Nursing Care Plans for Eating Disorders PDF

11/16/23, 11:19 AM Realizeit for Student pplication of the Nursing Process Although anorexia and bulimia have several differences, many similarities are found in assessing, planning, implementing, and evaluating nursing care for clients with these disorders. Thus, this section addresses both eatin...

11/16/23, 11:19 AM Realizeit for Student pplication of the Nursing Process Although anorexia and bulimia have several differences, many similarities are found in assessing, planning, implementing, and evaluating nursing care for clients with these disorders. Thus, this section addresses both eating disorders and highlights differences where they exist. Assessment Several specialized tests have been developed for eating disorders. An assessment tool such as the Eating Attitudes Test (Box 20.2 ) is often used in studies of anorexia and bulimia. This test can also be used at the end of treatment to evaluate outcomes because it is sensitive to clinical changes. BOX 20.2 Eating Attitudes Test Please place an (X) under the column that applies best to each of the numbered statements. All the results will be strictly confidential. Most of the q other types of questions have been included. Please answer each question carefully. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPH… 1/13 11/16/23, 11:19 AM Realizeit for Student *Scoring: The patient is given the questionnaire without the Xs, just blank. Three points are assigned to endorsements that coincide with the Xs; the adjacent alternatives are weighted as 2 points and 1 point, respectively. A total score of over 30 indicates significant concerns with eating behavior. History Family members often describe clients with anorexia nervosa as perfectionists with above-average intelligence who are achievementoriented, dependable, eager to please, and seeking approval before onset of the condition. Parents describe clients as being “good, causing us no trouble” until the onset of anorexia. Likewise, clients with bulimia are often focused on pleasing others and avoiding conflict. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPH… 2/13 11/16/23, 11:19 AM Realizeit for Student Clients with bulimia, however, often have a history of impulsive behavior such as substance abuse and shoplifting as well as anxiety, depression, and personality disorders (Schultz & Videbeck, 2013). General Appearance and Motor Behavior Clients with anorexia appear slow, lethargic, and fatigued; they may be emaciated, depending on the amount of weight loss. They may be slow to respond to questions and have difficulty deciding what to say. They are often reluctant to answer questions fully because they do not want to acknowledge any problem. They often wear loose-fitting clothes in layers, regardless of the weather, both to hide weight loss and to keep warm (clients with anorexia are generally cold). Eye contact may be limited. Clients may turn away from the nurse, indicating their unwillingness to discuss problems or to enter treatment. Clients with bulimia may be underweight or overweight but are generally close to expected body weight for age and size. General appearance is not unusual, and they appear open and willing to talk. Mood and Affect Clients with eating disorders have labile moods that usually correspond to their eating or dieting behaviors. Avoiding “bad” or fattening foods gives them a sense of power and control over their bodies while eating, binging, or purging leads to anxiety, depression, and feeling out of control. Clients with eating disorders often seem sad, anxious, and worried. Those with anorexia seldom smile, laugh, or enjoy any attempts at humor; they are somber and serious most of the time. In contrast, clients with bulimia are initially pleasant and cheerful as though nothing is wrong. The pleasant façade usually disappears when they begin describing binge eating and purging; they may express intense guilt, shame, and embarrassment. Nursing Care Plan: Bulimia Nursing Diagnosis Ineffective Coping: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources Assessment Data Inability to meet basic needs Inability to ask for help Inability to solve problems Inability to change behaviors Self-destructive behavior Suicidal thoughts or behavior Inability to delay gratification Poor impulse control Stealing or shoplifting behavior Desire for perfection Feelings of worthlessness Feelings of inadequacy or guilt Unsatisfactory interpersonal relationships Self-deprecatory verbalization Denial of feelings, illness, or problems Anxiety Sleep disturbances Low self-esteem Excessive need to control Feelings of being out of control Preoccupation with weight, food, or diets Distortions of body image Overuse of laxatives, diet pills, or diuretics Secrecy regarding eating habits or amounts eaten Fear of being fat Recurrent vomiting Binge eating Compulsive eating Substance use Immediate The client will: Be free from self-inflicted harm throughout hospitalization. Identify