Skill List > Eating Disorders (Mental Health)
Clinical Alert
As mental healthcare legislation requirements may differ in different jurisdictions (e.g., England, Wales, Scotland, and Ireland), it is important that nurses and other members of the psychiatric care team make themselves aware of the relevant regulations applicable in their own country regarding the involuntary admission, care and detention of patients. If practising in the Republic of Ireland, the nurse must be aware of the Mental Health Commission Rules pertaining to seclusion and restraint.

Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.
Authors:
Based on Mosby Nursing Skills
Adapted by: Tommy Healy
BA MA CertCBT GradCertEduc RPN RGN RNT
Updated by: Catherine Johnson RGN RMN
Last updated: October 2017

Learning Objective
After reading the skill overview, following up some of the references/web sites and completing the self-test quiz you should be ready to be assessed in practice in the skill of caring for patients with eating disorders.

Introduction

People with eating disorders experience severe disruptions in normal eating patterns and a significant disturbance in the perception of body shape and weight (National Institute for Health and Care Excellence (NICE) 2017, Stuart 2013). Eating disorders are real, complex, and devastating conditions that can have serious consequences for physical and emotional health, productivity, and relationships. Eating disorders are serious, potentially life-threatening conditions; eating disorders are not fads, phases, or lifestyle choices. The risk for deliberate self-harm and suicide should be foremost in the assessment process. Even when there is no intention of self-harm in the patient diagnosed with an eating disorder, there is an increased risk of falls and injuries, including fractures as a result of loss of bone mineral density (BMD), osteopenia, and eventually osteoporosis.

Therapeutic interactions may be more difficult for nurses caring for patients in extreme cases. Being supervised by a competent, supportive, more experienced clinician, and sharing with peers, help to minimise feelings of frustration and can contribute to therapeutic growth in the nurse (Ibrahim 2016).

Resulting physical changes brought about by anorexia nervosa can include:

  • An abnormally slow heart rate (bradycardia) and/or irregular pulse.
  • Low blood pressure (hypotension), with a risk for heart failure as the heart muscle changes.
  • Loss of bone mineral density (BMD), osteopenia, and eventually osteoporosis.
  • Muscle loss and weakness.
  • Severe fluid, electrolyte, and acid–base imbalances, such as low potassium in the blood (hypokalaemia) and dehydration, which can cause kidney failure.
  • Amenorrhoea (cessation of menstruation).
  • Fainting, fatigue, and overall weakness.
  • Dry skin and hair (often with hair loss), and growth of a downy layer of hair (lanugo) all over the body in an effort to keep warm.

The earlier a person seeks treatment, the more likely they will be to recover physically and emotionally. Many people struggle with anorexia, bulimia, or binge eating disorder. These individuals need to seek professional help, but many of them keep their illness secret.

Goals of assessment and treatment include:

  • Determination of whether physical or psychiatric condition warrants hospitalisation (Ibrahim 2016).
  • Treating the psychological issues.
  • Reducing behaviours or thoughts that lead to disordered eating.
  • Restoring the patient to a healthy weight.
  • Preventing relapse.

Cultural considerations

  • In the past, anorexia nervosa was mostly seen in females in affluent families in Western Europe and North America, but it has spread more widely in sociocultural societies with Western influences.
  • People in Western societies and cultures are exposed to unrealistically thin beauty ideals by the media, which contributes to concern with weight and body shape.
  • Society tends to view eating disorders as a disease of young, white women. This potentially prevents timely diagnosis and reinforces a stigma that limits treatment for males or people of other ages or cultures.
  • Be aware of, and sensitive to, any cultural differences that may be perceived as disrespectful, such as eye contact or the use of touch.
  • Healthcare professionals should respect genetic diversity of body shape and size.
  • Education can help by improving media communication. Use an interpreter as needed when a language barrier exists.
  • Use an interpreter as needed when a language barrier exists.
  • People may choose medical practitioners or traditional healers and therapies to treat mental distress.

