NCP Eating Disorders Obesity
EATING DISORDERS: OBESITY
Obesity is defined as an excess accumulation of body fat at least
20% over average desired weight for age, sex, and height or a body
mass index (kg/m2) of greater than 27.8 for men and greater than 27.3
for women. Obesity is a chronic condition considered by some to be a
disability. The general prognosis for achieving and maintaining weight
loss is poor; however, the desire for a healthier lifestyle and reduction
of risk factors associated with life-threatening illnesses motivate many
people toward diets and weight-loss programs.
CARE SETTING
Community level unless morbid obesity requires brief inpatient stay
RELATED CONCERNS
Cerebrovascular accident (CVA)/stroke
Cholecystitis with cholelithiasis
Cirrhosis of the liver
Diabetes mellitus/Diabetic ketoacidosis
Heart failure: chronic
Hypertension: severe
Myocardial infarction
Obesity: surgical interventions (gastric partitioning/gastroplasty,
gastric bypass)
Psychosocial aspects of care
Thrombophlebitis: deep vein thrombosis
Patient Assessment Database
ACTIVITY/REST
May report: Fatigue,
constant drowsiness
Inability/lack of desire
to be active or engage
in regular exercise;
sedentary lifestyle
Dyspnea with exertion
May exhibit:
Increased heart
rate/respirations with
activity
CIRCULATION
May exhibit:
Hypertension, edema
EGO INTEGRITY
May report: History of
cultural/lifestyle factors
affecting food choices
Weight may/may not
be perceived as a
problem
Eating relieves
unpleasant feelings,
e.g., loneliness,
frustration, boredom
Perception of body
image as undesirable
SOs resistant to weight
loss (may sabotage
patient’s efforts)
FOOD/FLUID
May report:
Normal/excessive
ingestion of food
Experimentation with
numerous types of
diets ("yo-yo" dieting)
with varied/short-lived
results
History of recurrent
weight loss and gain
May exhibit: Weight
disproportionate to
height
Endomorphic body type
(soft/round)
Failure to adjust food
intake to diminishing
requirements (e.g.,
change in lifestyle from
active to sedentary,
aging)
PAIN/DISCOMFORT
May report:
Pain/discomfort on
weight-bearing joints or
spine
RESPIRATION
May report: Dyspnea
May exhibit:
Cyanosis, respiratory
distress (Pickwickian
syndrome)
SEXUALITY
May report: Menstrual
disturbances,
amenorrhea
TEACHING/LEARNING
May report: Problem
may be lifelong or
related to life event
Family history of
obesity
Concomitant health
problems may include
hypertension, diabetes,
gallbladder and
cardiovascular disease,
hypothyroidism
Discharge plan DRG
projected mean
length of inpatient
stay: 5.1 days
considerations: May
require support with
therapeutic regimen;
home modifications,
assistive
devices/equipment.
Refer to section at end
of plan for
postdischarge
considerations.
DIAGNOSTIC STUDIES
Metabolic/endocrine studies: May reveal abnormalities, e.g.,
hypothyroidism, hypopituitarism, hypogonadism, Cushing’s
syndrome (increased insulin levels), hyperglycemia,
hyperlipidemia, hyperuricemia, hyperbilirubinemia. It is also
suggested that the cause of these disorders may arise from
neuroendocrine abnormalities within the hypothalamus, which
result in various chemical disturbances.
Anthropometric measurements: Measures fat-to-muscle
ratio.
NURSING PRIORITIES
1. Assist patient to identify a workable method of weight control
incorporating healthful foods.
2. Promote improved self-concept, including body image, self
esteem.
3. Encourage health practices to provide for weight control
throughout life.
DISCHARGE GOALS
1. Healthy patterns for eating and weight control identified.
2. Weight loss toward desired goal established.
3. Positive perception of self verbalized.
4. Plans developed for future weight control.
5. Plan in place to meet needs after discharge.
NURSING DIAGNOSIS: Nutrition: imbalanced, more
than body requirements
May be related to
Food intake that exceeds body needs
Psychosocial factors
Socioeconomic status
Possibly evidenced by
Weight of 20% or more over optimum body weight; excess
body fat by skinfold/other measurements
Reported/observed dysfunctional eating patterns, intake
more than body requirements
DESIRED OUTCOMES/EVALUATION CRITERIA—
PATIENT WILL:
Knowledge: Diet (NOC)
Identify inappropriate behaviors and consequences
associated with overeating or weight gain.
