Anorexia nervosa is a critical eating disorder characterized by an abnormally low body weight, an overwhelming fear of weight gain, and distorted body image, leading to severe restrictions in food intake. This condition poses significant life-threatening risks if not promptly identified and managed with appropriate interventions.
Understanding Anorexia Nervosa
Recognized as a psychiatric disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), anorexia nervosa often coexists with other mental health issues like anxiety disorders, depression, and substance use disorders.
Anorexia nervosa is broadly categorized into two main subtypes:
- Restricting Type: Defined by strict calorie limitation, often accompanied by excessive exercise, without engaging in binge eating or purging behaviors.
- Bingeing/Purging Type: Characterized by episodes of binge eating followed by compensatory purging behaviors such as self-induced vomiting or misuse of laxatives, diuretics, or enemas.
The profound malnutrition associated with anorexia nervosa can impact virtually every organ system in the body. Early intervention is essential to mitigate long-term health complications, including cardiac failure, renal dysfunction, and osteoporosis.
Anorexia nervosa is associated with a high mortality rate and a challenging remission trajectory. Treatment is complex, often complicated by the patient’s denial or lack of recognition of their condition. The primary goals of treatment are centered on weight stabilization and restoration, elimination of restrictive and compensatory behaviors, addressing underlying psychological issues, and fostering sustainable long-term behavioral changes.
The Role of Nursing Process
Nurses across various healthcare settings play a crucial role in the care of patients with anorexia nervosa. In medical settings, nurses may encounter these patients when they are hospitalized for complications such as electrolyte imbalances, cardiac arrhythmias, and severe malnutrition. Psychiatric nurses are also involved in caring for individuals with anorexia, particularly in cases involving suicide attempts, depression, and anxiety. The nursing care encompasses vigilant monitoring, management of medical complications, careful refeeding strategies, and intensive psychological support.
Comprehensive Nursing Assessment
The initial step in nursing care is a thorough nursing assessment, designed to gather comprehensive physical, psychosocial, emotional, and diagnostic data. This section will detail both subjective and objective data pertinent to anorexia nervosa.
Review of Health History
1. Patient and Family Interviews: Initiate interviews with the patient and their family or support system. Frame questions to elicit signs and symptoms of disordered eating patterns. Recognize that many individuals with anorexia may be in denial about their condition or underestimate its severity. Often, medical attention is sought due to concerns raised by family members.
2. Identify Reported Symptoms: Assess for common complaints associated with anorexia nervosa. Patients may report experiencing:
- Difficulty concentrating
- Headaches
- Irritability
- Constipation
- Dizziness
- Fatigue
- Amenorrhea
3. Weight History Review: Carefully document the patient’s weight history. Anorexia nervosa is defined by significantly low body weight, intense fear of weight gain, and a distorted perception of body weight. Note any significant weight fluctuations and patterns.
4. Eating Behavior Description: Encourage the patient and family to describe observed eating behaviors. Patients with anorexia may develop rigid routines around food, exhibiting obsessive calorie counting, hoarding or concealing food, or strict avoidance of certain foods or entire food groups. Family or friends might observe behaviors such as immediate bathroom visits after meals, dishonesty about food intake, or discovery of laxatives or diuretics.
5. Weight Loss Methods Inquiry: Inquire about methods used to lose weight. Patients may attempt weight reduction through:
- Fasting or severe caloric restriction
- Excessive exercise regimens
- Self-induced vomiting (purging)
- Misuse of laxatives, enemas, diet pills, appetite suppressants, or herbal weight loss products.
6. Perception of Appearance: Explore the patient’s beliefs and perceptions about their physical appearance. Individuals with anorexia often perceive themselves as overweight, even when clinically underweight. They may fixate on specific body areas perceived as having excess fat and persistently seek weight loss, despite reassurance from others.
7. Peer Influence Assessment: For children and adolescents, assess the role of peer pressure. Peer influence can be a potent factor, particularly in young people. Teenagers may attempt to control their weight to gain social acceptance. Social media platforms also contribute to perceptions of attractiveness, often emphasizing thinness, dieting, and excessive exercise.
