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The Role of Therapeutic Exercise to Manage Bulimia Nervosa within the Clinical Setting

Sarah Sawhook

BSN Nursing Program, Seton Hill University

SNU 315 75: Research & Evidence-Based Practice

Carrie Slagle, MSN

November 26, 2022

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Introduction: Clinical Problem

In patients who are diagnosed with bulimia nervosa (P), what is the effect of exercise and

dietary interventions (I) compared to dietary interventions (C) on eating disorder recovery (O)?

This is a therapy PICOT question because it investigates a therapeutic treatment that can be

implemented into the careplan of clients diagnosed with eating disorders (EDs). More

specifically, the population of interest for this research are those with Bulimia Nervosa (BN),

which is only one of many types of EDs that exist. BN is the ED of choice for this research

because there is adequate information from the literature review, along with positive outcomes

relating to the implementation of exercise into the clinical setting. To clarify, individuals are

typically diagnosed with BN if they binge on food and then purge on a regular basis (NEDA,

n.d.).

The inclusion criteria for this research is relatively broad and is based upon age, gender,

treatment setting, and body mass index (BMI). Primarily, the population of this research are

female adults from the outpatient setting with a BMI that ranges from 17.5-35.0. In other words,

in accordance with the BMI, patients with BMI can be classified as slightly underweight, healthy

weight, overweight, or obese. It is important to note that this research can also apply to males.

However, there is more information about the female population since their gender alone

predisposes them to EDs. Even though the outpatient setting is the predominant focus, the

inpatient setting is still included within the research. The standard treatment for BN is dietary

intervention since nutrition is used to regulate calories, vitamins, minerals, and electrolytes.

Dietary regulation is imperative for recovery since binging and purging alters the nutritional

status of the body, creating nutritional deficiencies and imbalances. The purpose of this research
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is to explore the therapeutic effects of physical activity (PA), when combined with adequate

nutrition. These therapeutic effects can be physiological, such as body weight regulation,

reduction of pain, and the stabilization of vital signs & electrolyte values. Therapeutic effects can

also be psychological, such as improved mood, improved body image, increased awareness,

reduced levels of compulsive exercise (CE), increased self-confidence, and etc… Overall, the

expected therapeutic outcome with the addition of PA into the care plan is the reduction or

absence of the binge-purge cycle.

Background: Clinical Problem

An eating disorder (ED) is a complex psychological disorder characterized by distorted

thoughts, negative attitudes, and abnormal behaviors towards food (NADA, n.d.). In short, EDs

are problematic because they negatively affect the quality of the individual’s life. Bulimia

nervosa (BN) is characterized by a vicious cycle of binging and purging (NADA, n.d.). Binging

occurs when one consumes an excessive amount of food within a short period of time. During a

binge, the individual feels out of control, as if they are unable to stop eating (NADA, n.d.). In

order to compensate for the excessive calories consumed from the binge, those with BN purge or

use extreme measures as an attempt to burn calories. Typical examples of purging behaviors are:

self-induced vomiting, excessive use of laxatives/diuretics/enemas, misuse of herbal

products/dietary supplements/other medications, overexercising, and fasting (National Eating

Disorders Association, n.d.). Due to these extreme behaviors, BN has a detrimental effect on

various organs and body systems.

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BN can disrupt the gastrointestinal (GI) system, cardiovascular system, musculoskeletal

system, and respiratory system. Self-induced vomiting can lead to enamel erosion and dental

caries due to exposure of excessive acid on the teeth (Ahacic, 2016). Also, self-induced vomiting

can lead to esophagitis since the frequent exposure of acid leads to irritation and inflammation

within the esophagus (Ahacic, 2016). Abdominal pain and bloating are common GI symptoms.