Demonstrate change in eating patterns and involvement in
individual exercise program.
Nutritional Status (NOC)
Display weight loss with optimal maintenance of health.
ACTIONS/INTERVENTIONS RATIONALE
Weight Reduction Assistance
(NIC)
Independent
Identifies/influences choice of
Review individual cause for some interventions.
obesity, e.g., organic or
nonorganic.
Implement/review daily food diary, Provides the opportunity for the
e.g., caloric intake, types and individual to focus on/internalize a
amounts of food, eating habits. realistic picture of the amount of
food ingested and corresponding
eating habits/feelings. Identifies
patterns requiring change and/or a
base on which to tailor the dietary
program.
Helps identify when patient is
Discuss emotions/events eating to satisfy an emotional
associated with eating. need, rather than physiological
hunger.
Although there is no basis for
recommending one diet over
Formulate an eating plan with the another, a good reducing diet
patient, using knowledge of should contain foods from all basic
individual’s height, body build, food groups with a focus on low-fat
age, gender, and individual intake and adequate protein intake
patterns of eating, energy, and to prevent loss of lean muscle
nutrient requirements. Determine mass. It is helpful to keep the plan
which diets and strategies have as similar to patient’s usual eating
been used, results, individual pattern as possible. A plan
frustrations/factors interfering developed with and agreed to by
with success. the patient is more likely to be
successful.
Elimination of needed components
can lead to metabolic imbalances,
e.g., excessive reduction of
Emphasize the importance of carbohydrates can lead to fatigue,
avoiding fad diets. headache, instability/weakness,
and metabolic acidosis (ketosis),
interfering with effectiveness of
weight loss program.
Denying self by excluding
desired/favorite foods results in a
sense of deprivation and feelings
of guilt/failure when individual
"succumbs to temptation." These
Discuss need to give self feelings can sabotage weight loss.
permission to include
desired/craved food items in The patient who binges
dietary plan. experiences guilt about it, which is
also counterproductive because
negative feelings may sabotage
further weight loss efforts.
Reasonable weight loss (1–2 lb/wk)
Be alert to binge eating and results in more lasting effects.
develop strategies for dealing with Excessive/rapid loss may result in
these episodes, e.g., substituting fatigue and irritability and
other actions for eating. ultimately lead to failure in
meeting goals for weight loss.
Identify realistic increment goals Motivation is more easily sustained
for weekly weight loss.
by meeting "stair-step" goals.
Provides information about
effectiveness of therapeutic
regimen and visual evidence of
success of patient’s efforts.
(During hospitalization for
controlled fasting, daily weighing
Weigh periodically as individually may be required. Weekly weighing
indicated, and obtain appropriate is more appropriate after
body measurements. discharge.)
ACTIONS/INTERVENTIONS RATIONALE
Weight Reduction Assistance
(NIC)
Independent
Exercise furthers weight loss by
Determine current activity levels reducing appetite; increasing
and plan progressive exercise energy; toning muscles; and
program (e.g., walking) tailored to enhancing cardiac fitness, sense of
the individual’s goals and choice. well-being, and accomplishment.
Commitment on the part of the
patient enables the setting of more
realistic goals and adherence to
the plan.
Develop an appetite reeducation Signals of hunger and fullness
plan with patient. often are not recognized, have
become distorted, or are ignored.
Reducing tension provides a more
Emphasize the importance of relaxed eating atmosphere and
avoiding tension at mealtimes and encourages more leisurely eating
not eating too quickly. patterns. This is important because
a period of time is required for the
appestat mechanism to know the
stomach is full.
Techniques that modify behavior
Encourage patient to eat only at a may be helpful in avoiding diet
table or designated eating place failure.
and to avoid standing while
eating. Water retention may be a problem
because of increased fluid intake
Discuss restriction of salt intake and fat metabolism.
and diuretic drugs if used.
Changes in weight and exercise
Reassess calorie requirements necessitate changes in plan. As
every 2–4 wk; provide additional weight is lost, changes in
support when plateaus occur. metabolism occur, resulting in
plateaus when weight remains
stable for periods of time. This can
create distrust and lead to
accusations of "cheating" on
caloric intake, which are not
helpful. Patient may need
additional support at this time.
