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Nursing Field Notes / Mental Health · Psychiatric Care
🍽️ EATING DISORDERS SET NG-018 Anorexia Nervosa NG-106 Bulimia Nervosa NG-221 CBT NG-271 Therapeutic Communication

Anorexia Nervosa 🪞

A serious, treatable illness — and a medical emergency when the body starts to fail

NG-018 Mental Health ADHD-friendly visual edition

Anorexia nervosa is an eating disorder in which the client is preoccupied with weight and with what they eat, driven by a distorted body image and an unrealistic fear of being overweight. The behaviors lead to restriction and malnutrition. It carries the highest mortality rate of any mental health disorder — from medical complications and from suicide — so the nursing priorities are cardiac status, fluids & electrolytes, and a non-judgmental therapeutic relationship.

📄 Simple Nursing original — opens in Drive →

🪞 The perception is the illnessDistorted body image + unrealistic fear of obesity. The client sees themselves as overweight.
🚨 Highest mortality of any mental disorderMedical complications and suicide. Screen for suicidal ideation every time.
💓 The heart is the dangerBradycardia · hypotension · hypothermia + hypokalemia (K⁺ < 3.5) → dysrhythmias.
🍽️ Meals are supervised1-on-1 during the meal and for 1 hour after · strict intake record · morning weights before intake.
🧨

WHAT IT IS

STEP 1 · THE DISORDER

Two things define it: what the client believes about their body, and what the body does when it is starved.

🪞 Distorted body image — the core feature

ATI Anorexia nervosa: the client has an unrealistic fear of obesity. KAPLAN Clients see themselves as overweight even when they are not. This is a perceptual disturbance, not vanity and not a choice — arguing with the perception does not change it.

THE PERSON WHAT THEY SEE 🪞 the reflection is WARPED 💭 The belief driving it: “I am overweight.” “If I stop, I will lose control.” “My worth depends on this.” Unrealistic fear of obesity — a perceptual distortion, not a preference. 🧠 WHY ARGUING FAILS The distortion is part of the illness. Debating the mirror puts you on opposite sides. Acknowledge the feeling, then redirect to the plan and to observable progress.
🧠 “The mirror lies, and the client believes it.” Your job is not to win the argument about the mirror — it is to keep the body safe while therapy works on the belief.

📖 The clinical picture, in plain words

  • Preoccupation with weight and with what is eaten
  • Intense fear of gaining weight, even as nutritional status worsens
  • Distorted body image — self-evaluation is dominated by body shape and weight
  • Persistent restriction of nutritional intake leading to malnutrition
  • Often accompanied by excessive, driven exercise

❌ Never describe the client as “just being dramatic” or “doing it for attention” — in the chart or out loud.

🧠 Fear · Perception · Restriction. Three words that separate anorexia nervosa from every other diagnosis on the unit.

🔄 How is this different from bulimia?

🪞 ANOREXIA🔄 BULIMIA
Restriction is the main behaviorBinge then compensatory behavior
Body weight is significantly low for the personWeight is often normal or near-normal
Behavior feels consistent with the client's goal (ego-syntonic) — insight is often limitedBehavior often causes shame and is hidden
Danger: starvation physiology + refeedingDanger: electrolyte loss from compensatory behavior

👉 Full page: NG-106 — Bulimia Nervosa.

🧠 “Anorexia restricts. Bulimia cycles.” Both end at the same monitor — the cardiac monitor.
📊

WHO & WHY

STEP 2 · RISK FACTORS

No single cause — biology, psychology and environment all contribute.

🚨 The number the exam wants: highest mortality of any mental disorder

KAPLAN Which statements are true regarding anorexia nervosa? ✅ Clients see themselves as overweight. ✅ Adolescent females are the most affected group. ✅ Anorexia nervosa has the highest mortality rate of all mental disorders — from medical complications and from suicide.

Because suicide is a leading cause of death in this disorder, suicide risk assessment is part of routine care — not something you do only if the client seems sad.

🧠 “Deadliest diagnosis on the psych unit.” If a question asks which mental health disorder has the highest mortality, the answer is anorexia nervosa.

👥 Who is affected

  • Adolescent females are the most affected group — but it occurs across all genders, ages, body sizes and backgrounds
  • Often begins in adolescence or young adulthood
  • Higher risk in environments that emphasize appearance or leanness (certain sports, dance, modeling)

❌ Never rule the diagnosis out because the client is male, older, or does not “look like” they have an eating disorder.

