7 Eating Disorders: Anorexia & Bulimia Nervosa Nursing Care Plans

Eating Disorders.Anorexia & Bulimia Nervosa Nursing Care Plans is an illness of starvation, brought on by severe disturbance of body image and a morbid fear of obesity.  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 exerciseexcessively.

Bulimia nervosa is an eating disorder (binge-purge syndrome) characterized by extreme overeating followed by self-induced vomiting, trying to get rid of the extra calories in an unhealthy way. It may include abuse of laxatives and diuretics.

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Although these disorders primarily affect women, approximately 5%–10% of those afflicted are men, and both disorders can be present in the same individual.

Eating disorders are a range of psychological conditions that cause unhealthy eating habits to develop. They might start with an obsession with food, body weight, or body shape.

In severe cases, eating disorders can cause serious health consequences and may even result in death if left untreated.

Those with eating disorders can have a variety of symptoms. However, most include the severe restriction of food, food binges, or purging behaviors like vomiting or over-exercising.

Although eating disorders can affect people of any gender at any life stage, they’re most often reported in adolescents and young women. In fact, up to 13% of youth may experience at least one eating disorder by the age of 20 (2Trusted Source).

Summary Eating disorders are mental health conditions marked by an obsession with food or body shape. They can affect anyone but are most prevalent among young women.

What causes them?

Experts believe that eating disorders may be caused by a variety of factors.

One of these is genetics. Twin and adoption studies involving twins who were separated at birth and adopted by different families provide some evidence that eating disorders may be hereditary.

This type of research has generally shown that if one twin develops an eating disorder, the other has a 50% likelihood of developing one too, on average (3Trusted Source).

Personality traits are another cause. In particular, neuroticism, perfectionism, and impulsivity are three personality traits often linked to a higher risk of developing an eating disorder (3Trusted Source).

Other potential causes include perceived pressures to be thin, cultural preferences for thinness, and exposure to media promoting such ideals (3Trusted Source).

In fact, certain eating disorders appear to be mostly nonexistent in cultures that haven’t been exposed to Western ideals of thinness (4Trusted Source).

That said, culturally accepted ideals of thinness are very present in many areas of the world. Yet, in some countries, few individuals end up developing an eating disorder. Thus, they are likely caused by a mix of factors.

More recently, experts have proposed that differences in brain structure and biology may also play a role in the development of eating disorders.

In particular, levels of the brain messenger’s serotonin and dopamine may be factors (5, 6).

However, more studies are needed before strong conclusions can be made.

Summary Eating disorders may be caused by several factors. These include genetics, brain biology, personality traits, and cultural ideals.

1. Anorexia nervosa

Anorexia nervosa is likely the most well-known eating disorder.

It generally develops during adolescence or young adulthood and tends to affect more women than men (7Trusted Source).

People with anorexia generally view themselves as overweight, even if they’re dangerously underweight. They tend to constantly monitor their weight, avoid eating certain types of foods, and severely restrict their calories.

Common symptoms of anorexia nervosa include (8):

Being considerably underweight compared with people of similar age and height

Very restricted eating patterns

An intense fear of gaining weight or persistent behaviors to avoid gaining weight, despite being underweight

A relentless pursuit of thinness and unwillingness to maintain a healthy weight

A heavy influence of body weight or perceived body shape on self-esteem

A distorted body image, including denial of being seriously underweight

Obsessive-compulsive symptoms are also often present. For instance, many people with anorexia are often preoccupied with constant thoughts about food, and some may obsessively collect recipes or hoard food.

Such individuals may also have difficulty eating in public and exhibit a strong desire to control their environment, limiting their ability to be spontaneous.

Anorexia is officially categorized into two subtypes — the restricting type and the binge eating and purging type (8).

Individuals with the restricting type lose weight solely through dieting, fasting, or excessive exercise.

Individuals with the binge eating and purging type may binge on large amounts of food or eat very little. In both cases, after they eat, they purge using activities like vomiting, taking laxatives or diuretics, or exercising excessively.

