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 a distorted perception of weight. Persons that are anorexic will see themselves as fat even when they are not.
Not all patients with anorexia are thin. Some disguise their thinness and eating habits, making it difficult to recognize this condition. Unhealthy mental and behavioral components are a major aspect of the disease process.
Some signs of anorexia include:
- Intense fear of gaining weight
- Distorted self-image
- Being extremely self-critical
- Having suicidal or self-harming thoughts
- Feeling irritable and/or depressed
- Changes in eating habits
- Sudden change in dietary preferences
- Withdrawing from friends and social events
- Thinning, brittle hair and nails
- Excessive exercise
- Absence of menstruation
- Stomach pain or bloating
- Intentional vomiting or the usage of laxatives or diuretics
- Using diet pills or appetite suppressants
- Eroded teeth or calluses on knuckles from induced vomiting
- Intolerance of cold
Anorexia is generally divided into two subtypes:
- Restrictor type. This patient sets severe limits on their food intake.
- Bulimic type. This patient presents with binging and purging. They eat more than they should and then induce vomiting or take excessive laxatives.
Aside from healthcare providers assessing medical history, lab results, and performing psychological testing, anorexia can be diagnosed based on three criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published by the American Psychiatric Association.
- Restriction of calorie consumption leading to weight loss or failure to gain weight.
- Intense fear of gaining weight.
- Having distorted views of themselves and their condition.
The biggest challenge with anorexia is that the person suffering may not admit that they are, unless the problem becomes serious enough to become life-threatening. Treatment goals for anorexia include:
- Weight loss stabilization
- Restoration of weight
- Elimination of problematic eating patterns
- Treatment of psychological issues and development of long-term behavioral changes
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 nonjudgmental support and psychological treatment to learn healthy coping strategies.
Nursing Care Plans Related to Anorexia
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
- Eating disorder
- Limited food intake
- Induced purging
- Excessive exercise
As evidenced by:
- Excessive weight loss
- Hair loss
- Brittle nails
- Dry skin
- Electrolyte imbalances
- Loss of menses
- 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.
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.
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.
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
- 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
- Frequently looking at self in the mirror
- Obsessive weight checking
- Not eating in public
- 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.
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.
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.
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
- Alteration in nutritional state
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.
- 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.
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.
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.
- Anorexia nervosa. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/anorexia-nervosa/symptoms-causes/syc-20353591. Accessed on Dec 16, 2022
- 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
- Doenges, M. E., Moorhouse, M. F. (1993). Nurses’s Pocket Guide: Nursing Diagnoses with Interventions (4th Ed.). F.A. Davis Company.