8. Mental Health History: Note any personal or family history of mental illness. Anorexia nervosa has a genetic component; individuals with a female relative with anorexia are at increased risk. Many patients also present with co-occurring psychiatric disorders or have a family history of mental illness. Monitor for the presence of anxiety disorders, major depressive disorder, or obsessive-compulsive disorder.
9. Trauma History: Assess for past trauma. Physical, emotional, or sexual abuse can contribute to body image issues and eating disorders in susceptible individuals. Disordered eating may emerge as a maladaptive coping mechanism.
10. Emotional State Evaluation: Evaluate the patient’s emotional state. Patients with anorexia are often highly self-critical and have a strong need for control. They may socially withdraw from friends and family. Nurses should assess for suicidal ideation, as suicide is a significant cause of mortality in anorexia nervosa.
11. History of Disordered Eating: Explore any history of disordered eating patterns. Anorexia nervosa shares characteristics with other eating disorders. Avoidant/Restrictive Food Intake Disorder (ARFID), for instance, can occur in children and involves extreme food selectivity or lack of interest in eating, potentially progressing to anorexia. Other eating disorders to consider include bulimia nervosa, binge eating disorder, pica, and rumination disorder.
12. Predisposing Factors Identification: Identify predisposing factors for anorexia nervosa, which is more prevalent in:
- Females
- Adolescents (typically onset between 13 and 18 years of age)
- Caucasians (over 95% of cases)
- Individuals with perfectionistic personality traits
- Patients with difficulties expressing emotions
- Patients who struggle with conflict resolution
- Patients with low self-esteem
- Patients whose mothers encourage weight loss
- Athletes in sports that emphasize leanness, such as gymnastics, dance, or running.
Alt Text: A young woman with anorexia nervosa experiences distorted body image, perceiving herself as overweight in the mirror despite being underweight.
Physical Assessment
1. Comprehensive Physical Exam: Conduct a thorough physical assessment as anorexia can lead to systemic complications affecting every body system. Physical signs of anorexia may include:
- Thinning, brittle hair and nails
- Lanugo (fine, downy hair covering the body)
- Edema
- Stomach discomfort or bloating
- Cold extremities (hands and feet)
- Breast atrophy
- Loss of muscle mass
- Cardiac arrhythmias
2. Signs of Purging Behaviors: Observe for physical indicators of purging, which may include:
- Dental enamel erosion
- Parotid gland enlargement
- Esophagitis
- Gastrointestinal bleeding
- Russell’s sign (calluses on the knuckles from self-induced vomiting)
3. Vital Signs Monitoring: Monitor vital signs closely. Patients with anorexia may exhibit orthostatic hypotension, bradycardia, and hypothermia due to inadequate caloric intake and metabolic dysregulation.
4. Height and Weight Measurement: Accurately measure and record the patient’s height and weight. These measurements are crucial for evaluating treatment progress. Patients with anorexia often present with a significantly low Body Mass Index (BMI).
5. SCOFF Questionnaire Administration: Utilize the SCOFF questionnaire as a screening tool to assess the likelihood of anorexia nervosa. This tool includes five key questions:
- Sick: Do you make yourself sick because you feel uncomfortably full?
- Control: Do you worry you have lost control over how much you eat?
- One stone: Have you recently lost more than one stone (14 pounds or 6.35 kg) in a 3-month period?
- Fat: Do you believe yourself to be fat when others say you are too thin?
- Food: Would you say food dominates your life?
A positive response to two or more questions suggests a higher likelihood of an eating disorder.
Diagnostic Procedures
1. Blood Tests: Order blood tests to assess for complications of starvation and guide treatment. Common tests include:
- Complete Blood Count (CBC)
- Complete Metabolic Profile (CMP)
- Urinalysis
- Renal Function Panel
- Liver Function Tests (LFTs)
- Thyroid-Stimulating Hormone (TSH)
- Hormone tests (e.g., testosterone levels)
2. Cardiovascular Assessment: Evaluate cardiovascular status due to the high risk of cardiac complications associated with anorexia, which are a leading cause of morbidity and mortality. Obtain an Electrocardiogram (ECG) to detect potentially life-threatening arrhythmias.