non–food-related methods of dealing with stress or crises; for example, initiate interaction with others or keep a journal within 2 to 3 days. Verbalize feelings of guilt, anxiety, anger, or an excessive need for control within 3 to 4 days. Stabilization https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPH… 3/13 11/16/23, 11:19 AM Realizeit for Student The client will Demonstrate more satisfying interpersonal relationships. Demonstrate alternative methods of dealing with stress or crises. Eliminate shoplifting or stealing behaviors. Express feelings in non–food-related ways. Verbalize understanding of disease process and safe use of medications, if any. Community The client will Verbalize more realistic body image. Follow through with discharge planning, including support groups or therapy as indicated. Verbalize increased self-esteem and self-confidence. Implementation Nursing Interventions Rationale Ask the client directly about thoughts of suicide or The client’s safety is a priority. You will not give the client ideas about suicide by self-harm. addressing the issue directly. Set limits with the client about eating habits (e.g., Limits will discourage binge behavior, such as hiding, sneaking, and gulping food will be eaten in a dining room setting, at a table, food, and help the client return to normal eating patterns. Eating three meals a only at conventional mealtimes). day will prevent starvation and subsequent overeating in the evening. Encourage the client to eat with other clients when Eating with other people will discourage secrecy about eating, though initially the tolerated. client’s anxiety may be too high to join others at mealtime. Encourage the client to express feelings, such as Expressing feelings can help decrease the client’s anxiety and the urge to anxiety and guilt about having eaten. engage in purging behaviors. Encourage the client to use a diary to write types and amounts of foods eaten and feelings that occur before, during, and after eating, especially related to urges to engage in binge or purge behaviors. A diary can help the client explore food intake, feelings, and relationships among these feelings and behaviors. Initially, the client may be able to write about these feelings and behaviors more easily than talk about them. Discuss the types of foods that are soothing to the client and that You may be able to help the client see how he or she has used relieve anxiety. food to deal with feelings. Maintain a nonjudgmental approach when discussing the client’s feelings. Being nonjudgmental gives the client permission to discuss feelings that may be negative or unacceptable to him or her without fear of rejection or reprisal. Encourage the client to describe and discuss feelings verbally. However, avoid discussing food-related feelings during mealtimes, Separating feelings from food-related behaviors will help the client and begin to separate dealing with feelings from eating or purging identify non–food-related ways to express and deal with feelings. behaviors. Help the client explore ways to relieve anxiety, express feelings, It is important to help the client separate emotional issues from and experience pleasure that are not related to food or eating. food and eating behaviors. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPH… 4/13 11/16/23, 11:19 AM Realizeit for Student Encourage the client to express his or her feelings about family Expressing feelings can help the client identify, accept, and work members and significant others and their roles and relationships. through feelings in a direct manner. Give positive feedback for the client’s efforts to discuss feelings. Teach the client and significant others about bulimic behaviors, physical complications, nutrition, and so forth. Refer the client to a dietitian if indicated.* Encourage the client and significant others to discuss feelings and interpersonal issues in non–food-related settings (i.e., discourage discussion of family problems at mealtimes). Referral for family therapy may be indicated. Teach the client and significant others about the purpose, action, timing, and possible adverse effects of medications, if any.* Your sincere praise can promote the client’s attempts to deal openly and honestly with anxiety, anger, and other feelings. The client and significant others may have little knowledge of the illness, food, and nutrition. Factual information can be useful in dispelling incorrect beliefs and in separating food from emotional issues. The client’s significant others may not understand the importance of separating emotional issues from foods and food-related behaviors. Antidepressant and other medications may be prescribed for bulimia. Remember, some antidepressant medications may take several weeks to achieve a therapeutic effect. Teach the client about the use of the problem-solving process: identify the problem, examine alternatives, weigh the pros and cons Successful use of the problem-solving