Anorexia can be very damaging to the body. Over time, individuals living with it may experience the thinning of their bones, infertility, brittle hair and nails, and the growth of a layer of fine hair all over their body (9).

In severe cases, anorexia can result in heart, brain, or multi-organ failure and death.

Summary People with anorexia nervosa may limit their food intake or compensate for it through various purging behaviors. They have an intense fear of gaining weight, even when severely underweight.

2. Bulimia nervosa

Bulimia nervosa is another well-known eating disorder.

Like anorexia, bulimia tends to develop during adolescence and early adulthood and appears to be less common among men than women (7Trusted Source).

People with bulimia frequently eat unusually large amounts of food in a specific period of time.

Each binge eating episode usually continues until the person becomes painfully full. During a binge, the person usually feels that they cannot stop eating or control how much they are eating.

Binges can happen with any type of food but most commonly occur with foods the individual would normally avoid.

Individuals with bulimia then attempt to purge to compensate for the calories consumed and relieve gut discomfort.

Common purging behaviors include forced vomiting, fasting, laxatives, diuretics, enemas, and excessive exercise.

Symptoms may appear very similar to those of the binge eating or purging subtypes of anorexia nervosa. However, individuals with bulimia usually maintain a relatively normal weight, rather than becoming underweight.

Common symptoms of bulimia nervosa include (8):

Recurrent episodes of binge eating with a feeling of lack of control

Recurrent episodes of inappropriate purging behaviors to prevent weight gain

A self-esteem overly influenced by body shape and weight

A fear of gaining weight, despite having a normal weight

Side effects of bulimia may include an inflamed and sore throat, swollen salivary glands, worn tooth enamel, tooth decay, acid reflux, irritation of the gut, severe dehydration, and hormonal disturbances (9).

In severe cases, bulimia can also create an imbalance in levels of electrolytes, such as sodium, potassium, and calcium. This can cause a stroke or heart attack.

Summary People with bulimia nervosa eat large amounts of food in short periods of time, then purge. They fear gaining weight despite being at a normal weight.

3. Binge eating disorder

Binge eating disorder is believed to be one of the most common eating disorders, especially in the United States (10Trusted Source).

It typically begins during adolescence and early adulthood, although it can develop later on.

Individuals with this disorder have symptoms similar to those of bulimia or the binge eating subtype of anorexia.

For instance, they typically eat unusually large amounts of food in relatively short periods of time and feel a lack of control during binges.

People with binge eating disorder do not restrict calories or use purging behaviors, such as vomiting or excessive exercise, to compensate for their binges.

Common symptoms of binge eating disorder include (8):

Eating large amounts of foods rapidly, in secret and until uncomfortably full, despite not feeling hungry

Feeling a lack of control during episodes of binge eating

Feelings of distress, such as shame, disgust, or guilt, when thinking about the binge eating behavior

No use of purging behaviors, such as calorie restriction, vomiting, excessive exercise, or laxative or diuretic use, to compensate for the binging

People with binge eating disorder often have overweight or obesity. This may increase their risk of medical complications linked to excess weight, such as heart disease, stroke, and type 2 diabetes (11Trusted Source).

Summary People with binge eating disorder regularly and uncontrollably consume large amounts of food in short periods of time. Unlike people with other eating disorders, they do not purge.

4. Pica

Pica is another eating disorder that involves eating things that are not considered food.

Individuals with pica crave non-food substances, such as ice, dirt, soil, chalk, soap, paper, hair, cloth, wool, pebbles, laundry detergent, or cornstarch (8).Pica can occur in adults, as well as children and adolescents. That said, this disorder is most frequently observed in children, pregnant women, and individuals with mental disabilities (12Trusted Source).

Individuals with pica may be at an increased risk of poisoning, infections, gut injuries, and nutritional deficiencies. Depending on the substances ingested, pica may be fatal.

However, to be considered pica, the eating of non-food substances must not be a normal part of someone’s culture or religion. In addition, it must not be considered a socially acceptable practice by a person’s peers.

