determine body weight for age and height.
Measuring a person’s weight accurately is the first step in the initial assessment. Weight is used as a basis for caloric and nutritional requirements. BMI may be used by some healthcare professionals.
2. Assess the patient’s nutritional status.
Information about the patient’s initial nutritional status will help identify the problem and its severity. Since anorexic patients do not get adequate nutrients from food, the possibility of malnutrition is extremely high, if not entirely certain. Nutritional imbalances can be visualized through lab tests for electrolytes, protein levels, albumin, and more.
3. Assess the patient’s eating pattern.
Eating patterns are often abnormal in patients suffering from anorexia. An understanding of the patient’s eating pattern will provide baseline data and determine what interventions might be helpful.
Interventions:
1. Establish a minimum weight goal and daily nutritional requirements.
Patients with anorexia are fearful of gaining weight. Instead of providing a weight range that may cause patients to feel their number is “too high,” work towards a minimum weight number.
2. Provide smaller meals or snacks.
Re-introduction to food may be tricky as rapid refeeding may cause gastric dilation, especially after a long period of intense dieting. The patient may also fear large meals and need to start with bites or snacks.
3. Allow the patient to choose what they eat from a selective menu.
This way, the patient is made to feel like they are in control of the situation while helping them gain some confidence, ultimately leading to healthier choices.
4. Consider other markers of health.
Weight isn’t the most important goal. When the patient begins to have better digestion, sex hormones have returned along with menses, energy and sleep are improved, and the patient is mentally stable, they are likely at a stable weight.
5. Administer parenteral nutrition.
Nutritional support can be provided if the caloric intake is insufficient to sustain their metabolic needs. TPN may be required to stabilize electrolytes.
6. Consult with a knowledgeable dietician.
The dietician should be well-versed in treating patients with eating disorders to provide the most helpful and unbiased nutritional support.
Ineffective Adolescent Eating Dynamics
Anorexia is an eating disorder characterized by an intense fear of gaining weight, a distorted perception of weight, and an abnormally low body weight resulting from calorie restriction and unhealthy eating habits.
Nursing Diagnosis: Ineffective Adolescent Eating Dynamics
Related to:
- Anxiety
- Depression
- Poor self-esteem
- Excessive stress
- Peer pressure or media influence
- Unhealthy dietary habits
- History of abuse
- Negative parental influence on eating behaviors
As evidenced by:
- Depressive symptoms
- Avoiding participation in mealtimes
- Food refusal
- Inadequate appetite
- Undereating
- Overeating (binging)
Expected outcomes:
- Patient will maintain healthy eating patterns, as evidenced by eating at appropriate mealtimes and consuming an adequate amount of calories.
- Patient will maintain a BMI within normal limits.
Assessment:
1. Assess the patient’s nutritional status and BMI.
Anorexia is an eating disorder that often involves restricting calorie intake. Patients may also be particular about the foods they will consume. The nurse should obtain the patient’s height and weight to assess their BMI which is an indicator of their nutritional status.
2. Assess for psychological disorders.
Anxiety disorders or depression often occur alongside anorexia and unhealthy eating habits.
3. Assess the patient’s relationships with others.
Adolescents are at risk for peer pressure and bullying, which can cause them to develop negative perceptions of their appearance and weight. Assess for bullying online or in person.
4. Assess the patient’s goals related to eating.
Goals associated with weight loss and appearance are often correlated with disordered eating.
Interventions:
1. Establish a minimum weight goal along with acceptable daily nutritional requirements.
Weight restoration is the ultimate goal in anorexia treatment. Set a minimum goal weight and daily caloric intake as advised by a dietician.
2. Supervise the patient during and after meals.
Consistent supervision helps ensure adherence to the dietary treatment regimen and prevents relapse.
3. Encourage family meals.
Adolescents who share meals with their families experience better dietary intake that may last a lifetime. This also allows parents to model appropriate eating habits.
4. Refer to family-based therapy.
Family-based therapy is essential for the treatment of anorexia in adolescents.
Risk for Impaired Skin Integrity
With poor eating habits, patients with anorexia experience nutritional deprivation. This will result in physical changes in the hair, skin, and nails.
Nursing Diagnosis: Risk for Impaired Skin Integrity
Related to:
- Alteration in nutritional state
- Purging
- Emaciation
- Dehydration
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred and the goal of nursing interventions is aimed at prevention.
Expected outcomes:
- Patient will verbalize understanding of how poor nutrient intake affects the skin and hair.
- Patient will demonstrate the prevention of skin breakdown.
- Patient will demonstrate improved hair growth and skin appearance.
Assessment:
1. Observe skin or hair abnormalities.
Assess for thinning hair with breakage, thin, brittle nails, dry, itchy skin, and more that signals poor nutrition.
2. Inspect skin surfaces or pressure points.
Lack of hydration and proper nutrition leads to decreased perfusion and poor circulation. Patients with severe anorexia nervosa may be extremely underweight with bony prominences at an increased risk for pressure sores or skin breakdown.
Interventions:
1. Encourage bathing every other day instead of daily.
Frequent baths contribute to further drying of the skin. Do not scrub the skin with abrasive cleansers or cloths.
2. Instruct to use skin cream or lotion frequently, especially after bathing.
Lotions and creams will aid in lubricating the skin, which will decrease itching. Maintaining soft and smooth skin may also help in boosting their self-esteem.
3. Encourage vitamins.
Biotin is often taken to support hair and nail strength.
4. Educate the patient on the importance of frequent changing of position.
Changing positions will help circulation and prevent sores on bony prominences by avoiding prolonged pressure.
5. Emphasize the importance of adequate fluid intake and proper nutrition.
Improved nutrition and hydration will enhance skin suppleness and elasticity and prevent dryness and cracking.
References
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- Anorexia Nervosa. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/9794-anorexia-nervosa. Accessed on Dec. 16, 2022
- Anorexia Nervosa. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/eating-disorders/anorexia-nervosa. Accessed on Dec. 16, 2022
- Anorexia nervosa – Symptoms and causes. (2018, February 20). Mayo Clinic. Retrieved January 2024, from https://www.mayoclinic.org/diseases-conditions/anorexia-nervosa/symptoms-causes/syc-20353591
- Anorexia nervosa: What it is, symptoms, diagnosis & treatment. (2021, November 17). Cleveland Clinic. Retrieved January 2024, from https://my.clevelandclinic.org/health/diseases/9794-anorexia-nervosa
- Bernstein, B. E. (2023, August 9). Anorexia nervosa treatment & management: Approach considerations, pharmacologic therapy, types of psychological therapy. Diseases & Conditions – Medscape Reference. Retrieved January 2024, from https://emedicine.medscape.com/article/912187-treatment#showall
- Doenges, M. E., Moorhouse, M. F. (1993). Nurses’s Pocket Guide: Nursing Diagnoses with Interventions (4th Ed.). F.A. Davis Company.
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