Young people and eating disorders

  • Under-nutrition can decrease cognitive development in children and have a negative impact on behaviour and school performance. The child or teenager may feel irritable, unable to focus, lack energy, and have a headache or nausea. Low levels of iron have an immediate effect on memory and ability to concentrate. Adolescents may be more vulnerable to illnesses when undernourished because of their compromised immune system.
  • Risk factors for eating disorders include family factors such as low family connectedness, absence of positive adult role models, parental dieting, and criticism of the child’s weight. Environmental factors may include weight-related teasing, poor involvement in school, peer group encouragement to diet, and involvement in weight-related sports. Other factors that correlate to unhealthy weight control behaviours may include the presence of other risk activities such as smoking, substance use, or unprotected sex.
  • Teenage dieting usually precedes anorexia and bulimia, but it is unclear whether it causes, triggers, or is the first step to eating disorders.
  • Unhealthy weight control behaviours in teenagers may include body image dissatisfaction and distortion, low self-esteem, low sense of control over life, depression, and anxiety.
  • There can be medical consequences of eating disorders even when weight does not appear to be dangerously low. Stunted height can signal severe malnutrition (De Onis & Branca 2016).
  • There are no standardised tables or formulas available for ‘ideal weight’ in children and adolescents because growth patterns are not generalised. The American Academy of Pediatrics and the American Psychiatric Association have set practice guidelines that encourage providers to determine an individual adolescent’s goal weight range using past growth charts, menstrual history, midparental height, and even bone age as guides. The Center for Disease Control and Prevention (CDC) recommends the use of growth charts to plot body mass index (BMI) for age (2–20 years) and gender. Those who fall below the fifth percentile in BMI for age are considered underweight if the healthcare practitioner considers it below the expected growth rate for the individual(De Onis & Branca 2016). The UK National Child Measurement Programme measures and weighs children at school, and parents are informed by letter if their child is assessed as overweight or obese. The Royal College of Paediatrics and Child Health has launched new growth charts for school-age children that combine data from the World Health Organisation Child Growth Standards up to age 4 years and the UK90 Growth Reference from 4–18 years (Royal Colege of Paediatric and Child Health 2012). Using the new charts, health staff will now be able to use BMI to assess a child’s weight as a matter of routine.
  • Children and teenagers with eating disorders rarely seek treatment on their own and are likely to deny the problem.
  • Coordination of treatment may be complex, including several healthcare services, family, and school.
  • It is not appropriate or helpful to blame families for a child’s eating problems, but identifying stressful situations within a family can help make the recovery less difficult.
  • Because parents are the ‘gatekeepers’ for treatment, it is important that the practitioner helps them feel comfortable and understood, while also respecting the child’s privacy.
  • Parental consent and agreement from patients are both needed for collaborative treatment.
  • Communicate and collaborate with the patient and parents to create a care plan that is patient- and family-centred.
  • It is developmentally appropriate for teenagers to rebel against authority. They may resist treatment assignments, avoid becoming engaged in discussions, and may miss appointments. Although some flexibility may help the therapeutic alliance, the need for weighing, blood tests, and hospitalisation (if indicated) must be enforced for patient safety.
  • Give choices to patients as often as possible, so they feel some control in the situation.
  • Treat the patient like an adult by speaking to them directly and respectfully. Do not talk to the adolescent through their parents. Be aware of how the patient interacts with relatives and friends; an abuser could be present.
  • Contact the local authority’s Children’s Services or the National Society for the Prevention of Cruelty to Children (NSPCC) if abuse or neglect is suspected.
  • There is no evidence that commercial weight loss programmes are safe or effective for children or teenagers. Patients should be referred to a multidisciplinary paediatric team.

Older people and eating disorders

  • Anorexia nervosa is especially dangerous in older people with poor health. Nurses in hospitals, community care, long-term care, or assisted living can help identify older people with an eating disorder.
  • Physiological factors may cause weight loss because taste buds become less sensitive, appetite naturally decreases, and medications can further blunt taste and smells. Pain and some illnesses can diminish appetite. But healthy ageing does not include depression, self-neglect, hopelessness, or food refusal.
  • People with less meaningful social contact can have ‘no appetite’, stop eating, and ‘waste away’. Some common causes could be that eating is one of the few areas over which older adults still have control, so refusing food may be a way of exerting power or gaining attention. They may convince themselves they do not need to eat much, or they may refuse food to save money. Hopelessness, despair, or depression can lead to an indirect suicide attempt (Wand et al. 2017).
  • Promote self-care and involvement in purposeful activities and social contact.
  • Monitor older patients for isolation, which can increase fears that worsen when there are limitations with immobility.
  • Ask directly if the patient has experienced abuse or neglect. Contact Adult Social Services if abuse or neglect is suspected.

