1. health and fitness
2. weight loss

Mental Health
Eating Disorder Outreach Service (EDOS)
Ongoing Management Guidelines and Discharge Planning
CONSISTENCY IS THE KEY TO MANAGING A PATIENT WITH AN EATING DISORDER.
ALL MANAGEMENT DECISIONS SHOULD BE MADE AT YOUR REGULAR TEAM REVIEWS UNLESS
MEDICAL OR PSYCHOLOGICAL EMERGENCIES OCCUR. THE FOLLOWING GUIDELINES AND
RESOURCES HAVE BEEN DEVELOPED TO ASSIST YOU IN THE ONGOING MANAGEMENT OF
YOUR PATIENT.
Ongoing Medical Management
• Continue supplemental thiamine 100mg daily orally and multivitamins
• Continue to monitor and manage blood chemistry as clinically indicated - FBC, E/LFTs, phosphate, Mg,
ECG, B12/folate, TFTS and other investigations
• Continue ECG’s as clinically indicated
• Continue to monitor BSL’s 1-2 hrs post meal and early morning as clinically indicated
• Hypoglycaemic episodes often occur in the early re-feeding stage of severely malnourished clients. Low
BGLs (<4.0mmol/l) should be managed according to the document Insulin Subcutaneous Order and
Blood Glucose Record Adult (that include Guidelines for Medical Officer responding to Blood Glucose
Alerts and Hypoglycaemia Management in Diabetes: BGL less than 4 mmol/L. However, in view of the
risk of excess simple carbohydrate precipitating re-feeding syndrome and rebound hypoglycaemia in
these patients secondary to inadequate glycogen stores, wherever the above document recommends
giving a fast acting carbohydrate, a slow acting carbohydrate (eg. one of the following: Tetrapak of
Resource Plus/Ensure Plus Fortisip/glass milk and crackers), should be given in addition at the same
time.
Ongoing Nutritional Management (by ward dietitian)
• Continue liaising with medical team re: electrolytes, ECGs, oedema etc
• Monitor fluid intake (requirement ~35ml/kg unless medical management indicates other)
• Continue providing feedback to the patient re weight progress using BMI Banding. Weight in kilograms
should not be discussed with patient.
• Once risk of re-feeding syndrome is minimised continue progressing the meal plan in 2000kJ aliquots at
3 to 4 daily intervals until goal energy intake is reached. Goal energy intake is calculated using the
following equation
120kJ/kg weight x 1.4 (activity factor) x 1.5 (repletion factor)
• Patients are expected to consume 100% of meal plan in order to meet goal for weight regain of 1 –
1.5kg/week. The three step meal plan can be instituted once risk of re-feeding syndrome is minimised
to ensure that nutritional goals are always met.
Version No: 02 Effective date: 05/2012
Review date: 05/2013
© State of Queensland (Queensland Health) 2011
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Tomorrow’s Queensland: strong, green, smart, healthy and fair
• The process for the three step meal plan is as follows
− Step 1: Prescribed meals; if less than 100% completed in allocated time frame, go to step 2
− Step 2: Liquid Supplement; if less than 100% completed in 10 minute period, go to step 3
− Step 3: Nasogastric Bolus; remainder of liquid supplement to be delivered via nasogastric bolus
• Ensure the current meal plan is clearly written out with a supplement replacement option of equivalent
energy content documented for each meal and snack. Copies of the meal plan should be made
available for staff and patient
• It is essential that only food on the meal plan is consumed ie. NO food to be brought in from outside, &
NO diet foods/lollies/chewing gum as these can be used to diminish appetite and/or may have a laxative
effect
− Menu items can be adjusted according to food availability within your service.
− Nutrient intake must be divided over a minimum of 3 meals and 3 - 4 snacks.
− Snacks may be required during the night or as a late supper to avoid low BSLs
− Foods of low energy density should be limited eg fruit (max 3 serves per day). Soup is not appropriate
− Coffee/tea must be limited to 3 cups/day
− At least one hot main meal must be included each day
− Ensure adequate protein source at each meal – encourage high quality protein options
• If 1kg/week is not achieved at goal intake then assess and manage compensatory behaviours &/ or
continue to increase meal plan by 2000kJ aliquots until adequate rate of weight gain.
• Weight Goal for discharge – BMI >17kg/m2, or progression of 2 BMI bands from admission weight if
admitted at BMI >15kg/m2
• Meal Plan for Discharge - Negotiate meal plan for discharge with patient keeping in mind the long term
weight goal of achieving a normal body weight ie >BMI 20kg/m2. Meal plan can include liquid
supplements.
Ongoing Nursing Management
• Leave guidelines are provided to help guide decisions
• Observations (to continue as clinically indicated)
− QID lying & standing blood pressure. Staff should notify RMO if:
Pulse is below 60bpm,
Temp below 35.5c, and/or;
Systolic BP below 90, or if;
Significant postural drop of more than 10mmHg
• BSL’s to continue if clinically indicated.
• ECG to continue as clinically indicated
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• Monitor and contain eating disorder behaviours
− Visual observations to be reviewed according to risk of eating disorder behaviours
− Shared room (rather than single room)
− Exercise
Monitor and contain excessive physical activity
− Vomiting /chewing spitting
Support at meals and post meals
All toilet needs should be attended to prior to meals
When risk is high supervise in toilet and shower
− Laxatives/diuretics
Manage constipation as clinically indicated with stool softeners
No laxatives from home
Supervise toilet use
− Inappropriate fluid intake
Monitor fluid intake for under or over drinking
− Restriction
If possible provide supervision during and after meals to observe and record intake.
− Request family members to assist with the management plan, by NOT bringing in food and medications
(laxatives) from home, NOT visiting during meal times, or allowing patient to exercise.
• Continue to monitor the patient’s nutritional status and eating behaviours
− Weight:
Measure and record, weight & urine specific gravity twice weekly at 6.30am after voiding
− Bowel chart:
Record bowel activity (or lack of) daily as patient will have reduced gut motility
− Intake:
Check all meals against the meal plan
Record all offered food & fluids as well as all consumed intake including fluids.
Discharge Planning
In order to provide patients with an opportunity to utilise community treatment, it is recommended that the
patients should meet each of the following six criteria prior to discharge
1.
2.
3.
4.
BMI ≥ 17
Medically stable
Psychologically safe
Demonstrated adequate nutritional intake during leave
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5. Have an established community treatment plan
− Weekly GP follow-up for weighing and bloods for four weeks, and ongoing as clinically indicated
− Assigned a case manager from the local mental health service
6. Have an established early intervention plan
− Identified readmission weight with a goal of providing for a voluntary solution focussed admission.
• Voluntary or involuntarily readmission should be facilitated if BMI ≤ 14, or medically compromised in line
with the Queensland Health Access Pathways (available via QHEPS)
Enquiries regarding the Ongoing Management Guidelines should be directed to EDOS on 07 31140809
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