Nursing diagnosis: imbalanced Nutrition: Less than Body Requirements 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 normal range or overweight (bulimia)
Pale conjunctiva and mucous membranes, poor skin turgor and muscle tone, edema
Excessive loss of hair, increased growth of hair on body (lanugo)
Amenorrhea
Hypothermia
Bradycardia, cardiac irregularities, hypotension
Desired Outcomes/Evaluation Criteria—Client Will
Knowledge: Diet
Verbalize understanding of nutritional needs.
Nutritional Status
Establish a dietary pattern with caloric intake adequate to regain or maintain appropriate weight.
Demonstrate weight gain toward individually expected range.
Nursing intervention with rationale:
1. Establish a minimum weight goal and daily nutritional requirements.
Rationale: Provides comparative baseline for effectiveness of therapy. Note: Malnutrition is a mood-altering condition, leading to depression and affecting cognitive function and decision making. Improved nutritional status enhances thinking ability, allowing initiation of psychological work.
2. Contract with client regarding commitment to therapeutic program and meeting specific dietary needs and goals.
Rationale: When client agrees to a contract, individual success is enhanced.
3. Use a consistent approach. Sit with client while eating; present and remove food without persuasion or comment. Promote pleasant environment and record intake.
Rationale: Client 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, client can begin to trust staff responses. The single area in which client has exercised power and control is food and eating, and she or he may experience guilt or rebellion if forced to eat. Structuring meals and decreasing discussions about food will decrease power struggles with client and avoid manipulative games.
4. Provide small, frequent, and nutritionally dense meals and supplemental snacks, as appropriate.
Rationale: Gastric dilation may occur if refeeding is too rapid following a period of starvation dieting. Client may feel bloated for weeks while body adjusts to increased food intake. Note: Client at risk for developing refeeding syndrome.
5. Make selective menu available, and allow client to control choices as much as possible.
Rationale: Client who gains confidence in self and feels in control of environment is more likely to eat preferred foods.
6. Be alert to choices of low-calorie foods and beverages, hoarding food, and disposing of food in various places, such as pockets or wastebaskets.
Rationale: Client will try to avoid taking in what is viewed as excessive calories and may go to great lengths to avoid eating.
7. Maintain a regular weighing schedule, such as Monday and Friday before breakfast in same attire, and graph results.
Rationale: Provides accurate ongoing record of weight loss or gain. Also diminishes obsessing about changes in weight.
8. Weigh with back to scale, depending on program protocols.
Rationale: Although some programs prefer that client does not see the results of the weighing, this can force the issue of trust in client who usually does not trust others.
9. Avoid room checks and other control devices whenever possible.
Rationale: External control reinforces feelings of powerlessness and therefore is usually not helpful.
10. Provide one-to-one supervision and have client with bulimia remain in the day room area or in sight with no bathroom privileges for a specified period, such as 2 to 3 hours, following eating if contracting is unsuccessful.
Rationale: Prevents vomiting during or immediately after eating. Client may desire food and eating, but use a binge-purge syndrome to control weight. Note: Some clients purge for the first time in response to establishment of a weight-gain program.
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