8 Eating Disorders: Anorexia & Bulimia Nervosa Nursing Care Plans

Anorexia nervosa is starvation driven by a distorted body image and a morbid fear of obesity. The patient keeps their weight far below normal for age and height by starving or exercising to excess.

Bulimia nervosa is the binge-purge syndrome: extreme overeating followed by self-induced vomiting, often with laxative and diuretic abuse, to get rid of the calories.

These disorders mostly affect women, but 5%–10% of patients are men, and both disorders can show up in the same person.

Nursing Care Plans and Management

Your priorities: establish adequate nutritional intake, correct fluid and electrolyte imbalance, help the patient build a realistic body image, and improve self-esteem. Remember that with anorexia, food is the medication.

Nursing Problem Priorities

1. Restore healthy eating patterns with nutritional support and guidance.
2. Address the underlying psychological factors through individual therapy.
3. Use cognitive-behavioral therapy or other evidence-based therapy to change unhealthy thoughts and behaviors.
4. Monitor and manage co-occurring conditions like depression or anxiety.
5. Involve family or support systems when appropriate.
6. Educate patients and caregivers about the dangers of disordered eating.

Nursing Assessment

Assess for the following subjective and objective data:

• Drastic weight change, either significant loss or rapid gain
• Preoccupation with body shape, size, and weight
• Distorted body image and excessive concern about appearance
• Restrictive eating: avoiding food groups or severely limiting calories
• Binge eating with a sense of loss of control
• Compulsive or excessive exercise to compensate for food
• Obsessive food rituals: cutting food into tiny pieces, rearranging it
• Avoidance of social situations involving food
• Irritability, anxiety, or depression
• Fatigue, dizziness, weakness, or energy fluctuations

Nursing Diagnosis

Formulate the diagnosis from your assessment and clinical judgment. The work here centers on nutrition, fluid balance, body image, coping, skin integrity, and thought process.

Nursing Goals

Goals and expected outcomes may include:

• The patient verbalizes understanding of nutritional needs.
• The patient establishes a dietary pattern with calories adequate to regain or maintain appropriate weight.
• The patient demonstrates weight gain toward the expected range.
• The patient maintains improved fluid balance: adequate urine output, stable vital signs, moist mucous membranes, good skin turgor.
• The patient verbalizes the causative factors behind the fluid deficit and how to correct it.
• The patient shows improved ability to make decisions and problem-solve.
• The patient establishes a more realistic body image and accepts self as an individual.
• The patient accepts responsibility for their own actions and learning.
• The patient expresses feelings freely and appropriately.
• The patient demonstrates more autonomous coping, with clearer family boundaries.
• The patient recognizes and resolves conflict appropriately.
• The patient identifies and demonstrates behaviors to maintain soft, intact skin.
• The patient connects signs and symptoms (weight loss, tooth decay) to the behaviors of not eating or binging-purging.
• The patient plans lifestyle changes to maintain a normal weight and seeks resources to support them.

Nursing Interventions and Actions

1. Promoting Adequate Nutrition

Laxative abuse blocks nutrient absorption, and inadequate intake in anorexia drives nutrient deficiencies. Both have serious physical and emotional consequences.

For Bulimia Nervosa

Identify the patient's elimination patterns. Monitoring bowel movements and related behaviors helps you build strategies to prevent self-induced vomiting. Create an environment where the patient can discuss their habits.

Assess suicide potential. In bulimia, warning signs include more co-morbid psychiatric symptoms and a history of sexual abuse.

Outline the risks of laxative, emetic, and diuretic abuse. Bulimic patients often abuse all three.

Supervise the patient during meals and for 1 hour after. Prevents vomiting during or after eating.

For Anorexia Nervosa

Supervise the patient during meals and for 1 hour after. Ensures compliance with the dietary program. For a hospitalized anorexic patient, food is medication.

Offer liquids over solids. Fluids remove the need to choose between foods, which the anorexic patient finds difficult.

Expect weight gain of about 1 lb (0.5 kg) per week. Shows whether the regimen is working.

If edema or bloating occurs after the patient resumes normal eating, reassure them it is temporary. They may fear they are getting fat and stop following the plan.

For Bulimia and Anorexia

Establish a minimum weight goal and daily nutritional requirements. Malnutrition alters mood, drives depression and agitation, and impairs cognition and decision-making. Better nutrition restores the thinking the patient needs for psychological work.