process can help increase of each alternative, select and implement an approach, and the client’s self-esteem and confidence. evaluate its success. Explore with the client his or her personal strengths. Making a written list is sometimes helpful. You can help the client discover his or her strengths; he or she needs to identify them, so it will not be useful for you to make a list for the client. Discuss the idea of accepting a less than “ideal” body weight with The client’s previous expectations or perception of an ideal weight the client. may have been unrealistic and even unhealthy. Encourage the client to incorporate fattening (or “bad”) foods into the diet as he or she tolerates. Refer the client to assertiveness training books or classes if indicated.* This will enhance the client’s sense of control of overeating. Many bulimic clients are passive in interpersonal relationships. Assertiveness training may foster a sense of increased confidence and healthier relationship dynamics. Refer the client to long-term therapy if indicated. Contracting with the Treatment for eating disorders is often a long-term process. The client may be helpful to promote follow-through with continuing client may be more likely to engage in ongoing therapy if he or therapy.* she has contracted to do this. Ongoing therapy may need to include significant others to sustain the Dysfunctional relationships with significant others are often a client’s non–food-related coping skills.* primary issue for clients with eating disorders. Refer the client, family, and significant others to support groups in the These groups can offer support, education, and resources to community or via the internet (e.g., Anorexia Nervosa and Associated clients and their families or significant others. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPH… 5/13 11/16/23, 11:19 AM Realizeit for Student Disorders, Overeaters Anonymous).* Refer the client to a substance-dependence treatment program or substance-dependence support group (e.g., Alcoholics Anonymous), if Substance use is common among clients with bulimia. appropriate.* *Collaborative interventions. Adapted from Schultz, J. M., & Videbeck, S. L. (2013). Lippincott’s manual of psychiatric nursing care plans (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. It is important to ask clients with eating disorders about thoughts of self-harm or suicide. It is not uncommon for these clients to engage in self-mutilating behaviors, such as cutting. Concern about self-harm and suicidal behavior should increase when clients have a history of sexual abuse. Thought Processes and Content Clients with eating disorders spend most of the time thinking about dieting, food, and food-related behavior. They are preoccupied with their attempts to avoid eating or eating “bad” or “wrong” foods. Clients cannot think about themselves without thinking about weight and food. The body image disturbance can be almost delusional; even if clients are severely underweight, they can point to areas on their buttocks or thighs that are “still fat,” thereby fueling their need to continue dieting. Clients with anorexia who are severely underweight may have paranoid ideas about their family and health care professionals, believing they are their “enemies” who are trying to make them fat by forcing them to eat. Sensorium and Intellectual Processes Generally, clients with eating disorders are alert and oriented; their intellectual functions are intact. The exception is clients with anorexia who are severely malnourished and showing signs of starvation, such as mild confusion, slowed mental processes, and difficulty with concentration and attention. Judgment and Insight Clients with anorexia have limited insight and poor judgment about their health status. They do not believe they have a problem; rather, they believe others are trying to interfere with their ability to lose weight and to achieve the desired body image. Facts about failing health status are not enough to convince these clients of their true problems. Clients with anorexia continue to restrict food intake or to engage in purging despite the negative effect on health. In contrast, clients with bulimia are ashamed of the binge eating and purging. They recognize these behaviors as abnormal and go to great lengths to hide them. They feel out of control and unable to change, even though they recognize their behaviors as pathologic. Self-Concept Low self-esteem is prominent in clients with eating disorders. They see themselves only in terms of their ability to control their food intake and weight. They tend to judge themselves harshly and see themselves as “bad” if they eat certain foods or fail to lose weight. They overlook or ignore other personal characteristics or achievements as less important than thinness. Clients often perceive themselves as helpless, powerless, and ineffective. This feeling of lack of control over themselves and their environment only strengthens their desire