🧠 The stereotype is a trap. Assess the behavior and the physiology, not the appearance.

🧩 Contributing factors

  • Biological/genetic — family history of eating disorders, anxiety or mood disorders
  • Psychological — perfectionism, rigidity, low self-esteem, a strong need for control
  • Social/cultural — appearance pressure, weight-related teasing, social media comparison
  • Trauma or major life transition as a trigger

Frequently coexists with depression (NG-112), anxiety (NG-236) and obsessive-compulsive traits (NG-075).

🧠 “Control is the theme.” When everything else feels unmanageable, intake becomes the one controllable variable — that framing helps you understand the behavior instead of judging it.
🔎

FINDINGS

STEP 3 · WHAT THE BODY SHOWS

Starvation → malnutrition. The body turns the thermostat down and every system slows.

🧍 Head-to-toe assessment findings

🪶 LANUGO Fine, soft, downy body hair — the body insulating itself ❄️ COLD INTOLERANCE Always cold · low body temp · cool, mottled hands & feet 💓 LOW VITAL SIGNS Low temperature Low blood pressure (hypotension) Low heart rate — below 60 bpm 🦴 REDUCED BONE DENSITY Osteopenia / osteoporosis · muscle wasting & weakness 💇 HAIR & SKIN Thinning scalp hair · dry skin · brittle nails · yellow-tinged palms 🩸 AMENORRHEA No menstruation — from hormonal shutdown in starvation 🚽 GI SLOWDOWN Constipation · bloating Delayed gastric emptying Early fullness after small amounts 💧 PERIPHERAL EDEMA Low protein & fluid shifts — swelling around ankles ⭐ HESI: lanugo · irregular heart rate · bradycardia · low potassium
🧠 “Everything slows and everything shrinks.” Slow heart, slow gut, slow hormones, slow temperature. Lanugo is the body's last attempt to stay warm — remember it as “the blanket the body grows.”

🔬 Skin cross-section — why lanugo appears

Body fat is the body's insulation. When the fat layer under the skin thins, the body loses heat quickly, so it grows a coat of fine, soft, downy hair — lanugo — to trap warmth against the skin.

✅ WELL-NOURISHED SKIN epidermis dermis subcut. fat muscle Thick fat layer = insulation warmth is retained · skin is supple 🚨 MALNOURISHED SKIN Thin fat layer → HEAT ESCAPES cold intolerance · low body temperature → the body grows LANUGO as a blanket lanugo
🧠 “No blanket of fat → grow a blanket of hair.” Lanugo, cold intolerance and low body temperature are all the same finding wearing three different names.

💓 The cardiac picture — why the potassium matters

Answer first: starvation causes bradycardia and hypotension, and hypokalemia (potassium below 3.5 mEq/L) causes cardiac dysrhythmias. Put those together and you have the most dangerous combination on this page.

✅ NORMAL rate & rhythm 🐢 BRADYCARDIA — heart rate below 60 long gap between beats 🧪 LOW POTASSIUM changes the tracing flat T U wave ⬆ flat T wave · prominent U wave · prolonged QT → dysrhythmia risk 🧪 Serum potassium (adult reference) 3.5 5.0 🚨 LOW NORMAL Below 3.5 mEq/L = hypokalemia → dysrhythmias

HESI An adolescent client with anorexia nervosa — which physical findings support the diagnosis? ✅ Lanugo · ✅ Irregular heart rate · ✅ A pulse rate in the 40s · ✅ A serum potassium well below the reference range.

🧠 “Slow pulse + low K⁺ = monitor.” Those two findings together are what turn a psychiatric admission into a medical one.

🧪 Labs the team follows

  • Potassium — hypokalemia < 3.5 mEq/L → dysrhythmias ⭐ (typical adult reference range is 3.5–5.0 mEq/L — verify against your lab)
  • Phosphorus & magnesium — critical before and during nutritional restoration
  • Sodium and overall fluid balance
  • CBC — anemia, leukopenia; albumin/prealbumin — protein status
  • Glucose — hypoglycemia; renal & liver function
  • ECG — rate, rhythm, QT interval
🧠 “K, Phos, Mag.” Those three letters are the whole refeeding-safety story — memorize them as a set.

🏥 When hospitalization is needed

Care is typically outpatient, but admission is indicated when the client is medically unstable:

  • Unstable vital signs — bradycardia, hypotension, hypothermia
  • Cardiac dysrhythmia or ECG changes
  • Significant electrolyte disturbance
  • Severe dehydration or rapid clinical deterioration
  • Severe malnutrition requiring supervised nutritional restoration
  • Suicidal ideation or inability to be safe in the community
🧠 “Unstable body → inpatient bed.” The decision is medical, not motivational.
🩺

CARE

STEP 4 · WHAT THE NURSE DOES

Medical stability first, structure second, insight third — in that order.