Use a consistent approach. Sit with the patient while they eat. Present and remove food without comment. Keep the environment pleasant and record intake. The patient reacts to pressure, and any comment that reads as coercion turns food into a battleground. Food is often the one area the patient controls, so structuring meals and cutting food talk reduces power struggles.

Provide smaller meals and supplemental snacks. Refeeding too fast after starvation causes gastric dilation. The patient may feel bloated for 3–6 weeks while the body adjusts.

Offer a selective menu and let the patient control choices. A patient who feels in control is more likely to eat preferred foods.

Watch for low-calorie choices, food hoarding, and disposal of food in pockets or wastebaskets. Patients go to great lengths to avoid what they see as excessive calories.

Weigh on a regular schedule, such as Monday and Friday before breakfast in the same attire, and graph the results. Provides an accurate record and reduces obsessing over daily changes.

Weigh with the patient's back to the scale, per program protocol. Seeing the number can force a trust issue with a patient who already does not trust others.

Avoid room checks and other control devices when possible. External control reinforces powerlessness and usually does not help.

If contracting fails, provide one-to-one supervision and keep the bulimic patient in the day room with no bathroom privileges for 2 hours after eating. Prevents vomiting. The patient may purge for the first time once a weight-gain program starts.

Monitor the exercise program and set limits. Chart activity. Moderate exercise maintains muscle tone and fights depression, but patients may exercise to excess to burn calories.

Stay matter-of-fact and nonjudgmental with tube feedings or hyperalimentation. Anything the patient reads as punishment undermines their confidence.

Watch for the patient disconnecting tubing or emptying hyperalimentation. Check measurements and tape tubing snugly. Sabotage to prevent weight gain is common.

Provide nutritional therapy within a hospital program when the condition is life-threatening. The underlying problem cannot resolve without improved nutrition. Hospitalization controls food intake, vomiting, elimination, medications, and activity, separates the patient from contributing relationships, and exposes them to others with the same problem.

Involve the patient in a behavior modification program. Reward weight gain; ignore loss. Gives structure while leaving the patient some control. Behavior modification works in mild cases or for short-term gain.

Provide diet and snacks with preferred-food substitutions when available. Variety lets the patient choose foods they may enjoy.

Administer liquid diet, tube feedings, and hyperalimentation if needed. When intake cannot sustain metabolic needs, nutritional support prevents malnutrition and death while therapy continues. High-calorie liquid feedings can be given as medication at preset times.

Blenderize and tube-feed anything left on the tray after a set period if indicated. Used in behavior modification to deliver the needed calories.

Administer supplemental nutrition as appropriate. Total parenteral nutrition (TPN) may be required in life-threatening situations, but enteral feeding is preferred because it preserves gastrointestinal function and reduces gut atrophy.

Avoid laxatives. Counterproductive, since the patient may use them to purge food and calories.

Administer medication as indicated. See Pharmacologic Management.

Assist with electroconvulsive therapy (ECT) if indicated. Explain the reason and that it is not punishment. In rare cases of severe, life-threatening malnutrition, a short ECT series may help the patient begin eating and become accessible to psychotherapy.

2. Enhancing Fluid Balance

Fluid restriction, diuretics, and laxatives put these patients at risk for deficient fluid volume, dehydration, and electrolyte imbalance.

Monitor and record vital signs, capillary refill, mucous membranes, and skin turgor. Indicators of circulating volume. Orthostatic hypotension raises fall risk with sudden position changes.

Note the amount and type of fluid intake. Measure urine output accurately. The patient may abstain entirely, causing dehydration, or substitute fluids for calories, disturbing electrolytes.

Review electrolyte and renal function results. Fluid and electrolyte shifts and decreased renal function can worsen recovery and may need intervention.

Discuss strategies to stop vomiting and laxative and diuretic use. Addressing the feelings behind these behaviors prevents continued fluid loss. The bulimic patient has learned that vomiting releases anxiety.

Identify actions to regain or maintain fluid balance, including a specific fluid intake schedule. Involving the patient in planning improves the odds of success.

Administer and monitor IV, TPN, and electrolyte supplements as indicated. Emergency measure to correct imbalance and prevent cardiac dysrhythmias.

3. Promoting Positive Body Image and Self-Esteem

These patients see themselves as overweight or unattractive even at a dangerously low weight. That distortion feeds shame, worthlessness, and a negative self-concept.

Assess feelings of helplessness and hopelessness. Loss of control is the underlying problem and may come with more serious emotional disorders. 54% of anorexic patients have a history of major affective disorder, and 33% have a history of minor affective disorder.