to control their weight. Roles and Relationships Eating disorders interfere with the ability to fulfill roles and to have satisfying relationships. Clients with anorexia may begin to fail at school, which is in sharp contrast to previously successful academic performance. They withdraw from peers and pay little attention to friendships. They believe that others will not understand or fear that they will begin out-of-control eating with others. Clients with bulimia feel great shame about their binge eating and purging behaviors. As a result, they tend to lead secret lives that include sneaking behind the backs of friends and family to binge and purge in privacy. The time spent buying and eating food and then purging can interfere with role performance both at home and at work. Physiological and Self-Care Considerations https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPH… 6/13 11/16/23, 11:19 AM Realizeit for Student The health status of clients with eating disorders relates directly to the severity of self-starvation or purging behaviors or both (see Table 20.2 ). In addition, clients may exercise excessively, almost to the point of exhaustion, in an effort to control weight. Many clients have sleep disturbances, such as insomnia, reduced sleep time, and early-morning wakening. Those who frequently vomit have many dental problems, such as loss of tooth enamel, chipped and ragged teeth, and dental caries. Frequent vomiting may also result in mouth sores. Complete medical and dental examinations are essential. Data Analysis Nursing diagnoses for clients with eating disorders include the following: Imbalanced nutrition: Less than/more than body requirements Ineffective coping Disturbed body image Chronic low self-esteem Other nursing diagnoses may be pertinent, such as deficient fluid volume, constipation, fatigue, and activity intolerance. Outcome Identification For severely malnourished clients, their medical condition must be stabilized before psychiatric treatment can begin. Medical stabilization may include parenteral fluids, total parenteral nutrition, and cardiac monitoring. Examples of expected outcomes for clients with eating disorders include the following: The client will establish adequate nutritional eating patterns. The client will eliminate use of compensatory behaviors such as excessive exercise and use of laxatives and diuretics. The client will demonstrate coping mechanisms not related to food. The client will verbalize feelings of guilt, anger, anxiety, or an excessive need for control. The client will verbalize acceptance of body image with stable body weight. Interventions Establishing Nutritional Eating Patterns Typically, inpatient treatment is for clients with anorexia nervosa who are severely malnourished and for clients with bulimia whose binge eating and purging behaviors are out of control. Primary nursing roles are to implement and supervise the regimen for nutritional rehabilitation. Total parenteral nutrition or enteral feedings may be prescribed initially when a client’s health status is severely compromised. When clients can eat, a diet of 1,200 to 1,500 calories/day is ordered, with gradual increases in calories until clients are ingesting adequate amounts for height, activity level, and growth needs. Typically, allotted calories are divided into three meals and three snacks. A liquid protein supplement is given to replace any food not eaten to ensure consumption of the total number of prescribed calories. The nurse is responsible for monitoring meals and snacks and often initially will sit with a client during eating at a table away from other clients. Depending on the treatment program, diet beverages and food substitutions may be prohibited, and a specified time may be set for consuming each meal or snack. Clients may also be discouraged from performing food rituals such as cutting food into tiny pieces or mixing food in unusual combinations. The nurse must be alert for any attempts by clients to hide or to discard food. After each meal or snack, clients may be required to remain in view of staff for 1 to 2 hours to ensure they do not empty the stomach by vomiting. Some treatment programs limit client access to bathrooms without supervision, particularly after meals, to discourage vomiting. As clients begin to gain weight and become more independent in eating behavior, these restrictions are reduced gradually. In most treatment programs, clients are weighed only once daily, usually upon awakening and after they have emptied the bladder. Clients should wear minimal clothing, such as a hospital gown, each time they are weighed. They may attempt to place objects in their clothing to give the appearance of weight gain Clients with bulimia are often treated on an outpatient basis. The nurse must work closely with clients to establish normal eating patterns and to interrupt the binge-and-purge cycle. He or she encourages clients to eat meals with their families or if they live alone, with friends. Clients should always sit at a table in a designated eating area, such as a kitchen or dining room. It is easier for clients to follow a nutritious eating plan if it is written in advance and groceries are purchased for the planned menus. Clients must avoid buying foods frequently consumed during binges, such as cookies, candy bars, and potato chips. They should discard or move to the kitchen food that was kept at work, in the car, or in the bedroom. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPH… 7/13 11/16/23, 11:19 AM Realizeit for Student Identifying Emotions and Developing Coping Strategies Because clients with anorexia have problems with self-awareness, they often have difficulty identifying and expressing feelings (alexithymia). Therefore, they often express these feelings in terms of somatic complaints, such as feeling fat or bloated. The nurse can help clients begin to recognize emotions such as anxiety or guilt by asking them to describe how they are feeling and allowing adequate time for response. The nurse should not ask, “Are you sad?” or “Are you anxious?” because a client may quickly agree rather than struggle for an answer. The nurse encourages the client to describe his or her feelings. This approach can eventually help clients recognize their emotions and connect them to their eating behaviors. NURSING INTERVENTIONS For Eating Disorders Establishing nutritional eating patterns Sit with the client during meals and snacks. Offer liquid protein supplement if the client is unable to complete meal. Adhere to treatment program guidelines regarding restrictions. Observe the client following meals and snacks for 1 to 2 hours. Weigh the client daily in uniform clothing. Be alert for attempts to hide or discard food or inflate weight. Helping the client identify emotions and develop non–food-related coping strategies Ask the client to identify feelings. Self-monitoring using a journal Relaxation techniques Distraction Assist the client in changing stereotypical beliefs. Helping the client deal with body image issues Recognize benefits of a more near-normal weight. Assist in viewing self in ways not related to body image. Identify personal strengths, interests, and talents. Providing client and family education (see “Client and Family Education: For Eating Disorders”) Self-monitoring is a cognitive–behavioral technique designed to help clients with bulimia. It may help clients identify behavior patterns and then implement techniques to avoid or replace them (Richards, Shingleton, Goldman, Siegel, & Thompson-Brenner, 2016). Self-monitoring techniques raise client awareness about behavior and help them regain a sense of control. The nurse encourages clients to keep a diary of all food eaten throughout the day, including binges, and to record moods, emotions, thoughts, circumstances, and interactions surrounding eating and binging or purging episodes. In this way, clients begin to see connections between emotions and situations and eating behaviors. The nurse can then help clients develop ways to manage emotions, such as anxiety, using relaxation techniques or distraction with music or another activity. This is an important step toward helping clients find ways to cope with people, emotions, or situations that do not involve food. Dealing with Body Image Issues The nurse can help clients accept a more normal body image. This may involve clients agreeing to weigh more than they would like, to be healthy, and to stay out of the hospital. When clients experience relief from emotional distress, have increased self-esteem, and can meet their emotional needs in healthy ways, they are more likely to accept their weight and body image. The nurse can also help clients view themselves in terms other than weight, size, shape, and satisfaction with body image. Helping clients to identify areas of personal strength that are not food-related broadens clients’ perceptions of themselves. This includes identifying talents, interests, and positive aspects of character unrelated to body shape or size. Providing Client and Family Education One primary nursing role in caring for clients with eating disorders is providing education to help them take control of nutritional requirements independently. This teaching can be done in the inpatient setting during discharge planning or in the outpatient setting. The nurse provides extensive teaching about basic nutritional needs and the effects of restrictive eating, dieting, and the binge-and-purge cycle. Clients need encouragement to set realistic goals for eating throughout the day. Eating only salads and vegetables during the day may set up clients for later binges as a result of too little dietary fat and carbohydrates. For clients who purge, the most important goal is to stop. Teaching should include information about the harmful effects of purging by vomiting and laxative abuse. The nurse explains that purging is an ineffective means of weight control and only disrupts the