Summary Individuals with pica tend to crave and eat non-food substances. This disorder may particularly affect children, pregnant women, and individuals with mental disabilities.

5. Rumination disorder

Rumination disorder is another newly recognized eating disorder.

It describes a condition in which a person regurgitates food they have previously chewed and swallowed, re-chews it, and then either re-swallows it or spits it out (13Trusted Source).

This rumination typically occurs within the first 30 minutes after a meal. Unlike medical conditions like reflux, its voluntary (14).

This disorder can develop during infancy, childhood, or adulthood. In infants, it tends to develop between 3–12 months of age and often disappears on its own. Children and adults with the condition usually require therapy to resolve it.

If not resolved in infants, rumination disorder can result in weight loss and severe malnutrition that can be fatal.

Adults with this disorder may restrict the amount of food they eat, especially in public. This may lead them to lose weight and become underweight (8, 14)

Summary Rumination disorder can affect people at all stages of life. People with the condition generally regurgitate the food they’ve recently swallowed. Then, they chew it again and either swallow it or spit it out.

6. Avoidant/restrictive food intake disorder

Avoidant/restrictive food intake disorder (ARFID) is a new name for an old disorder.

The term replaces what was known as a “feeding disorder of infancy and early childhood,” a diagnosis previously reserved for children fewer than 7 years old.

Although ARFID generally develops during infancy or early childhood, it can persist into adulthood. What’s more, it’s equally common among men and women.

Individuals with this disorder experience disturbed eating either due to a lack of interest in eating or distaste for certain smells, tastes, colors, textures, or temperatures.

Common symptoms of ARFID include (8):

Avoidance or restriction of food intake that prevents the person from eating sufficient calories or nutrients

Eating habits that interfere with normal social functions, such as eating with others

Weight loss or poor development for age and height

Nutrient deficiencies or dependence on supplements or tube feeding

It’s important to note that ARFID goes beyond normal behaviors, such as picky eating in toddlers or lower food intake in older adults.

Moreover, it does not include the avoidance or restriction of foods due to lack of availability or religious or cultural practices.

Summary ARFID is an eating disorder that causes people to underreact. This is either due to a lack of interest in food or an intense distaste for how certain foods look, smell, or taste.

Other eating disorders

In addition to the six eating disorders above, less-known or less common eating disorders also exist. These generally fall under one of three categories (8):

Purging disorder. Individuals with purging disorder often use purging behaviors, such as vomiting, laxatives, diuretics, or excessive exercising, to control their weight or shape. However, they do not binge.

Night eating syndrome. Individuals with this syndrome frequently eat excessively, often after awakening from sleep.

Other specified feeding or eating disorder (OSFED). While not found in the DSM-5, this includes any other conditions that have symptoms similar to those of an eating disorder but don’t fit into any of the categories above.

One disorder that may currently fall under OSFED is orthorexia. Although increasingly mentioned in the media and scientific studies, orthorexia has yet to be recognized as a separate eating disorder by the current DSM.

Individuals with orthorexia tend to have an obsessive focus on healthy eating, to an extent that disrupts their daily lives.

For instance, the affected person may eliminate entire food groups, fearing they’re unhealthy. This can lead to malnutrition, severe weight loss, difficulty eating outside the home, and emotional distress.

Individuals with orthorexia rarely focus on losing weight. Instead, their self-worth, identity, or satisfaction is dependent upon how well they comply with their self-imposed diet rules (15).

Summary Purging disorder and night eating syndrome are two additional eating disorders that are currently not well described. The OSFED category includes all eating disorders, such as orthorexia, that don’t fit into another category.

Nursing Care Plans

Nursing care planning for patients with eating disorders: anorexia nervosa, bulimia nervosa includes establishing adequate nutritional intake, correcting fluid and electrolyte imbalance, assist patient to develop a realistic body image and improving self-esteem. Other than the mentioned above, it is also an important nursing priority to provide support in the treatment program and coordinate program with order disciplines.