Note withdrawal and discomfort in social settings. May signal isolation and fear of rejection, which compound worthlessness.

Have the patient draw a picture of self. Opens a discussion of how the patient perceives self and body versus reality.

Encourage a personal development program, ideally in a group, with guidance on grooming and makeup. Improving appearance supports self-esteem, and feedback from others promotes self-worth.

Suggest disposing of "thin" clothes as weight is gained. Removes the visual reminder of the thinner self and gives an incentive to maintain weight.

Help the patient face the changes of puberty and sexual fears. Provide sex education as needed. Adolescent physical and psychological change can drive eating disorders. Feeling powerless over sexual sensations leads to an unconscious drive to desexualize self, which the patient tries to overcome by controlling their body.

Establish a therapeutic nurse-patient relationship. Within it, the patient can begin to trust and try new thinking and behavior.

Promote self-concept without moral judgment. The patient sees self as weak-willed even while feeling power and control through dieting and weight loss.

State the rules clearly: weighing schedule, staying in sight during meals and medication, and the consequences of breaking them. Carry them out consistently and without comment. Consistency builds trust. Failure to follow rules is the patient's choice and is met matter-of-factly so it does not reinforce the behavior.

Confront unrealistic statements with reality. The patient is often denying the psychological side of their situation and expressing inadequacy and depression.

Be aware of your own reactions. Do not argue. Disgust and hostility are not uncommon with these patients. Prognosis often stays poor even with weight gain because other problems remain. Manage your own response so it does not interfere with care.

Help the patient take control in areas other than dieting and weight, such as daily activities, work, and leisure. Personal ineffectiveness, low self-esteem, and perfectionism are part of the problem; the patient needs help problem-solving control in life.

Help the patient set goals unrelated to eating and reach them one at a time, simple to complex. Realistic, achievable goals build a sense of control and foster success.

Encourage the patient to take charge of their life by making their own decisions and accepting self as they are now. The patient often does not know what they want, because parents have made decisions for them, and believes they must be perfect.

Let the patient know it is acceptable to be different from the family, especially the mother. Building an identity separate from family is a goal of therapy.

Use cognitive-behavioral or interpersonal psychotherapy rather than interpretive therapy. Both have similar results, but cognitive-behavioral works faster, and interpersonal work helps the patient discover feelings and needs they never learned to interpret as a child.

Encourage the patient to express anger and acknowledge it when they do. Anger is part of self and is acceptable. Many of these patients were taught anger is unacceptable and must relearn how to express it.

Teach strategies other than eating for handling feelings. Have the patient keep a feelings diary, especially around thoughts of food. Feelings are the underlying issue, and the patient uses food instead of dealing with them.

Watch for suicidal ideation and behavior. Intense anxiety about weight gain, depression, and hopelessness can lead to suicide attempts, especially in an impulsive patient.

Involve the patient in group therapy. A place to talk about feelings and try new behaviors.

Refer to occupational or recreational therapy. Builds interests and skills to fill the time the eating obsession used to occupy and encourages social interaction.

4. Promoting Positive Coping

Healthy coping for the patient and family means professional help from a multidisciplinary team and building real coping skills: self-care, self-compassion, a support network, and a healthier relationship with food.

Identify interaction patterns. Have each family member speak for self. Do not allow two members to discuss a third who is absent from the conversation. Enmeshed families speak for each other and need to own their own words and actions.

Discourage members from seeking each other's approval. Watch for verbal and nonverbal approval-checking. Acknowledge the patient's competent actions. Each person needs an internal sense of self-esteem rather than living up to the family's expectations.

Listen with regard when the patient speaks. Models competence and self-worth by showing the patient they are heard.

Communicate that it is acceptable for family members to be different from each other. Reinforces individuation, confronts rigidity, and opens options for new behavior.

Encourage and allow expression of feelings, including crying and anger. These families often have not allowed free expression and need permission to learn it.

Prevent other members from intruding on a dyad. Inappropriate intrusion into family subsystems keeps people from working out problems.

Reinforce that the parents are a couple with rights of their own. The intense focus on the anorexic child is often the only thing the couple interacts around; they need to restore their own relationship.

Keep the patient out of conflicts between the parents. Help the parents identify and solve their marital differences. A parent-child coalition creates triangulation. The anorexia regulates the family system while the parents deny their own conflict.

