Nursing Interventions *denotes collaborative interventions

Rationale

Note: It is especially important to use the following interventions selectively in developing an individual care plan for the client. There are several different kinds of interventions presented here that can be used with different approaches to the care of clients with anorexia. Some measures may be appropriate for clients whose nutritional state is severely compromised (total parenteral nutrition or nasoduodenal tube feedings), whereas others may be more effective in decreasing the attention given to food itself (e.g., to focus only on weight, not on intake and output) with a client whose nutritional state is not as severely compromised. You may want to develop a specific protocol for each client, with nursing interventions (e.g., tube feedings, supervision at and after meals) and client privileges based on compliance with calorie consumption or weight gain.

If the client is critically malnourished:

Parenteral nutrition through a central catheter may be indicated. Monitor the client closely for signs and symptoms of infection.

Adequate nutrition, electrolytes, and so forth can be provided parenterally. The client has no opportunity to vomit this kind of nutritive substance. The client’s immune system may be compromised related to malnutrition and a central line catheter provides a portal for infection.

Tube feedings may be used alone or with oral or parenteral nutrition. Use of a feeding tube may be effective.

Fortified liquid diets can be provided through tube feedings. The use of a feeding tube decreases the chance of vomiting or siphoning feedings.

Supervise the client for a specified time (initially 90 minutes, decreasing gradually to 30 minutes) after tube feeding, or remove the tube after feeding.

Supervision decreases the client’s opportunity to vomit or siphon feedings. Removing the tube prevents siphoning feedings.

Offer the client the opportunity to eat food orally. Use tube feedings if the client consumes insufficient calories or loses weight or if indicated by medical condition (electrolytes and acid-base balance). Decrease tube feedings as oral consumption becomes adequate.

The client may prefer to eat food orally rather than have a tube feeding; however, the client’s physical health is a priority.

When tube feeding is indicated (see above), insert the tube immediately in a matter-of-fact, nonpunitive manner, and administer feeding. Do not use tube feeding as a threat or punishment, and do not allow bargaining.

Limits and consistency are essential in avoiding power struggles and decreasing manipulative behavior. Remember, tube feedings are medical treatment, not punishment.

Parenteral nutrition or tube feedings may be best administered at night.

Using these methods at night may decrease attention given to the client by others and will interfere less in the client’s daytime activities.

General interventions (consider for any client):

^*Monitor the client’s vital signs, electrolytes, acid-base balance, liver enzymes, albumin, and other medical measures as indicated and ordered by the physician.

The client’s physical health is a priority. Information regarding the client’s clinical state is necessary to plan effective nursing care.

Monitor the client’s intake and output. Keep records at the nursing station (not at the client’s bedside or room) and do not allow the client to complete records. Observations of intake and output should be made in an unobtrusive and matter-of-fact manner.

The client may provide inaccurate information on intake or output records. It is important to minimize direct attention given for eating and to remove emotional issues from food and eating.

Establish a contract with the client regarding treatment, if the client will agree.

Contracting can promote the client’s sense of control and self-responsibility and help establish goals, but is ineffective if the client is not in agreement with its terms.

Initially, do not allow the client to eat with other clients or visitors.

Other clients may repeat family patterns by urging the client to eat or giving attention to the client for not eating.

Provide a structure to the client’s mealtimes. Tell the client when it is time to eat, present the food, and state limits in a consistent matter-of-fact manner.

Clear limits let the client know what is expected.

Do not bribe, coax, or threaten the client or focus on eating at all; withdraw your attention if the client refuses to eat. When the mealtime is over, remove food without discussion.

It is important to minimize the client’s secondary gain from not eating. Issues of control (especially regarding eating) are central to the client’s problem and must not be reinforced.

Supervise the client during and after meals (initially for 90 minutes, then decrease gradually). Do not allow the client to use the bathroom until at least 30 minutes after each meal.

The client may spill, hide, or discard food. The client may use the bathroom to vomit or dispose of concealed foods.