3. Further Testing: Initiate additional diagnostic tests as clinically indicated to investigate other potential complications. These may include:
- Drug testing for substance abuse (prescription and illicit drugs)
- Chest X-ray to assess for esophageal damage from vomiting
- Bone density tests to evaluate for osteoporosis
- Serum vitamin D levels
- Fecal occult blood test to assess for gastrointestinal trauma from laxative abuse.
Nursing Interventions for Anorexia Nervosa
Nursing interventions are fundamental to the patient’s recovery process. The following section outlines key nursing interventions for anorexia nervosa.
1. Inpatient Care Anticipation: Recognize the necessity for inpatient care for patients with severe malnutrition or acute psychological risk. Indications for hospital admission include:
- Significant weight loss or failure to gain weight
- Significant edema
- Vital sign instability
- Severe electrolyte imbalances
- Cardiac arrhythmias
- Acute medical comorbidities
- Altered mental status
- Psychosis
- High suicide risk
- Lack of adequate social support
- Limited access to outpatient treatment
- Non-adherence to treatment or persistent purging behaviors
2. Vital Signs and Lab Monitoring: In an inpatient setting, closely monitor vital signs for orthostatic changes and hypothermia, ECG for arrhythmias, lab values for electrolyte abnormalities, and intake and output for hydration status and renal function.
3. Medication Considerations: Pharmacological interventions may be considered. Olanzapine is often the initial drug of choice for patients who do not respond to initial care strategies. Selective Serotonin Reuptake Inhibitors (SSRIs) may be prescribed to address co-morbid conditions like anxiety or major depressive disorder.
Note: Tricyclic antidepressants (TCAs) are generally avoided due to the risk of cardiotoxicity, particularly in malnourished individuals. Bupropion is contraindicated in patients with eating disorders due to an increased risk of seizures.
4. Refeeding Protocol Initiation: Nutritional rehabilitation is a cornerstone of anorexia treatment. Refeeding involves a carefully planned and gradual increase in caloric intake to achieve a target weight. Refeeding must be implemented cautiously to prevent refeeding syndrome, a potentially fatal condition characterized by severe fluid and electrolyte shifts. Close collaboration with a registered dietitian is essential. Oral feeding is preferred, but tube feeding may be necessary for severely underweight patients.
5. Bone Health Promotion: Recommend calcium and vitamin D supplementation to mitigate bone density loss. Estrogen replacement therapy, such as oral contraceptives, may be considered to treat osteopenia, particularly in women.
6. Safety Precautions Implementation: Patients with anorexia may have co-occurring mental health disorders that increase the risk of self-harm and suicide. Implement appropriate safety precautions to ensure patient safety.
7. Psychotherapy Initiation: Psychotherapy is critical for treating eating disorders and is recommended as ongoing outpatient treatment for at least one year after weight restoration. Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT) are commonly used psychotherapeutic approaches. Family-based therapy is particularly important for adolescents. Other therapeutic modalities may be added based on individual needs.
8. Activity Restriction: Limit excessive physical exercise and activities to reduce energy expenditure and facilitate weight gain. Acknowledge that this may impact the patient’s coping mechanisms and offer alternative activities such as journaling or creative arts.
9. Progress Monitoring: Ongoing surveillance is necessary to ensure sustained weight maintenance, overall health improvement, and prevention of relapse into unhealthy eating behaviors.
10. Patient and Family Support: Provide empathetic support to both the patient and their family. Utilize active listening and empathetic communication. Avoid making comments, positive or negative, about the patient’s weight or appearance; instead, focus on their strengths and positive qualities.
Nursing Care Plans and Diagnoses
Once nursing diagnoses are identified for anorexia nervosa, nursing care plans provide a framework for prioritizing assessments and interventions to achieve both short-term and long-term care goals. The following are examples of nursing care plans for anorexia nervosa:
Deficient Fluid Volume
Patients with anorexia nervosa may develop deficient fluid volume due to restricted intake and purging behaviors aimed at weight control.
Nursing Diagnosis: Deficient Fluid Volume
Related to:
- Purging behaviors (self-induced vomiting, laxative, diuretic use)
- Insufficient fluid intake
- Extreme food and fluid 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 exhibit normal skin turgor and moist mucous membranes.
Assessments:
- Hydration Status: Assess hydration status by reviewing hematocrit, electrolyte levels, urinalysis, and kidney function tests for indicators of fluid volume deficit.