neuroendocrine system. In addition, purging promotes binge eating by decreasing the anxiety that follows the binge. The nurse explains that if clients can avoid purging, they may be less likely to engage in binge eating. The nurse also teaches the techniques of distraction and delay because https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPH… 8/13 11/16/23, 11:19 AM Realizeit for Student they are useful against both binging and purging. The longer clients can delay either binging or purging, the less likely they are to carry out the behavior. CLIENT AND FAMILY EDUCATION For Eating Disorders Client Basic nutritional needs Harmful effects of restrictive eating, dieting, and purging Realistic goals for eating Acceptance of healthy body image Family and Friends Provide emotional support. Express concern about the client’s health. Encourage the client to seek professional help. Avoid talking only about weight, food intake, and calories. Become informed about eating disorders. It is not possible for family and friends to force the client to eat. The client needs professional help from a therapist or psychiatrist. The nurse explains to family and friends that they can be most helpful by providing emotional support, love, and attention. They can express concern about the client’s health, but it is rarely helpful to focus on food intake, calories, and weight. Nursing Care Plan: Anorexia Nursing Diagnosis Ineffective Coping: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources Assessment Data Denial of illness or resistance to treatment Inability to ask for help Inability to problem solve Inability to meet basic needs Inability to meet role expectations Feelings of helplessness or powerlessness Depressive behavior anxiety Guilt Anger Suicidal ideas or feelings of manipulative behavior Regressive behavior Hyperactivity Sleep disturbances, such as early awakening Social isolation Decreased sexual interest Rumination Refusal to eat Dread of certain foods or types of foods (such as carbohydrates) Disgust at the thought of eating Preoccupation with food Hiding or hoarding food Preoccupation with losing weight Unceasing pursuit of thinness Intense fear of becoming obese Family problems Low self-esteem Problems with sense of identity Delusions Body image distortions Expected Outcomes Immediate The client will Be free of self-inflicted injury throughout hospitalization. Participate in treatment program; for example, participate in at least one activity per shift or two interactions per shift within 2 to 3 days. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPH… 9/13 11/16/23, 11:19 AM Realizeit for Student Demonstrate decreased manipulative, depressive, or regressive behavior and suicidal ideas and feelings within 3 to 4 days. Demonstrate beginning trust relationship with others within 3 to 4 days. Verbalize recognition of perceptual distortions (e.g., distorted body image) within 4 to 5 days. Identify non–food-related coping mechanisms; for example, talking with others about feelings, keeping a journal within 4 to 5 days. Interact with others in non–food-related ways within 3 to 4 days. Demonstrate increased social skills; for example, approach others for interaction, make eye contact, and so forth within 3 to 4 days. Stabilization The client will Demonstrate more effective interpersonal relationships with family or significant others. Exhibit age-appropriate behavior; for example, complete school assignments on time without prompting from staff. Demonstrate change in attitudes about food and eating. Verbalize increased feelings of self-worth. Demonstrate non–food-related coping mechanisms. Demonstrate decreased associations between food and emotions. Verbalize knowledge of illness and medications, if any. Community The client will Participate in continuing therapy after discharge, if appropriate. Demonstrate independence and age-appropriate behaviors. Verbalize a realistic perception of body image. Implementation Nursing Interventions Rationale Assess and observe the client closely for self-destructive behavior Clients with anorexia nervosa are at risk for self-destructive or suicidal intent. behaviors. The client’s safety is a priority. Initially, limit the number of staff assigned to and interacting with the client, then gradually increase the variety of staff interacting with the client. Maintain consistency of treatment. One staff member per shift should be identified to have the final word on all decisions (though other staff or the client may have input).