Special considerations

  • Ask the patient if they are receiving any other mental health services in order to prevent duplication of care and maintain continuity of care.
  • Treat any comorbid disorders such as depression, panic disorder, generalised anxiety disorder, and bipolar disorder along with the eating disorder.
  • Disordered eating, even in the absence of substantial weight loss, can be associated with menstrual irregularity, which could impact fertility.
  • Patients who are attempting to conceive but are experiencing infertility should have eating disorders treated fully before trying reproductive technologies. Pregnancy is a special challenge for mother and fetus, and it should be monitored as a high-risk pregnancy.

Patient and family education

  • Assess the patient’s ability and readiness to learn on admission and periodically, recognising that a patient who is malnourished and fatigued may have a limited ability to think clearly enough for formal education.
  • Use handouts for patient education so family or friends may also read them (if the patient desires).
  • If needed, provide the patient and family with information about eating disorders and explain why the person should see a psychiatrist, if appropriate.
  • Provide information about unit rules and procedures on admission and as needed. Explain that the rules are based on safety.
  • Nurses can give family members the opportunity to express their concerns and to offer observations about the patient. If the patient is an adult, the nurse cannot disclose any information about the patient unless the patient has consented to it.
  • Enlist the cooperation of family in setting and achieving goals in the plan of care.
  • Support for the family may focus on the general well-being of the patient, rather than the eating disorder, if the topic appears to be sensitive.
  • Ask the family members what kind of support may be helpful.
  • Identify developmental and culturally relevant support groups for the patient and family.
  • Educate the patient and family about basic relaxation and coping strategies for anxiety.
  • Provide support and guidance to patients and families through difficult issues that may result from the patient’s refusal to follow the plan of care. This may include involuntary admission and detention in hospital and other life-sustaining treatments.

Preparation and safety

  • During the initial nursing interview and in subsequent shifts, assess the patient for recent or current suicidal or self-harm ideation.
  • Ask the patient about a history of abuse, neglect, or traumatic experiences, and assess the patient’s reaction to recent events and stressors to determine possible triggers for worsening of an eating disorder.
  • Assess the need to refer the patient to specialist services, such as a sexual abuse counsellor, domestic violence counsellor, a religious or spiritual leader, and a registered mental health professional such as a psychologist.
  • Assess whether the patient misuses alcohol or other substances, or has psychiatric issues contributing to the distress.
  • Observe the patient’s behaviour, body language, and verbal and non-verbal expression, noticing those that may be related to eating disorders and related anxiety.
  • Ask the patient if they have unintended weight loss or symptoms of eating disorders. Assess their ability to cope with the related anxiety.
  • Check weight and height on admission, and refer to a dietician if body mass index (BMI) is low, or if an eating disorder is suspected (Table 1).

Table 1 Body mass index. (Based on World Health Organisation 2017)

Classification

BMI

Underweight

< 18.50

Normal

18.5–24.99

Overweight (pre-obese)

25.0–29.9

Obesity

≥ 30.0

  • For accurate monitoring of weight during admission or hospitalisation, be consistent in using the same scales each day before breakfast and after the patient has passed urine. Use a hospital gown or same clothing each day. Ask the patient to stand on the scale facing away from it, so that they do not see the weight.
  • Ask the patient for permission before touching them for physical examination. Offer to allow another trusted person to be with the patient during procedures, especially if the examination is invasive or if privacy is required. If possible, assign a female nurse to young women and girls who have been sexually abused, are very self-conscious, or have a poor body image.
  • On admission, ask about the use of laxatives, diuretics, ‘diet pills’, or ‘natural’ products used to promote weight loss so that an appropriate medication regimen may be put in place.
  • Rule out medical causes of eating disorder symptoms. Some debilitating effects of prolonged semi-starvation may include orthostatic hypotension, bradycardia, and electrocardiogram changes as well as gastric, haematological, and metabolic abnormalities (Culbert et al. 2015).
  • Assess the patient’s understanding of the plan of care and willingness to cooperate with it.