Collaborative
Consult with dietitian to determine
caloric/nutrient requirements for Individual intake can be calculated
individuals weight loss. by several different formulas, but
weight reduction is based on the
basal caloric requirement for 24 hr,
depending on patient’s sex, age,
current/desired weight, and length
of time estimated to achieve
desired weight. Note: Standard
tables are subject to error when
applied to individual situations,
and circadian rhythms/lifestyle
patterns need to be considered.
Provide medications as indicated:
Appetite-suppressant drugs, May be used with
e.g., diethylpropion caution/supervision at the
(Tenuate), mazindol beginning of a weight loss program
(Sanorex), Sibutramine to support patient during stress of
(Meridia); behavioral/lifestyle changes. They
are only effective for a few weeks
and may cause problems of
addition in some people.
May be necessary when
Hormonal therapy, e.g., hypothyroidism is present. When
thyroid (Euthroid), no deficiency is present,
levothyroxine (Synthroid); replacement therapy is not helpful
and may actually be harmful.
Note: Other hormonal treatments,
such as human chorionic
gonadrotropin (HCG), although
widely publicized, have no
documented evidence of value.
ACTIONS/INTERVENTIONS RATIONALE
Weight Reduction Assistance
(NIC)
Collaborative
Lipase inhibitor blocks absorption
Orlistat (Xenical); of approximately 30% of dietary
fat. Facilitates weight
loss/maintenance when used in
conjuction with a reduced-calorie
diet. Also reduces risk of regain
after weight loss.
Obese individuals have large fuel
Vitamin, mineral reserves but are often deficient in
supplements. vitamins and minerals. Note: Use
of Xenical inhibits absorption of
water-soluble vitamins and beta-
carotene. Vitamin supplement
should be given at least 2 hr
before or after Xenical.
Aggressive therapy/support may
be necessary to initiate weight
loss, although fasting is not
Hospitalize for fasting regimen generally a treatment of choice.
and/or stabilization of medical Patient can be monitored more
problems, when indicated. effectively in a controlled setting,
to minimize complications such as
postural hypotension, anemia,
cardiac irregularities, and
decreased uric acid excretion with
hyperuricemia.
These interventions may be
necessary to help the patient lose
weight when obesity is life-
Prepare for surgical interventions, threatening. (Refer to CP: Obesity:
e.g., gastric partitioning/bypass, Surgical Interventions.)
as indicated.
NURSING DIAGNOSIS: Body Image disturbances/Self-
Esteem, chronic low
May be related to
Biophysical/psychosocial factors such as patient’s view of
self (slimness is valued in this society, and mixed messages
are received when thinness is stressed)
Family/subculture encouragement of overeating
Control, sex, and love issues
Possibly evidenced by
Verbalization of negative feelings about body (mental
image often does not match physical reality)
Fear of rejection/reaction by others
Feelings of hopelessness/powerlessness
Preoccupation with change (attempts to lose weight)
Lack of follow-through with diet plan
Verbalization of powerlessness to change eating habits
DESIRED OUTCOMES/EVALUATION CRITERIA—
PATIENT WILL:
Body Image (NOC)
Verbalize a more realistic self-image.
Demonstrate some acceptance of self as is, rather than an
idealized image.
Self-Esteem (NOC)
Seek information and actively pursue appropriate weight
loss.
Acknowledge self as an individual who has responsibility for
self.
ACTIONS/INTERVENTIONS RATIONALE
Body Image Enhancement
(NIC)
Independent
Mental image includes our ideal
Determine patient’s view of being and is usually not up-to-date. Fat
fat and what is does for the and compulsive eating behaviors
individual. may have deep-rooted
psychological implications, (e.g.,
compensation for lack of love and
nurturing or a defense against
intimacy).
Provide privacy during care Individual usually is sensitive/self-
activities. conscious about body.
Promote open communication Supports patient’s own
avoiding criticism/judgment about responsibility for weight loss;
patient’s behavior. enhances sense of control, and
promotes willingness to discuss
difficulties/setbacks and problem-
solve. Note: Distrust and
accusations of "cheating" on
caloric intake are not helpful.
