Guidelines for Management of Anorexia Nervosa (Nursing Protocol)

Guidelines for Management of Patients with Nutritional Deficiency

Being underweight or malnourished is a risk to your health. It interferes with your ability to go about your daily activities and even think clearly. As your health care providers, we feel that it is necessary for you to be in the hospital to assure your safety and to help you establish healthier patterns of eating.

Goals

To stabilize heart rate, blood pressure, electrolytes, bodyweight, and temperature by improving nutritional status. This will be done by having you eat prescribed meals and limiting your activity.

Meal Plan

A nutritionist will meet with all patients within 24 hours of admission to discuss your eating habits and provide you with a meal plan.

The amount of food on the meal plan will be increased daily using 2 to 4 exchanges from the different food groups until a steady weight gain is achieved and outpatient energy goals are met. The nutritionist will meet with you daily to provide you with meal plans and to discuss nutritional goals. If your weight is normal for your height, you may be put on a weight maintenance meal plan and your expected daily weight gain may be adjusted.

Foods not provided in the meal plan include diet or lite foods, fat free foods, foods from home, caffeinated beverages or added salt packages.

If meals are not entirely completed within 30 minutes, then one Ensure supplementation will be given. If half the meal or less is eaten, then the caloric equivalent of the tray will be given as Ensure. You will have 20 minutes to drink Ensure under direct supervision. If you do not drink the Ensure in that 20 minutes, Ensure will be given via Nasogastric tube. Supplements are like medicine and are not negotiable. You will be on bedrest for at least one hour after each meal.

Fluids

You are expected to drink fluids as part of your meal plan. The quantity and nutritional value of the fluids will be determined by your care team.

Weight Expectations

Patients are expected to gain 0.2 kg daily or 0.44 lb per day. If expected weight gain is not achieved, then Ensure supplements will be given: 2 cans for the first day that the expected weight goal is not met, 3 for the second day, 4 for the third day.

Baseline weight will be determined the first morning after admission, before 7:30am. After that, your weight will be obtained each morning after you have urinated to empty your bladder and are dressed only in a gown. You will be weighed backwards on the scale. You, along with the team of healthcare providers, will together determine whether it is helpful for you to know your weight each morning. If IV fluids are given, a baseline weight will be taken 24 hours after IV fluids are complete.

Vital Signs

Vital signs will be taken every 4 hours. Minimal vital signs are heart rate > 50, blood pressure > 90/50, temperature > 97° F (36° C). If your vital signs are low then you will be on bedrest for the next four hours (bedside commode only). If vital signs are not low, then you may stay in your room on room rest without doing any physical activity, or may go to the patient activity room in a wheel chair if you are supervised by nursing or child life staff.

A heart monitor will be used if you have a low heart rate and at night.

A Multivitamin with Iron will be given each day along with extra phosphorous (as Neutraphos). Blood tests will be done to check electrolytes daily or as needed.

Workbook

A Workbook will be given to you on your first hospital day to help you with your illness while you are in the hospital. Each day team members will review your progress.

Team Meeting

After you have been evaluated by Psychiatry, Nutrition, and Adolescent Medicine, a team meeting will be scheduled to review your progress and discuss future plans (hopefully during day 2 or 3).

Guidelines for Management of Patients with Nutritional Deficiency

Meal Plan

1.Vegetarian, lactose-free (with proven lactose intolerance), and religious diets will be respected.

2.If the caloric equivalent of a refused meal is not known, then a standard of 2 cans of Ensure will be used. (Caloric equivalents for each meal are written on the menu exchange template.) If patient is on a 1250-1750 calorie meal plan, then 1 can of Ensure will be given if patient eats greater than 50% of the meal but does not finish the meal. If patient is on a 2000 (or above) calorie meal plan, then 2 cans of Ensure will be given if patient eats greater than 50% of the meal but does not finish the meal.

3.Eating greater than 50% of a meal means eating 50% or more of each item on the plate.

4.Ensure Plus may be substituted for Ensure if the patient needs to drink 3 or 4 cans of regular Ensure to reach a weight goal. Caloric equivalents should be used.

5.The maximum number of cans of Ensure for not reaching a weight goal will be 4 (or 1000 calories).

6.Bed-rest means in bed or bedside commode use supervised by a nurse or an adult caretaker.

7.Fluid count is totaled from the Nursing flow sheet. Fluid intake includes Neutraphos, Ensure, water, milk, and juice. At least 24 oz of fluids a day must come from milk or a milk substitute. The care team will determine the patient’s fluid needs upon admission.

8.Patients must be seated when eating. If on room-rest, patient may eat in a chair. If on bedrest, patient must stay in bed.

9.When at all possible, have patient observed when eating.

10.If weight goals are not met for 2 consecutive days when patient is on adequate calories, then nursing may institute a room search.

Vital Signs

1.HR should be taken for a full 60 seconds.

2.Two minutes between positions for vital sign orthostatics. Only 2 positions are needed; lying and standing.

3.Cardiac monitor should stay on if patient is on bedrest for low vital signs.

Bedrest/Roomrest

1.Patient may use commode only if on bed-rest.

2.Room-rest means sitting in chair/bed or lying down. No standing, unless going to the bathroom or showering. No exercising. Showering should be limited to 10 minutes in the bathroom.

3.Patient with stable vital signs may go to the activity room in a wheelchair for 1 hour. Supervision is needed by child life or nursing for visit to activity room. If the activity room is closed, patient may be wheeled to nursing station for 1 hour.

Purging

1.If a patient has a history of purging all wastebaskets will be removed from room and bags will be moved away from bed area.

2.Bathroom will be locked for 2 hours after meals. In addition, bed rest will be required for 2 hours after meals.