Provide a pleasant, relaxing environment for eating, and minimize distractions. Encourage the use of relaxation techniques, rest, and quiet before and after meals.

The client may have significant anxiety and guilt about eating, making mealtime very stressful.

Encourage the client to seek out a staff member after eating to talk about feelings of anxiety or guilt or if the client has the urge to vomit.

Talking with a staff member promotes a focus on emotional issues rather than on food. The client may feel guilt, remorse or shame after eating or eating certain foods (e.g., foods perceived as fattening by the client).

Allow the client increasing choices regarding food, mealtime, and so forth.

The client needs to develop independence in eating habits.

Grant and restrict privileges based on weight gain (or loss) and do not focus on eating, mealtimes, calorie counts, or physical activity. If weight loss occurs, decrease privileges and talk with the client to explore the circumstances and feelings involved.

Decreasing direct attention given to food and eating encourages the client to focus on emotional issues instead.

Weigh the client daily, after the client has voided and before the morning meal, with the client wearing only a hospital gown. Measure weight in a matter-of-fact manner; do not approve or disapprove of weight gain or loss.

Consistency is necessary for accurate comparison of weight over time. The client may retain urine or conceal weights on his or her body to increase weight measurement. Weight gain or loss is a measure of health, not of success or failure. A matter-of-fact attitude will help separate emotional issues from the client’s eating (or noneating) behaviors.

Monitor the client’s elimination patterns. The client’s diet should include sufficient fiber and adequate amounts of fluids.

The client may be constipated or have less frequent stools. Bulk and fluid promote adequate elimination.

Discourage the client’s use of enemas, laxatives, or suppositories.

The client may abuse laxative preparations as a means of controlling weight.

Observe and record the client’s physical activity; be aware that this may be covert (e.g., jogging in the shower, doing calisthenic exercises in bed).

The client may exercise to excess to control weight.

You may need to structure exercise activities into the client’s treatment plan. Do not forbid all physical exercise unless the client is critically ill and exercise would be truly harmful or unsafe.

Restricting physical activity too severely may greatly increase the client’s anxiety (see Care Plan 30: Obsessive-Compulsive Disorder). Also, moderate exercise is a valuable long-term health behavior and should not be discouraged.

Provide skin care, especially over bony prominences.

The client is at risk for skin breakdown due to diminished nutrition and lack of muscle and subcutaneous tissue.

Encourage the client to use a shower for bathing.

Sitting in a bathtub may be uncomfortable for the client due to bony prominences and lack of muscle or subcutaneous tissue.

Provide warm bedding. Be aware of room air temperatures.

The client is especially apt to feel cold because of decreased fat and subcutaneous tissue.

^*Provide or encourage dental hygiene. Referral to a dentist may be appropriate.

The client’s teeth or gums may be in poor condition due to the effects of vomiting (decreased tooth enamel from contact with gastric fluids) and malnutrition.

Gradually decrease limits on meals and snacks, and allow the client more control over food intake, choice of foods, preparation, and so forth.

The client needs to develop independent eating habits.

Give positive feedback for healthy eating behaviors.

Positive support tends to reinforce desired behaviors.

Be aware of your role in modeling healthy behavior.

You are a role model for the client.

^*Assess the client’s knowledge of weight, nutrition, and so forth. Client teaching may be indicated; this should be done in factual and unemotional terms and should be limited in frequency and duration. Refer the client to a dietitian for detailed instruction if appropriate.

The client may have false ideas about food, weight, and nutrition. The client needs to decrease his or her emotional investment in food or eating. Areas outside the nursing area of expertise are best referred to other health professionals.

Do not engage in nonteaching interactions with the client on topics of food and eating.

This allows you to focus on emotional issues with the client and limits focusing on food and eating.

Discharge should not occur until the client has reached a healthy weight, as agreed in the treatment plan. This limit should be maintained without bargaining after the goal has been set (although the client may have initial input into the goal).

The client’s physical health is a priority. Bargaining may undermine the limit. Allowing the client’s input in the treatment plan can encourage cooperation and enhance the client’s sense of control.