It is helpful for each individual to
Outline and clearly state understand area of own
responsibilities of patient and responsibility in the program so
nurse. that misunderstandings do not
arise.
Provides ongoing visual evidence
Graph weight on a weekly basis. of weight changes (reality
orientation).
Mental rehearsal is very useful in
Encourage patient to use imagery helping the patient plan for and
to visualize self at desired weight deal with anticipated change in
and to practice handling of new self-image or occasions that may
behaviors. arise (family gatherings, special
dinners) where constant decisions
about eating many foods will
occur.
Enhances feelings of self-esteem;
promotes improved body image.
Provide information about the use Properly fitting clothes enhance
of makeup, hairstyles, and ways of the body image as small losses are
dressing to maximize figure made and the individual feels more
assets. positive. Waiting until the desired
weight loss is reached can become
Encourage buying clothes instead discouraging.
of food treats as a reward for
weight loss. Removes the "safety valve" of
having clothes available "in case"
the weight is regained. Retaining
fat clothes can convey the
message that the weight loss will
Suggest the patient dispose of "fat not occur/be maintained.
clothes" as weight loss occurs.
Parents act as role models for the
child. Maladaptive coping patterns
(overeating) are learned within the
family system and are supported
through positive reinforcement.
Have patient recall coping Food may be substituted by the
patterns related to food in family parent for affection and love, and
of origin and explore how these eating is associated with a feeling
may affect current situation. of satisfaction, becoming the
primary defense.
May contribute to current issues of
self-esteem/patterns of coping.
Determine relationship history and
possibility of sexual abuse.
ACTIONS/INTERVENTIONS RATIONALE
Body Image Enhancement
(NIC)
Independent
The individual may harbor
Identify patient’s motivation for repressed feeling of hostility,
weight loss and assist with goal which may be expressed inward on
setting. the self. Because of a poor self-
concept the person often has
difficulty with relationships. Note:
When losing weight for someone
else, the patient is less likely to be
successful/maintain weight loss.
Beliefs about what an ideal body
looks like or unconscious
motivations can sabotage efforts
Be alert to myths the patient/SO to lose weight. Some of these
may have about weight and include the feminine thought of "If
weight loss. I become thin, men will pursue me
or rape me"; the masculine
counterpart, "I don’t trust myself
to stay in control of my sexual
feelings"; as well as issues of
strength, power, or the "good
cook" image.
Awareness of emotions that lead to
overeating can be the first step in
behavior change (e.g., people
often eat because of depression,
Assist patient to identify feelings anger, and guilt).
that lead to compulsive eating.
Encourage journaling. Replacing eating with other
activities helps retrain old patterns
and establish new ways to deal
with feelings.
Develop strategies for doing
something besides eating for Judgmental attitudes, feelings of
dealing with these feelings, e.g., disgust, anger, and weariness can
talking with a friend. interfere with care/be transmitted
to patient, reinforcing negative
Help staff be aware of and deal self-concept/image.
with own feelings when caring for
patient.
Collaborative Support groups can provide
companionship, enhance
Refer to community support motivation, decrease loneliness
and/or therapy group. and social ostracism, and give
practical solutions to common
problems. Group therapy can be
helpful in dealing with underlying
psychological concerns.
NURSING DIAGNOSIS: Social Interaction, impaired
May be related to
Verbalized or observed discomfort in social situations
Self-concept disturbance
Possibly evidenced by
Reluctance to participate in social gatherings
Verbalization of a sense of discomfort with others
DESIRED OUTCOMES/EVALUATIONS CRITERIA—
PATIENT WILL:
Social Involvement (NOC)
Verbalize awareness of feelings that lead to poor social
interactions.
Become involved in achieving positive changes in social
behaviors and interpersonal relationships.
ACTIONS/INTERVENTIONS RATIONALE
Socialization Enhancement
(NIC)
Independent
Social interaction is primarily
Review family patterns of relating learned within the family of origin.
and social behaviors. When inadequate patterns are
identified, actions for change can
be instituted.
Helps identify and clarify reasons
for difficulties in interacting with
Encourage patient to express others, e.g., may feel
feelings and perceptions of unloved/unlovable or insecure
problems. about sexuality.
May have coping skills that will be
useful in the process of weight
Assess patient’s use of coping loss. Defense mechanisms used to
skills and defense mechanisms. protect the individual may
contribute to feelings of
aloneness/isolation.