✅ Priority ladder — the acute phase

HESI What is the focus for the acute phase of treatment? Restoring nutritional status and medical stability — the body has to be safe before therapy can do its work.

1
Medical stability — vital signs including orthostatics and temperature, cardiac monitoring when indicated, electrolytes, hydration.
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2
Supervised nutrition per the prescribed plan — stay with the client during each meal and for 1 hour after; one-on-one supervision during feedings.
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3
Objective monitoring — strict record of intake and output, morning weights taken before any oral intake, same scale, same clothing, after voiding.
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4
Activity limits — no exercise during the acute phase; activity is reintroduced only as the treatment plan allows.
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5
Therapy & insight — help the client identify triggers, and use a cognitive behavioral approach to examine dysfunctional thoughts and beliefs.
🧠 “Stabilize · Supervise · Record · Restrict · Reframe.” Five R-ish steps in the order the exam wants them.

⚖️ Why weights are done that way

  • Morning, before any oral intake — removes the effect of food and fluid
  • Same scale, same time, similar clothing, after voiding
  • Consistency is what makes the trend meaningful
  • Many programs discuss whether to share the number with the client — follow the treatment plan, because the number itself can be distressing
🧠 “Same scale, same time, empty bladder, before breakfast.” Change one variable and the trend becomes meaningless.

🧠 Therapy that works

  • Cognitive behavioral therapy — help the client examine dysfunctional thoughts and beliefs (see NG-221)
  • Family-based treatment — first-line for many adolescents
  • Nutritional counseling with a registered dietitian
  • Group and individual therapy; treat coexisting depression/anxiety
  • Medication may be prescribed for coexisting conditions — it is an adjunct, not the treatment for the eating disorder itself
🧠 “Feed the body, then challenge the thought.” A starved brain cannot do therapy well — that is why nutrition comes first.

💬 Communication — say this, not that

Encourage and reinforce “progress toward a healthy weight” and toward the client's own goals. Keep the tone matter-of-fact, warm and non-judgmental, and keep limits consistent between staff so the plan never becomes a negotiation.

✅ “I'll sit with you during your meal.”States the expectation calmly and offers presence — no bargaining, no bribery.
❌ “You look so much better already!”Comments on appearance land as comments about weight. Keep feedback on effort and progress, not on the body.
✅ “It sounds like eating feels frightening right now. Tell me about that.”Acknowledges the feeling without agreeing with the distortion.
❌ “You're not fat — look at yourself!”Arguing with the perception is unwinnable and damages trust.
✅ “The plan is the same for everyone on the unit, and I'll stay with you for an hour after.”Consistent limits reduce the anxiety of negotiating.
❌ “If you finish this, you can skip group.”Never trade treatment for intake. It reinforces control as currency.

👉 More on the technique itself: NG-271 — Therapeutic Communication.

🧠 “Praise the effort, never the body.” One sentence that will keep you out of trouble on every eating-disorder question.

🚨 Safety monitoring, every shift

  • Suicide risk — ask directly, document, follow unit protocol
  • Orthostatic vital signs, apical pulse for a full minute
  • Fall risk — weakness, dizziness, syncope
  • Skin integrity over bony prominences
  • Bathroom supervision per the plan of care
🧠 Ask about suicide out loud. Asking never plants the idea — not asking is what costs lives in the deadliest psychiatric diagnosis.

👨‍👩‍👧 Family teaching

  • This is an illness, not a choice or a phase
  • Do not police, comment on, or bargain over food at home — follow the team's plan
  • Avoid weight and appearance talk altogether, including about yourselves
  • Recovery is not linear — relapse is common and is not failure
  • Know the warning signs that need urgent review: fainting, chest pain, palpitations, confusion
🧠 “Be the parent, not the food police.” The team owns the meal plan; the family owns the relationship.
🚨

REFEEDING SYNDROME

STEP 5 · THE HIDDEN EMERGENCY

The most dangerous moment is not the starving — it is the first days of feeding again.

🔬 The mechanism — why the labs crash when nutrition restarts

Answer first: when nutrition resumes after prolonged malnutrition, insulin surges and drives phosphate, potassium and magnesium out of the bloodstream and into the cells, along with fluid. The serum levels fall fast — and that can cause cardiac failure, respiratory failure, dysrhythmias, seizures and delirium.