Included in this post are seven (7) nursing care plans and nursing diagnosis for patients with eating disorders: anorexia nervosa and bulimia nervosa:

  1. Imbalanced Nutrition: Less Than Body Requirements
  2. Risk for Deficient Fluid Volume
  3. Disturbed Thought Process
  4. Disturbed Body Image, Chronic Low Self-Esteem
  5. Impaired Parenting
  6. Risk for Impaired Skin Integrity
  7. Deficient Knowledge
  8. Other Possible Nursing Diagnoses
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Nursing Diagnosis

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
  • Anorexia & Bulimia Nervosa Nursing Care Plans

Desired Outcomes

  • Client will verbalize understanding of nutritional needs.
  • Client will establish a dietary pattern with caloric intake adequate to regain/maintain an appropriate weight.
  • Client will demonstrate weight gain toward the individually expected range.
Nursing Interventions Rationale
For Bulimia Nervosa:
Supervise the patient during mealtimes and for a specified period after meals (usually one hour). Prevents vomiting during or after eating.
Identify the patient’s elimination patterns. To prevent self-induced vomiting.
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.
Outline the risks of laxative, emetic, and diuretic abuse for the patient Bulimic patients may include abuse of laxatives, emetics, and diuretics.
For Anorexia Nervosa:
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.
Liquids are more acceptable than solid. Fluids eliminate the need to choose between foods – something the patient with anorexia may find difficult.
Expect weight gain of about 1 lb (0.5 kg) per week. To see the effectiveness of the treatment regimen.
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:
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.
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. Patient detects urgency and may react to pressure. Any comment that might be seen as coercion provides 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.Anorexia & Bulimia Nervosa Nursing Care Plans
Provide smaller meals and supplemental snacks, as appropriate. Gastric dilation may occur if refeeding is too rapid following a period of starvation dieting. Note: Patient may feel bloated for 3–6 weeks while the body adjusts to food intake.
Make selective menu available, and allow patient to control choices as much as possible. Patient who gains confidence in self and feels in control of the environment is more likely to eat preferred foods.
Be alert to choices of low-calorie foods and beverages; hoarding food; disposing of food in various places, such as pockets or wastebaskets. Patient will try to avoid taking in what is viewed as excessive calories and may go to great lengths to avoid eating.
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.
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.
Avoid room checks and other control devices whenever possible. External control reinforces feelings of powerlessness and therefore is usually not helpful.
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. Patient may desire food and use a binge-purge syndrome to maintain weight. Note: Patient may purge for the first time in response to the establishment of a weight gain program.
Monitor 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, weight and combating depression; however, patient may exercise excessively to burn calories.
Maintain matter-of-fact, nonjudgmental attitude if giving tube feedings, hyperalimentation, and so on. Perception of punishment is counterproductive to patient’s self-confidence and faith in own ability to control destiny.
Be alert to the possibility of the patient disconnecting tube and emptying hyperalimentation if used. Check measurements, and tape tubing snugly. Sabotage behavior is common in an attempt to prevent weight gain.
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 and elimination, medications, and activities can be monitored. It also separates the patient from SO (who may be contributing factor) and provides exposure to others with the same problem, creating an atmosphere for sharing.
Involve 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 in choices. Behavior modification may be effective in mild cases or for short-term weight gain.
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.
Administer liquid diet,  tube feedings,
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.
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.
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.
Avoid giving laxatives. Use is counterproductive because they may be used by the patient to rid the body of food and calories.
Administer medication as indicated:
A serotonin and histamine antagonist that 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.
Lifts depression and stimulates the appetite.
  • 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.
  • Antianxiety agents: alprazolam (Xanax)
Reduces tension, anxiety, nervousness and may help the patient to participate in treatment.
Promotes weight gain and cooperation with the psychotherapeutic program; however, used only when absolutely necessary because of the possibility of extrapyramidal side effects.
  • Monoamine oxidase inhibitors (MAOIs): tranylcypromine sulfate (Parnate)
May be used to treat depression when other drug therapy is ineffective; decreases urge to binge in bulimia.
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 patient to begin eating and become accessible to psychotherapy.
 

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