Procedure

  1. Be aware of the challenges and significant morbidity and mortality of eating disorders. 
    Rationale – According to some studies, people with anorexia are up to ten times more likely to die as a result of their illness compared with those without the disorder. A risk assessment for suicidal ideation must be carried out. Many people with anorexia also have coexisting mental and physical illnesses.
  2. Recognise disordered eating patterns, body image, and extreme distress in patients with anorexia nervosa. 
    Rationale – Eating disorders like anorexia can include emaciation, relentless pursuit of thinness, a distortion of body image, intense fear of gaining weight, and extremely disturbed eating behaviours. Eating, food, and weight control become obsessions. Early recognition of eating disorders can help prevent some of the devastating medical and psychological complications.
  3. Observe for, and ask about, signs of eating disorders in both male and female patients. 
    Rationale – Although women and girls are much more likely to develop an eating disorder, men and boys can develop anorexia or bulimia and binge-eating disorder.
  4. Recognise anorexia nervosa in patients with extreme weight loss and who hold a belief that they are fat despite excessive thinness. 
    Rationale – Cardinal signs for anorexia nervosa include a dangerously low body weight measurement relative to the age and gender. Calculations based on body mass index (BMI) (weight in kilograms divided by the height in metres squared) are more precise and form a useful measure in recognising anorexia nervosa (Varcarolis 2016).
  5. Recognise bulimia nervosa in patients who regularly binge eat and then attempt to prevent weight gain by purging, vomiting, misusing laxatives, or exercising excessively. 
    Rationale – Individuals with the binge/purge type of anorexia nervosa may have prominent parotid salivary glands – the largest of the salivary glands (due to hyperstimulation from repeated vomiting). Severe fluid, electrolyte, and acid–base imbalance may be present due to purging.
  6. Identify and observe aspects of patient behaviour peculiar to anorexia nervosa. Notice behavioural clues of disordered eating, including pretending to eat but throwing food away, showing compulsive behaviours, wearing baggy clothes to hide the body, complaints of fatigue or dizziness, chaotic food intake, frequent trips to the toilet, carrying own food in a backpack or handbag, or constantly talking about food. 
    Rationale – Many people want to keep their eating disorder a secret and may feel too ashamed to ask for help. Giving up binging and purging can be as difficult as breaking an addiction, so it is strongly resisted by most patients.
  7. Be aware of sociocultural and psychological factors for eating disorders, and decrease risk factors as much as possible. 
    Rationale – Risk factors include low self-esteem, cultural pressures to be thin as promoted by popular media, use of food as a way of coping with negative emotions, rigid thinking, not being allowed to express emotions, and history of sexual abuse. Obsessive compulsive disorder (OCD) and anxiety disorders are more prevalent in people with anorexia and bulimia with the onset of OCD usually presenting before the onset of an eating disorder. Post-traumatic stress syndrome (PTSD), panic disorder, or agoraphobia most often develop after the onset of the eating disorder (Turner et al. 2015).
  8. Use individualised nursing care and treatments to restore the person to a healthy weight, like providing food choice and preferences, if possible, and using nutrition supplements. Offer frequent healthy snacks and drinks between meals. Rationale – Nutritional restoration is the immediate focus in low-weight patients. Meaningful psychodynamic treatment is not possible for emaciated patients, and delays in feeding may be dangerous. Calories should be increased gradually to avoid a refeeding syndrome (Peebles et al. 2017, see Green 2011 in Additional resources).
  9. Keep a detailed record of foods and fluids consumed, with calorie and protein intake if needed. 
    Rationale – The maintenance of detailed records of the ongoing care plan for patients with an eating disorder is vitally important so that an accurate evaluation of appropriate weight gain and fluid and calorie intake may be recorded.
  10. Use interventions that reduce or eliminate behaviours of disordered eating to ensure that foods eaten are digested and nutrition is available for essential body functions. 
    Rationale – Nursing interventions can help prevent disordered behaviour while in the hospital, but they may be impractical in other settings. Staff members can observe the patient for 1 h after eating, limit exercise, and control the use of laxatives or other drugs that were misused.
  11. Monitor weight daily, following medical instructions and in accordance with the agreed nursing care plan, without showing the patient the number on the scale. 
    Rationale – The patient’s weight can be a trigger for escalation of disordered thoughts, anxiety, and unhealthy behaviours. Staff should simply tell the patient whether the weight is up or down.
  12. Hospitalisation is required for the monitoring of abnormal or unstable vital signs, for example, bradycardia (heart beat less than 40 bpm) and severe medical complications such as haematemesis, severe neutropenia or thrombocytopenia, severe hypokalaemia, uncontrolled type 1 diabetes, or syncope. 
    Rationale – Severe abnormal or unstable vital functions and their complications should always be medically assessed, treated, and supervised, and the hospital is the location where the appropriate expertise may be readily accessed. Hospital is the most appropriate treatment centre where any life-threatening symptoms need to be remediated.  Pay careful attention to maintenance of fluid, electrolytes, and acid-base balance. Normal blood potassium level is important to avoid both acute cardiac and respiratory catastrophe. Low sodium in the blood (hyponatraemia) may be seen with compulsive water-drinking or diuretic misuse and should be carefully monitored because rapidly occurring or very low values can lead to seizures (Williams et al. 2016).