- Vital Signs and Capillary Refill: Monitor vital signs and capillary refill. Hypotension, tachycardia, bradycardia, and delayed capillary refill can indicate decreased circulating volume and dehydration.
- Purging Behaviors: Assess for any purging behaviors, as these directly contribute to fluid loss and electrolyte imbalances.
- Symptoms of Deficient Fluid Volume: Inquire about symptoms such as headache, dizziness, fatigue, and difficulty concentrating, which may indicate hypovolemia.
Interventions:
- Intake and Output Monitoring: Strictly monitor intake and output, especially in inpatient settings, to assess hydration status and treatment plan adherence.
- Purging Behavior Prevention: Educate the patient about the ineffectiveness and dangers of purging behaviors for weight control, emphasizing that they primarily cause water loss and electrolyte imbalances, not fat loss. In outpatient settings, advise families to be vigilant and monitor for purging behaviors.
- Fluid and Electrolyte Administration: Administer intravenous fluids and electrolytes as prescribed to correct imbalances and reduce the risk of complications.
- Orthostatic Hypotension Monitoring: Monitor for orthostatic hypotension by assessing blood pressure in lying, sitting, and standing positions to detect significant drops indicative of hypovolemia.
Disturbed Body Image
Distorted body image is a core feature of anorexia nervosa, driving restrictive eating behaviors due to misperceptions of body size and shape.
Nursing Diagnosis: Disturbed Body Image
Related to:
- Mental health disorder
- Eating disorder
As evidenced by:
- Verbalizing feeling fat despite being underweight
- Fear of negative judgment from others
- Negative feelings about their body
- Feelings of hopelessness or powerlessness related to body image
- Self-harm behaviors
- Frequent mirror checking
- Obsessive weight checking
- Avoidance of eating in public
Expected Outcomes:
- Patient will verbalize positive feelings about their body.
- Patient will participate in eating meals in social settings.
- Patient will actively engage in therapy and psychological counseling to address body image issues.
Assessments:
- Self-Description: Ask the patient to describe their perception of their body and how they believe others see them to assess the extent of body image distortion.
- Negative Self-Talk: Listen for negative self-talk and comments during conversations, which can indicate underlying body image dissatisfaction.
- Appearance-Related Behaviors: Observe behaviors related to appearance, such as body checking or attempts to conceal their body, which provide insight into body image perceptions.
Interventions:
- Cognitive-Behavioral Therapy (CBT): Encourage participation in CBT to help modify dysfunctional thoughts, feelings, and behaviors related to body image.
- Therapeutic Nurse-Patient Relationship: Establish a trusting, non-judgmental nurse-patient relationship to build trust, essential for addressing chronic eating disorders.
- Underlying Mental Disorders: Address co-occurring mental health conditions such as personality disorders, depression, and substance abuse, as their treatment is crucial for long-term recovery.
- Media Literacy: Educate patients, especially adolescents, about unrealistic beauty standards portrayed in media and social media, which can contribute to body image distortions.
- Suicidal Ideation Monitoring: Closely monitor for suicidal ideation and behaviors, as hopelessness and severe anxiety about body image can increase suicide risk.
Imbalanced Nutrition: Less Than Body Requirements
Nutritional imbalances are a direct consequence of the restricted food intake and/or purging behaviors in anorexia nervosa, leading to inadequate nutrient levels.
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
- Amenorrhea
Expected Outcomes:
- Patient will verbalize understanding of nutritional needs.
- Patient will demonstrate weight improvement, achieving a BMI of at least 19.
- Patient will adhere to dietary interventions and treatment plans.
Assessments:
- Body Weight Assessment: Determine body weight in relation to age and height. Accurate weight measurement is crucial for establishing caloric and nutritional needs. BMI may be used as an indicator of nutritional status.
- Nutritional Status Evaluation: Assess overall nutritional status to identify deficiencies and severity. Lab tests for electrolytes, protein levels, and albumin can help quantify nutritional imbalances.
- Eating Pattern Assessment: Evaluate the patient’s eating patterns to establish baseline data and guide appropriate interventions.
Interventions:
- Weight Goal and Nutritional Requirements: Establish a minimum weight goal and daily nutritional requirements in collaboration with a dietitian. Focus on a minimum weight target to alleviate patient anxiety about exceeding a perceived “ideal” weight.
