Disturbed Body Image — Anorexia & Bulimia Nervosa Nursing Care Plan (NCP)

NURSING DIAGNOSIS: Body image, disturbed/Self-Esteem, chronic low

May be related to

Morbid fear of obesity; perceived loss of control in some aspect of life
Personal vulnerability; unmet dependency needs
Dysfunctional family system
Continual negative evaluation of self

Possibly evidenced by

Distorted body image (views self as fat even in the presence of normal body weight or severe emaciation)
Expresses little concern, uses denial as a defense mechanism, and feels powerless to prevent/make changes
Expressions of shame/guilt
Overly conforming, dependent on others’ opinions

Desired Outcomes

Establish a more realistic body image.
Acknowledge self as an individual.
Accept responsibility for own actions.

7 Eating Disorders (Anorexia & Bulimia Nervosa) Nursing Care Plan (NCP)

Disturbed Body Image — Anorexia & Bulimia Nervosa Nursing Care Plan (NCP): Nursing Interventions & Rationale

Nursing Interventions	Rationale
Have patient draw picture of self.	Provides opportunity to discuss patient’s perception of self/body image and realities of individual situation.
Involve in personal development program, preferably in a group setting. Provide information about proper application of makeup and grooming.	Learning about methods to enhance personal appearance may be helpful to long-range sense of self-esteem/image. Feedback from others can promote feelings of self-worth.
Suggest disposing of “thin” clothes as weight gain occurs. Recommend consultation with an image consultant.	Provides incentive to at least maintain and not lose weight. Removes visual reminder of thinner self. Positive image enhances sense of self-esteem.
Assist patient to confront changes associated with puberty/sexual fears. Provide sex education as necessary.	Major physical/psychological changes in adolescence can contribute to development of eating disorders. Feelings of powerlessness and loss of control of feelings (in particular sexual sensations) lead to an unconscious desire to desexualize self. Patient often believes that these fears can be overcome by taking control of bodily appearance/development/function.
Establish a therapeutic nurse/patient relationship.	Within a helping relationship, patient can begin to trust and try out new thinking and behaviors.
Promote self-concept without moral judgment	Patient sees self as weak-willed, even though part of person may feel sense of power and control (e.g., dieting/weight loss).
States rules clearly regarding weighing schedule, remaining in sight during medication and eating times, and consequences of not following the rules. Without undue comment, be consistent in carrying out rules.	Consistency is important in establishing trust. As part of the behavior modification program, patient knows risks involved in not following established rules (e.g., decrease in privileges). Failure to follow rules is viewed as patient’s choice and accepted by staff in matter-of-fact manner so as not to provide reinforcement for the undesirable behavior.
Respond (confront) with reality when patient makes unrealistic statements such as “I’m gaining weight, so there’s nothing really wrong with me.”	Patient may be denying the psychological aspects of own situation and is often expressing a sense of inadequacy and depression.
Be aware of own reaction to patient’s behavior. Avoid arguing.	Feelings of disgust, hostility, and infuriation are not uncommon when caring for these patients. Prognosis often remains poor even with a gain in weight because other problems may remain. Many patients continue to see themselves as fat, and there is also a high incidence of affective disorders, social phobias, obsessive-compulsive symptoms, drug abuse, and psychosexual dysfunction. Nurse needs to deal with own response/feeling so they do not interfere with care of patient.
Assist patient to assume control in areas other than dieting/weight loss, e.g., management of own daily activities, work/leisure choices.	Feelings of personal ineffectiveness, low self-esteem, and perfectionism are often part of the problem. Patient feels helpless to change and requires assistance to problem-solve methods of control in life situations.
Help patient formulate goals for self (not related to eating) and create a manageable plan to reach those goals, one at a time, progressing from simple to more complex.	Patient needs to recognize ability to control other areas in life and may need to learn problem-solving skills to achieve this control. Setting realistic goals fosters success.
Note patient’s withdrawal from and/or discomfort in social settings.	May indicate feelings of isolation and fear of rejection/judgment by others. Avoidance of social situations and contact with others can compound feelings of worthlessness.
Encourage patient to take charge of own life in a more healthful way by making own decisions and accepting self as she or he is at this moment (including inadequacies and strengths).	Patient often does not know what she or he may want for self. Parents (mother) often make decisions for patient. Patient may also believe she or he has to be the best in everything and holds self responsible for being perfect.
Let patient know that is acceptable to be different from family, particularly mother.	Developing a sense of identity separate from family and maintaining sense of control in other ways besides dieting and weight loss is a desirable goal of therapy/program.
Use cognitive-behavioral or interpersonal psychotherapy approach, rather than interpretive therapy.	Although both therapies have similar results, cognitive-behavioral seems to work more quickly. Interaction between persons is more helpful for patient to discover feelings/impulses/needs from within own self. Patient has not learned this internal control as a child and may not be able to interpret or attach meaning to behavior.
Encourage patient to express anger and acknowledge when it is verbalized.	Important to know that anger is part of self and as such is acceptable. Expressing anger may need to be taught to patient because anger is generally considered unacceptable in the family, and therefore patient does not express it.
Assist patient to learn strategies other than eating for dealing with feelings. Have patient keep a diary of feelings, particularly when thinking about food.	Feelings are the underlying issue, and patient often uses food instead of dealing with feelings appropriately. Patient needs to learn to recognize feelings and how to express them clearly.
Assess feelings of helplessness/hopelessness.	Lack of control is a common/underlying problem for this patient and may be accompanied by more serious emotional disorders. Note: Fifty-four percent of patients with anorexia have a history of major affective disorder, and 33% have a history of minor affective disorder.
Be alert to suicidal ideation/behavior.	Intense anxiety/panic about weight gain, depression, hopeless feelings may lead to suicidal attempts, particularly if patient is impulsive.
Involve in group therapy.	Provides an opportunity to talk about feelings and try out new behaviors.
Refer to occupational/recreational therapy.	Can develop interest and skills to fill time that has been occupied by obsession with eating. Involvement in recreational activities encourages social interactions with others and promotes fun and relaxation.