Identifies specific concerns and
suggests actions that can be taken
Have patient list behaviors that to effect change.
cause discomfort.
Practicing these new behaviors
enables the individual to become
comfortable with them in a safe
Involve in role-playing new ways situation.
to deal with identified
behaviors/situations. May be impeding positive social
interactions.
Discuss negative self-concepts
and self-talk, e.g., "No one wants
to be with a fat person," "Who
would be interested in talking to
me?"
Positive strategies enhance
Encourage use of positive self-talk feelings of comfort and support
such as telling one-self "I am OK," efforts for change.
or "I can enjoy social activities and
do not need to be controlled by
what others think or say."
Collaborative
Refer for ongoing family or
individual therapy as indicated. Patient benefits from involvement
of SO to provide support and
encouragement.
NURSING DIAGNOSIS: Knowledge Deficient [Learning
Need] regarding condition, prognosis, treatment,
self care, and discharge needs
May be related to
Lack of/misinterpretation of information
Lack of interest in learning, lack of recall
Inaccurate/incomplete information presented
Possibly evidenced by
Statements of lack of/request for information about obesity
and nutritional requirements
Verbalization of problem with weight reduction
Inadequate follow-through with previous diet and exercise
instructions
DESIRED OUTCOMES/EVALUATION CRITERIA—
PATIENT WILL:
Knowledge: Diet (NOC)
Verbalize understanding of need for lifestyle changes to
maintain/control weight.
Establish individual goal and plan for attaining that goal.
Begin to look for information about nutrition and ways to
control weight.
ACTIONS/INTERVENTIONS RATIONALE
Teaching: Prescribed Diet
(NIC)
Independent
Necessary to know what additional
Determine level of nutritional information to provide. When
knowledge and what patient patient’s views are listened to,
believes is most urgent need. trust is enhanced.
A high relapse rate at 5-year
follow-up suggests obesity cannot
be reliably reversed/cured. Shifting
Identify individual holistic long- the focus from initial weight
term goals for health (e.g., loss/percentage of body fat to
lowering blood pressure, overall wellness may enhance
controlling serum lipid and rehabilitation.
glucose levels).
"Smart" eating when dining out or
when traveling helps individual
manage weight while still enjoying
Provide information about ways to social outlets.
maintain satisfactory food intake
in settings away from home. Using different avenues of
accessing information furthers
patient’s learning. Involvement
with others who are also losing
Identify other sources of weight can provide support.
information, e.g., books, tapes,
community classes, groups. As weight is lost, changes in
metabolism occur, interfering with
further loss by creating a plateau
as the body activates a survival
Emphasize necessity of continued mechanism, attempting to prevent
follow-up care/counseling, "starvation." This requires new
especially when plateaus occur. strategies and aggressive support
to continue weight loss.
Promotes continuation of program.
Note: Fat loss occurs on a
generalized overall basis, and
there is no evidence that spot
reducing or mechanical devices aid
Identify alternatives to chosen in weight loss in specific areas;
activity program to accommodate however, specific types of exercise
weather, travel, and so on. or equipment may be useful in
Discuss use of mechanical toning specific body parts.
devices/equipment for reducing.
Promotes safety as patient
exercises to tolerance, not peer
pressure.
Prevents skin breakdown in moist
Determine optimal exercise heart skinfolds.
rate. Demonstrate proper
technique to monitor pulse.
Discuss necessity of good skin Reduces likelihood of relying on
care, especially during summer food to deal with feelings.
months/following exercise.
Provides opportunity for pleasure
Identify alternative ways to and relaxation without
"reward" self/family for "temptation." Activities/exercise
accomplishments or to provide may also use calories to help
solace. maintain desired weight.
Encourage involvement in social
activities that are not centered
around food, e.g., bike ride/nature
hike, attending musical event,
group sporting activities.
POTENTIAL CONSIDERATIONS following acute hospitalization
(dependent on patient’s age, physical condition/presence of
complications, personal resources, and life responsibilities)
Therapeutic Regimen: Ineffective management—complexity of
therapeutic regimen, perceived seriousness/benefits, mistrust of
regimen and/or health care personnel, excessive demands made
on individual, family conflict.