- Small, Frequent Meals: Provide smaller, more frequent meals or snacks to ease re-introduction to food, preventing gastric distress and reducing patient anxiety related to large meals.
- Selective Menu Options: Allow the patient to choose from a selective menu to promote a sense of control and encourage healthier food choices.
- Holistic Health Markers: Monitor broader health indicators beyond weight, such as improved digestion, return of menses, improved energy levels, sleep quality, and mental stability to assess overall recovery.
- Parenteral Nutrition: Consider parenteral nutrition (TPN) if oral intake is insufficient to meet metabolic needs, particularly for stabilizing electrolyte imbalances.
- Dietitian Consultation: Consult with a registered dietitian specialized in eating disorders to provide expert nutritional support and guidance.
Ineffective Adolescent Eating Dynamics
Ineffective adolescent eating dynamics in anorexia nervosa are characterized by unhealthy eating patterns driven by psychological and social factors.
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 mealtimes
- Food refusal
- Inadequate appetite
- Undereating
- Overeating (binging)
Expected Outcomes:
- Patient will establish healthy eating patterns, demonstrated by eating at appropriate mealtimes and consuming adequate calories.
- Patient will maintain a BMI within the normal range for their age and height.
Assessments:
- Nutritional Status and BMI: Assess nutritional status and BMI to determine the extent of nutritional deficit and guide intervention strategies.
- Psychological Disorders Screening: Screen for co-occurring psychological disorders such as anxiety and depression, which often exacerbate unhealthy eating habits.
- Social Relationships Assessment: Evaluate the patient’s social relationships, particularly peer relationships and exposure to bullying or negative social influences regarding body image.
- Eating-Related Goals: Assess the patient’s goals related to eating and weight, identifying any maladaptive goals focused on weight loss or appearance.
Interventions:
- Weight Goal and Nutritional Requirements: Establish a minimum weight goal and appropriate daily caloric intake in consultation with a dietitian, focusing on weight restoration as a primary treatment goal.
- Meal Supervision: Supervise the patient during and after meals to ensure adherence to dietary treatment and prevent compensatory behaviors.
- Family Meals Encouragement: Encourage family meals to improve adolescent dietary intake and allow parents to model healthy eating behaviors.
- Family-Based Therapy Referral: Refer the patient and family to family-based therapy, which is crucial for adolescent anorexia treatment.
Risk for Impaired Skin Integrity
Nutritional deficits in anorexia nervosa increase the risk of impaired skin integrity due to poor nutrient supply to skin tissues.
Nursing Diagnosis: Risk for Impaired Skin Integrity
Related to:
- Altered nutritional state
- Purging behaviors
- Emaciation
- Dehydration
As evidenced by:
- A risk diagnosis is identified by risk factors, not by existing signs and symptoms. Interventions are aimed at prevention.
Expected Outcomes:
- Patient will verbalize understanding of the impact of poor nutrition on skin and hair health.
- Patient will demonstrate preventive measures to maintain skin integrity.
- Patient will exhibit improvement in hair growth and skin appearance.
Assessments:
- Skin and Hair Examination: Observe for abnormalities such as thinning hair, brittle nails, and dry, itchy skin, which are indicative of poor nutrition.
- Pressure Point Inspection: Inspect skin surfaces, especially pressure points, for signs of potential breakdown due to decreased perfusion and poor circulation in emaciated patients.
Interventions:
- Bathing Frequency: Encourage bathing every other day rather than daily to prevent excessive skin drying. Avoid harsh cleansers or abrasive scrubbing.
- Skin Moisturizing: Instruct the patient to use skin creams or lotions frequently, particularly after bathing, to lubricate and hydrate the skin, reducing itching and improving skin integrity.
- Vitamin Supplementation: Recommend vitamin supplementation, particularly biotin, to support hair and nail strength.
- Position Changes: Educate the patient on the importance of frequent position changes to promote circulation and prevent pressure sores, especially over bony prominences.
- Fluid and Nutrition Education: Emphasize the importance of adequate fluid intake and proper nutrition for maintaining skin suppleness and elasticity and preventing dryness and cracking.