* Supervise or remain aware of the client’s interactions with others and intervene as appropriate. Initially limiting the number of staff can build trust, maximize consistency, and minimize manipulation. Consistency minimizes the possibility of manipulation of staff members by the client. Other clients or visitors, especially family members, may reinforce manipulative behavior or provide secondary gain for the client’s not eating. Do not restrict the client to his or her room as a restriction of Social isolation may be something the client desires or may be part privileges. of the client’s disorder. Remember the client’s age, and relate to the client accordingly. The client may appear to be younger than his or her actual age and Expect age-appropriate behavior from the client. may want to be dependent and avoid maturity and responsibility. Expect healthy behavior from the client. Encourage the client to do schoolwork while in the hospital if the client is missing school during hospitalization. When a client is diagnosed with an illness, you may expect and inadvertently reinforce behaviors characteristic of the disorder. Schoolwork is a normal part of an adolescent’s life. The client may receive a secondary gain from not being expected to do schoolwork or by falling behind in school. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPH… 10/13 11/16/23, 11:19 AM Give the client positive support and honest praise for accomplishments. Focus attention on the client’s positive traits and strengths (not on feelings of inadequacy). Realizeit for Student Positive support tends to provide reinforcement for desired behaviors. Do not flatter or be otherwise dishonest in interactions or with The client will not benefit from dishonest praise or flattery. Honest, feedback to the client. positive feedback can help build self-esteem. Foster successful experiences for the client. Arrange for the client to help others in specific ways, and suggest activities that are within his or her realm of ability, then increase complexity. Use group therapy and role-playing with the client. Give the client feedback on his or her behaviors and the reaction of others.* Be aware of your own feelings about the client and his or her behaviors. Express your feelings to other staff members rather than to the client.* Be nonjudgmental in your interactions with the client. Do not express approval or disapproval or be punitive to the client. Any activity that the client is able to complete provides an opportunity for positive feedback. The client can share feelings and try out new behaviors in a supportive, nonthreatening environment. The client may lack insight into his or her behaviors and their consequences or effect on others. You may have strong feelings of helplessness, frustration, and anger in working with this client. Working through your feelings will decrease the possibility of acting them out in interactions with the client. Issues of control, approval, and guilt are often problems with the client. Nonjudgmental nursing care decreases the possibility of power struggles. Remain aware of your own behavior with the client. Be Staff members are role models for appropriate behavior and self- consistent, truthful, and nonjudgmental. control. Make appropriate referrals for recreational or occupational The client may need to learn non–food-related ways to relax, spend therapy as appropriate.* leisure time, and so forth. Allow the client food only at specified snack and mealtimes. Do not talk with the client about emotional issues at these times. It is important for the client to separate emotional issues from food Encourage the client to ventilate his or her feelings at other and eating. times in ways not associated with food or eating. Withdraw your attention if the client is ruminating about food or Minimizing attention given to these behaviors may help decrease engaging in rituals about food or eating. them. Observe and record the client’s responses to stress. Encourage The client may be unaware of his or her responses to stress and may the client to approach the staff at stressful times. need to learn to identify stressful situations. Help the client identify others in the home environment with whom the client can talk and who can be supportive. Identify non–food-related activities that may decrease stress or anxiety The client needs to learn new skills to deal with stress. (e.g., hobbies, writing, and drawing). As tolerated, encourage the client to express his or her feelings regarding achievement, family issues, independence, social These issues are often problem areas for clients with anorexia. skills, sexuality, and control. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPH… 11/13 11/16/23, 11:19 AM Encourage the client to ventilate his or her feelings about family members, family dynamics, family roles, and so forth. Realizeit for Student Ventilation of feelings can help the client identify, accept, and work through feelings, even if these are painful or uncomfortable for the client. Include the client’s family and significant others in teaching, treatment, and follow-up plans. Teaching should include Family dynamics may play a significant role in anorexia nervosa. dynamics of illness, nutrition, medication use, if any.