  13. Where medically prescribed, insert an IV line for administration of fluids, or nasogastric feeding tube for enteral feedings in order to restore fluid and electrolyte balance, calories, and protein. 
    Rationale – As dehydration and malnutrition progress, frequent assessments of vital signs and laboratory tests can monitor the physical changes and indicate when electrolytes need to be replaced and when IV fluids or other interventions are needed to protect the patient who is unable or unwilling to eat.
  14. Ask female patients of childbearing age when their last menstrual period was. Discuss the patient’s wishes to avoid or achieve pregnancy. 
    Rationale – Although eating disorders cause an increased risk for infertility, patients with amenorrhoea need to know that fertility can resume before the first menstrual period. Contraception may need to be discussed. Cessation of menstruation can be a sign of an eating disorder, malnourishment, or excessive exercise.
  15. Treat gastrointestinal signs and symptoms that may result from eating disorders. 
    Rationale – Gastrointestinal (GI) distress can include oesophageal erosion, ulcers, abdominal pain, feeling full or bloated, or feeling dry and dehydrated. Following GI investigations, appropriate medical and nursing interventions may commence in the treatment of all identified GI problems.  The patient may need one-to-one observation while the IV is in situ or the feeding is given, because they may try to pull it out. The tubing and pumps are also safety issues for patients with suicidal or self-harm intentions.
  16. Where medically prescribed, insert an IV line for administration of fluids, or nasogastric feeding tube for enteral feedings in order to restore fluid and electrolyte balance, calories, and protein.
    Rationale – As dehydration and malnutrition progress, frequent assessments of vital signs and laboratory tests can monitor the physical changes and guide when electrolytes need to be replaced and when IV fluids or other interventions are needed to protect the patient who is unable or unwilling to eat. The patient may need one-to-one observation while the IV is in situ or the feeding is given, because they may try to pull it out. The tubing and pumps are also safety issues for patients with suicidal or self-harm intentions.
  17. Where the patient is detained involuntarily in accordance with the relevant mental health legislation, it is necessary to prevent them from leaving the hospital or admission unit. 
    Rationale – The consequences of leaving the admission unit without medical consent may prolong the treatment regimen and compromise patient safety and the treatment progress already achieved. Ensure that the patient’s rights are upheld and have been communicated to them in accordance with relevant mental health legislation or directives.
  18. Continue detention in accordance with mental health legislation, and encourage compliance with prescribed medication and treatment. 
    Rationale – If the patient is unable or unwilling to discuss and comply with treatment regimens, and the responsible clinician thinks it is necessary, local standard operating procedures may be employed enabling treatment to be given to the patient. This can be a stressful time for the patient, the family, and staff members, and personal support or counselling may be required by anyone involved in such a situation. Clinical supervision may be appropriate for the staff involved.
  19. Consider family-based therapies for effective treatment of children or adolescents with eating disorders, if appropriate or if residential programmes are not available. 
    Rationale – In family-based therapy, parents are empowered and given responsibility to return their child to physical health and to ensure full weight restoration. Multidisciplinary care should still be the goal of outpatient treatment, and referrals can be made to a family therapist, psychiatrist, and dietitian. Parents need permission to take a firm stand when the child has become unable to care for themselves and is overwhelmed by this powerful illness.
  20. Actively engage the patient in problem solving and discharge planning early in their stay. Keep the patient (and the people in their support system) involved and informed as much as possible in choosing the treatment and therapies the patient sees as helpful to them. 
    Rationale – The plan of care will most likely be followed and adhered to if the patient and family are involved in developing it. A variety of psychosocial interventions that combine management and supportive psychotherapy designed specifically for eating disorders are most effective (NICE 2017).
  21. Encourage activities, and modify group activities as needed. 
    Rationale – Attachment anxiety may cause the patient to be sensitive to rejection and avoid contact with others in times of stress. Recovery from trauma requires the reconstruction of basic capacities for trust, autonomy, initiative, competence, identity, and intimacy through building trusting relationships (Tasca & Balfor 2014).
  22. If recommended by the doctor, discuss possible therapeutic approaches for the eating disorder, such as medications and/or hospitalisation. 
