Nursing Diagnosis (NANDA-I)
Imbalanced nutrition: Less than body requirement
Refusal to eat; abuse of laxatives, diuretics, and/or diet pills; loss of 15 percent of expected body weight; pale conjunctiva and mucous membranes; poor muscle tone; amenorrhea; poor skin turgor; electrolyte imbalances; hypothermia; bradycardia; hypotension; cardiac irregularities; edema
Anxiety (Moderate to Severe)
Increased tension; increased helplessness; overexcited; apprehensive; fearful; restlessness; poor eye contact; increased difficulty taking oral nourishment; inability to learn
Chronic or situational low self-esteem/Disturbed body image/ Powerlessness
Distorted body image; views self as fat, even in the presence of normal body weight or severe emaciation; denies that problem with low body weight exists; difficulty accepting positive reinforcement; self-destructive behavior (self-induced vomiting, abuse of laxatives or diuretics, refusal to eat); preoccupation with appearance and how others perceive it (anorexia nervosa, bulimia nervosa)
Verbalization of negative feelings about the way he or she looks and the desire to lose weight (obesity)
Lack of eye contact; depressed mood (all)
Deficient fluid volume
Decreased fluid intake; abnormal fluid loss caused by self-induced vomiting; excessive use of laxatives, enemas, or diuretics; electrolyte imbalance; decreased urine output; increased urine concentration; elevated hematocrit; decreased blood pressure; increased pulse rate; dry skin; decreased skin turgor; weakness
Denial
Minimizes symptoms; unable to admit impact of disease on life pattern; does not perceive personal relevance of symptoms; does not perceive personal relevance of danger
Obesity
Compulsive eating; excessive intake in relation to metabolic needs; sedentary lifestyle; weight 20 percent over ideal for height and frame; BMI of 30 or more; reports the perception that eating is out of control
Risk for self-mutilation /Injury