* Refer the client and family to support groups in the community Support groups sponsored by professional organizations can offer or via the internet. However, caution the client and family about support, education, and resources to clients and their families. Some internet groups that encourage anorexia and provide guidance internet groups, however, encourage eating-disordered behavior and regarding evaluation of online resources.* unhealthy weight loss and can undermine therapeutic goals. *Collaborative interventions. Adapted from Schultz, J. M., & Videbeck, S. L. (2013). Lippincott’s manual of psychiatric nursing care plans (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. The National Eating Disorders Association (2018) provides the following suggestions to promote positive body image: Get rid of the notion that a particular diet, weight, or body size will automatically lead to happiness and fulfillment. Learn everything you can about anorexia nervosa, bulimia nervosa, binge eating disorder, and other types of eating disorders. Make the choice to challenge the false idea that thinness and weight loss are great and that body fat and weight gain are horrible or indicate laziness, worthlessness, or immorality. Avoid categorizing foods as “good/safe” versus “bad/dangerous.” Remember that we all need to eat a balanced variety of foods. Stop judging yourself and others based on body weight or shape. Turn off the voices in your head that tell you that a person’s body weight is an indicator of their character, personality, or value as a person. Limit time on social media. Don’t read or listen to others’ negative comments. Surround yourself with positive, supportive, real people. Become a critical viewer of the media and its messages about self-esteem and body image. Don’t accept that the images that you see are the ideals you should try to attain. Choose to value yourself based on your goals, accomplishments, talents, and character. Avoid letting the way you feel about your body weight and shape determine the course of your day. School nurses, student health nurses at colleges and universities, and nurses in clinics and doctors’ offices may encounter clients in various settings who are at risk for developing or who already have an eating disorder. In these settings, early identification and appropriate referral are primary responsibilities of the nurse. Routine screening of all young women in these settings would help identify those at risk for an eating disorder. Box 20.3 contains a sample of questions that can be used for such screening. Such early identification could result in early intervention and prevention of a full-blown eating disorder. BOX 20.3 Sample Screening Questions How often do you feel dissatisfied with your body shape or size? Do you think you are fat or need to lose weight, even when others say you are thin? Do thoughts about food, weight, dieting, and eating dominate your life? Do you eat to make yourself feel better emotionally and then feel guilty about it? Try-Its What is the Eating Attitudes Test? List four nursing interventions for a client suffering from Bulimia Nervosa. List four nursing interventions for a client suffering from Anorexia Nervosa. What are some sample screening questions the nurse may ask? https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPH… 12/13 11/16/23, 11:19 AM Realizeit for Student Review Anorexia nervosa is a life-threatening eating disorder characterized by body weight less than below minimum expectations, an intense fear of being fat, a severely distorted body image, and refusal to eat or binge eating and purging. Bulimia nervosa is an eating disorder that involves recurrent episodes of binge eating and compensatory behaviors such as purging, using laxatives and diuretics, or exercising excessively. Of clients with eating disorders, 90% are females. Anorexia begins between the ages of 14 and 18 years, and bulimia begins around age 18 or 19. Many neurochemical changes are present in individuals with eating disorders, but it is uncertain whether these changes cause or are a result of the eating disorders. Individuals with eating disorders feel unattractive and ineffective and may be poorly equipped to deal with the challenges of maturity. Societal attitudes regarding thinness, beauty, desirability, and physical fitness may influence the development of eating disorders. Severely malnourished clients with anorexia nervosa may require intensive medical treatment to restore homeostasis before psychiatric treatment can begin. Family therapy is effective for clients with anorexia; CBT is most effective for clients with bulimia. Interventions for clients with eating disorders include establishing nutritional eating patterns, helping the client identify emotions and develop coping strategies not related to food, helping the client deal with body image issues, and providing client and family education. Focus on healthy eating and pleasurable physical exercise; avoid fad or stringent dieting. Parents must become aware of their own behavior and attitudes and the way they influence children. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPH… 13/13