    Rationale – Medications can be used to treat bulimia nervosa, including antidepressants, antiemetics, and anticonvulsants. Fluoxetine, a selective serotonin reuptake inhibitor (SSRI) antidepressant, can be used for bulimia nervosa in those aged 18 years or above (British National Formulary 2017). For anorexia nervosa, antidepressants, antipsychotics, opiate antagonists, and mood stabilisers have been used, but research has not shown them to be clearly effective (Garner et al. 2016).Eating disorders (including binge eating disorders) need more research and focus on antidepressants, appetite suppressants, and anticonvulsants. Self-monitoring programmes can be helpful as the key goal is to support individuals to achieve a healthy body weight or BMI fo their age (NICE 2017).
  23. If recommended by the doctor, discuss possible therapeutic approaches to the eating disorder, such as individual or family therapy. 
    Rationale – In addition to medical monitoring and intensive nutritional support, patients also need psychotherapy for an integrated approach to treatment. Cognitive behavioural therapy (CBT) and/or other cognitive-orientated therapies are more effective than nutritional counselling alone in preventing relapse. Cognitive behavioural therapy strategies like cognitive restructuring and behavioural control can be very effective if started before a medical crisis. Cognitions include negative attitudes, assumptions, maladaptive beliefs, cognitive distortions, and misinterpretation (NICE 2017).
  24. Help patients to recognise triggers for disordered eating and behaviours and teach them better ways to cope.
    Rationale – If triggers are not recognised, then people are more likely to return to disordered eating behaviours. It is better to recognise and avoid triggers, if possible, or to learn better ways to cope with them. This is facilitated through engagement with CBT.
  25. Help patients cope with the distress of chronic anxiety and strong negative emotional responses to trauma-related memories that are difficult to manage. 
    Rationale – Patients may try to avoid vivid and painful feelings by substance misuse, dissociation, and unhealthy tension-reducing behaviours such as binge eating, promiscuous sex, and self-harm. They may want to stop therapy and give up on recovery instead of using new ways of coping that can be learned. Teaching stress-reduction activities, including grounding, breathing-relaxation techniques, and emotional regulation can be helpful.
  26. Provide patient teaching on admission about risk for falls and injuries, and ensure or provide nonslip footwear. Tell patients of any age they should use their call bell or light to get staff assistance if feeling weak or dizzy. Encourage patients to sit on the edge of the bed for a few minutes before standing and use extra care and gentleness when assisting with range-of-motion exercises or transferring patients with eating disorders. 
    Rationale – Medications to treat anxiety and other psychiatric conditions tend to increase risk for falls. Patients with eating disorders usually have reduced bone mineral density, osteopenia, or osteoporosis and their bones can easily fracture (Adkins 2017). Use extra care and gentleness when assisting with range-of-motion exercises or transferring patients with eating disorders.
  27. Give the patient information about resources for eating disorders information, treatment, and support for recovery by phone or online provided by both the statutory and voluntary services (see Additional resources). 
    Rationale – Encourages patients to contact eating disorders organisations for support and information online or by telephone helplines. These helplines are voluntary resources and provide a free, confidential referral and information service.
  28. Help the patient build a support network. Support is vital to successful treatment and recovery. 
    Rationale – Not all patients have support from family and friends. They may have dysfunctional families, no families, or friends who do not understand their eating disorder and psychiatric illness. Patients often have other psychiatric illnesses along with an eating disorder, and may find associated support groups in their communities and online.
  29. Provide patient teaching as ‘teachable moments’ occur. Involve the patient’s support person in the education as much as possible. 
    Rationale – Education is very important to help the patient towards a sustainable recovery. Provide verbal as well as written information, because handouts can be looked at again later when the patient’s mind is clearer, and they can be shared with the support person. Offer DVDs for eating disorder education or online sources, if available.
  30. Reintegrate the patient into community life as much as possible and promote personal growth. 
    Rationale – ‘Healing through meaning’ includes helping people recognise their capacities and offers new meaning potential.
  31. Continue intensive therapy and monitoring after discharge when medically necessary by transferring the patient to residential or outpatient treatment programmes and follow-up. Involve the social worker in finding available programmes for therapy that are appropriate. 
    Rationale – There are some inpatient facilities dedicated to the treatment of eating disorders. Specialised residential programmes for adults, adolescents, and children may also offer day treatment or fulfil other outpatient needs.
  32. Document care plan strategies, the patient’s responses and outcomes of care in the patient’s record. 
    Rationale – Accurate and thorough documentation is essential and allows for consistent care and communication. It is important to see whether interventions such as CBT or other talk therapies and medications are effective in improving the psychiatric symptoms and that any side effects of medication are closely monitored. Documenting affect, mood, thought patterns, behaviours, and sleep are very important when caring for patients with psychiatric illness. Likewise, the careful documentation of each element of the nursing care plan (its implementation and re-evaluation) will assist and ensure the most appropriate interventions are used to progress towards a complete recovery.