🍽️ NUTRITION RESTARTS after prolonged malnutrition 📈 INSULIN SURGES glucose arrives → insulin rises ⬇️ ELECTROLYTES SHIFT out of the blood, into the cells 🩸 BLOODSTREAM (serum) levels FALL — this is what you measure PO₄ K⁺ Mg ⬇ ⬇ ⬇ hypophosphatemia · hypokalemia hypomagnesemia insulin drives them IN nucleus 🧬 INSIDE THE CELL PO₄ K⁺ Mg PO₄ K⁺ H₂O H₂O 🚨 WHAT THAT CAUSES 💓 Cardiac: dysrhythmias, heart failure, fluid overload 🫁 Respiratory: weakness → respiratory failure 🧠 Neurologic: confusion, delirium, seizures 🩸 Blood & muscle: hemolysis, rhabdomyolysis ⏱️ Highest risk in the FIRST DAYS of refeeding ⭐ Phosphorus is the classic first lab to fall
🧠 “Feed too fast, the labs fall through the floor.” Remember the trio as “Phos, K, Mag — the refeeding three.” Phosphorus is the headline.

✅ How the team prevents it

  • Start nutritional restoration slowly and advance gradually, exactly as prescribed
  • Check electrolytes before starting and frequently during the first days — especially phosphorus, potassium and magnesium
  • Replace electrolytes as prescribed before and during advancement
  • Thiamine and other vitamins are commonly prescribed before nutrition is advanced
  • Cardiac monitoring and close attention to fluid balance — daily weights and strict I&O
  • Watch for edema, shortness of breath, confusion, weakness, palpitations — report immediately

❌ Never advance nutrition faster than prescribed because the client “finally agreed to eat.” Enthusiasm is not a reason to skip the protocol.

🧠 “Start low, go slow, check the phos.” Say it before every meal tray in the first week.
⚡

QUICK RECALL

SAY IT OUT LOUD
🪞 Distorted body imageUnrealistic fear of obesity — a perceptual disturbance, not a preference.
🚨 Highest mortalityOf all mental health disorders. Assess suicide risk routinely.
💓 Low HR · low BP · low temp+ hypokalemia (K⁺ < 3.5) = dysrhythmia risk.
🍽️ Supervise + recordStay through the meal and 1 hr after · strict intake · morning weights · no exercise.
🎯 Cover & check — 8 rapid-fire questions
Q1: What is the core psychological feature of anorexia nervosa?
A distorted body image with an unrealistic fear of obesity — clients see themselves as overweight. It is a perceptual disturbance, so arguing with it does not help.
Q2: Which mental health disorder has the highest mortality rate, and why?
Anorexia nervosa — from medical complications of starvation and from suicide. That is why suicide risk assessment is part of routine care.
Q3: Name the classic physical findings.
Lanugo (fine downy hair), amenorrhea, cold intolerance, low temperature, low blood pressure, bradycardia (heart rate below 60), dry skin and brittle nails, constipation, peripheral edema, muscle wasting and reduced bone density.
Q4: Which electrolyte is the priority, at what threshold, and what does it cause?
Potassium. Hypokalemia is a level below 3.5 mEq/L, and it causes cardiac dysrhythmias. Phosphorus and magnesium matter too, especially during nutritional restoration.
Q5: What is the focus of the acute phase of treatment?
Restoring nutritional status and medical stability. Therapy and insight work come after the body is safe.
Q6: List the mealtime nursing interventions.
Keep a strict record of intake, stay with the client during each meal and for 1 hour after, provide one-on-one supervision during feedings, take morning weights before any oral intake, help the client identify triggers, and hold exercise during the acute phase.
Q7: What is refeeding syndrome and how is it prevented?
When nutrition restarts after prolonged malnutrition, insulin drives phosphate, potassium and magnesium into the cells, so serum levels fall — risking dysrhythmias, heart failure, respiratory failure, confusion and seizures. Prevention: advance nutrition slowly as prescribed, check and replace electrolytes (especially phosphorus) before and during, give prescribed thiamine, and monitor cardiac status, daily weights and fluid balance.
Q8: The client says “I'm still too big.” What is the best response?
Acknowledge the feeling without agreeing with or arguing about the distortion — for example, “It sounds like that thought is really distressing right now. Tell me more about it.” Then redirect to the treatment plan and to observable progress. Do not debate appearance, and do not comment on how the client looks.