Confront sabotage behavior by family members. Blame, shame, and helplessness can drive unconscious behavior aimed at keeping the status quo.

Refer to family therapy groups, parents' groups, and parent effectiveness classes. Reduces overprotectiveness and supports work on unresolved conflict and change.

5. Improving Skin Integrity

Nutritional deficiency impairs wound healing and raises the risk of skin breakdown, and purging or scratching damages the skin directly.

Observe reddened, blanched, and excoriated areas. Indicators of breakdown risk that need more intensive treatment.

Bathe every other day instead of daily. Frequent baths dry the skin.

Apply skin cream twice a day and after bathing. Lubricates and decreases itching.

Massage skin gently, especially over bony prominences. Improves circulation and skin tone.

Encourage frequent position changes and staying active. Improves circulation and perfusion by preventing prolonged pressure.

Use specialized cushions or padding on bony areas. Adds support during prolonged sitting or lying and reduces pressure injury risk.

Emphasize adequate nutrition and fluid intake. Better nutrition and hydration improve skin condition.

6. Improving Thought Process

Disordered, rigid thinking about food, body image, and weight makes it hard for the patient to perceive reality. Therapy aims to challenge and restructure those patterns.

Account for the patient's distorted thinking. Lets you set realistic expectations and give appropriate support.

Do not challenge irrational thinking. Present reality concisely. Logic is hard when thinking is physiologically impaired; challenging the patient breeds distrust. Even with weight gain, the patient may struggle with eating-disorder attitudes, depression, or alcohol dependence for years.

Adhere strictly to the nutritional regimen. Better nutrition is essential for better brain function.

Review electrolyte and renal function tests. Imbalances impair cerebral function and may need correction before therapy can begin.

Use cognitive-behavioral techniques to challenge distorted thoughts. Psychoeducation and therapeutic communication, including cognitive restructuring and reframing, help the patient recognize and replace distorted beliefs about food, body image, and weight.

Refer to psychologists, psychiatrists, and dietitians. A multidisciplinary plan addresses both the physical and psychological sides through individual, group, and family therapy.

7. Initiating Patient Education and Health Teachings

These patients often lack effective coping skills and use disordered eating to manage stress and emotions without grasping the long-term consequences.

Determine readiness to learn. Learning starts where the learner is.

Note blocks to learning: physical, intellectual, emotional. Malnutrition, family problems, drug abuse, and affective or obsessive-compulsive symptoms can block learning until resolved.

Provide written information for the patient and significant others. Reinforces learning.

Discuss the consequences of the behavior. Electrolyte imbalances can cause sudden death; protein deficiency can suppress the immune system and damage the liver; binge eating and vomiting can rupture the stomach.

Review dietary needs. Encourage high-fiber foods and adequate fluids. The patient and family may need help planning a new way of eating, and constipation can follow stopping laxatives.

Teach relaxation and stress-management techniques: visualization, guided imagery, biofeedback. New ways to cope with anxiety and fear help the patient give up not eating and binging-purging.

Help set up a sensible exercise program and caution against overexercise. Exercise builds a positive body image and fights depression, but the patient may use it to control weight.

Discuss information about sex and sexuality. Avoidance of sexuality is an issue here, and realistic information helps the patient deal with self as a sexual being.

8. Administer Medications and Provide Pharmacologic Support

Medication is not first-line for eating disorders but supports a comprehensive plan. SSRIs like fluoxetine (Prozac) manage co-occurring anxiety or depression, and appetite stimulants like cyproheptadine (Periactin) may address weight loss in some cases.

Cyproheptadine (Periactin). A serotonin and histamine antagonist used in high doses to stimulate appetite, reduce preoccupation with food, and combat depression. Few serious side effects, though it can decrease mental alertness.

Tricyclic antidepressants: amitriptyline (Elavil), imipramine (Tofranil), desipramine (Norpramin). Lift depression and stimulate appetite.

SSRIs: fluoxetine (Prozac). Reduce binge-purge cycles and may help with anorexia. Monitor closely for side effects, though these are less significant than with tricyclics.

Antianxiety agents: alprazolam (Xanax). Reduce tension and anxiety so the patient can participate in treatment.

Antipsychotics: chlorpromazine (Thorazine). Promote weight gain and cooperation, used only when necessary because of possible extrapyramidal side effects.

Monoamine oxidase inhibitors (MAOIs): tranylcypromine sulfate (Parnate). Used for depression when other drug therapy fails; decrease the urge to binge in bulimia.