Ongoing care, monitoring and support

  • Patients must be re-evaluated each shift for level of anxiety and patient’s safety. Nursing observation has a key function here.
  • Consider hourly nursing rounds and a bed alarm for patients with high fall risk.
  • Identify if strategies are effectively reducing the frequency and intensity of symptoms.
  • Document effectiveness of medications given to reduce gastrointestinal symptoms and improve the ability to eat.
  • Assess the patient’s weight changes and re-evaluate the plan of care, if necessary.
  • Assess whether medications for sleep or anxiety are effective.
  • Ensure that interventions provided are developmentally and culturally appropriate.

Documentation and reporting

The nurse should record the following in the patient’s record:

  • Patient’s food and fluid intake during meals and snacks, or refusal of food offered.
  • Carefully monitored fluid intake and output.
  • Bowel movements and any bowel care that is needed.
  • Patient’s affect, activities, and behaviour in response to interventions.
  • Behaviours, and signs and symptoms that may lead to diagnosis of other physical or psychiatric disorders.
  • Whether or not the patient had self-harm, suicidal, or homicidal thoughts.
  • Patient education, counselling, or groups attended.
  • Patient’s and family’s cooperation with the treatment plan.
  • Presence of visitors and patient’s response to them.
  • Any new problems, or changes in plan of care or treatment.
  • Collaboration and partnership working with the psychiatrist and community mental health services. 
Your email :


Recipient: (email address)
To multiple recipients, separate email addresses with commas.


Note : (optional)