A nurse is reviewing the laboratory results of a client who has bulimia nervosa

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Nursing Care Plans
Recommended Resources

Anorexia nervosa 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 exercise excessively.

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.

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

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:

Nursing Diagnosis

Imbalanced Nutrition: Less Than Body Requirements

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

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.
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:
Cyproheptadine (Periactin)	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.
Antipsychotic drugs: chlorpromazine (Thorazine)	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.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.