However, hiatal hernias may occur from the surmount of pressure placed on the stomach,

diaphragm, and esophagus during binging and purging (Ahacic, 2016).The overuse of diuretics

and laxatives flushes out water and critical electrolytes out of the body such as sodium,

potassium, chloride, magnesium, and calcium (Ahacic, 2016). Self-induced vomiting can also

excrete fluids and electrolytes out of the body as well. An important function of electrolytes is to

regulate the electrical impulses of the heart. Thus, depletion of these vital electrolytes can lead to

cardiovascular complications, such as heart arrhythmias. Electrolytes are also important to

maintain skeletal muscle contraction. A deficiency of electrolytes can also lead to muscle fatigue

and weakness, especially if excessive exercise behaviors exist (Ahacic, 2016). Self-induced

vomiting increases the risk for aspiration pneumonia due to the possibility of inhaling vomited

food into the lungs (Ahacic, 2016). Within the female patient population, BN can lead to

abnormal menstrual cycles, or the absence of menstruation due to extreme behaviors that are

placed on the body. Irregular menstrual cycles may further complicate into infertility.

Even though BN is classified as a psychiatric disorder, the physiological complications

are numerous and can be serious, if not fatal. The mortality rate of EDs are significantly higher

compared to other psychiatric disorders. In fact, in a literature review that compares the mortality

risk of those diagnosed with EDs compared to those without EDs, Hoeken & Hoek (2020)
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discovered that the mortality risk is twice as high for those with bulimia nervosa after treatment.

Thus, effective interventions are absolutely necessary to regulate not only medical complications

from BN, but also the underlying psychological issues. In other words, the thoughts and extreme

behaviors of those with BN occur due to a poor mental and emotional state. In fact, if patients

obtain the opportunity to improve their mental and emotional well being, then this could prevent

these medical complications, along with the chance of relapse. Physical activity (PA) provides

numerous physiological and psychological benefits towards overall health. Exercise produces

endorphins, which can help regulate mood and boost confidence. Also, exercise can help

increase strength, which can shift the mindset for those in recovery to feel strong and focus on

increasing their strength instead of obsessing to look a certain way. Thus, exercise therapy may

help those with eating disorders restore their healthy relationship with food, exercise, and

body-image. Movement may also provide a sense of freedom, rather than feeling 100%

restricted. It can even be agreed by clinicians and researchers that PA can play an effective role

with treating EDs (Cook et al., 2016 & Danielsen et al., 2018).

Dietary intervention continues to be the standard treatment among those with BN in

nursing practice. Typical nursing diagnoses related to BN can include: “Imbalanced Nutrition:

Less Than Body Requirements”, “Risk for Imbalanced Fluid Volume”,and “Risk for Electrolyte

Imbalance” (Ernstmeyer & Christman (Eds.), 2022). Nurses can give patients an IV in order to

help correct any nutritional deficiencies and fluid and electrolyte imbalances. Also, if prescribed,

nurses can administer supplements to patients via the oral route. Nurses have the responsibility to

make sure that each patient meets their daily caloric intake, which is set by the registered

dietitian (RD). In addition, nurses ensure that patients are making progress to gradually reach
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their target weight (Ernstmeyer & Christman (Eds.), 2022). The ultimate role of the nurse is to

encourage patients to be engaged and accountable within meeting their dietary needs. Nurses

should administer balanced and regular meals and snacks to normalize eating habits in order to

prevent a binge from occurring. Nurses support patients during meal time by engaging in

conversation with them in order to facilitate normal eating behaviors in a social setting. It is

important to avoid any conversations relating to food and exercise because it can be triggering

and distract from normal conversations during mealtime. (Ernstmeyer & Christman (Eds.),

2022). Even though nurses provide a calm and supportive environment during mealtime, they

also have to be firm in order to prevent patients from veering away from their meal plan or

engaging in binge-purging behaviors. Patients have to be fully observed during meals just to

ensure that they do not throw away food or hide food that they are required to eat (Ernstmeyer &

Christman (Eds.), 2022). After mealtime, it is important for nurses to monitor patients for at least

one hour to avoid patients from purging their consumed food (Ernstmeyer & Christman (Eds.),

2022). Patients can be encouraged to journal their feelings after eating to increase bodily-mind

awareness and promote mindfulness. Nurses can give autonomy to patients by having them

decide what to eat on the menu, as they progress within recovery.

Even though RDs provide meal plans and are the experts at nutrition, nurses can still

offer nutrition counseling within their scope of practice. They can offer adequate advice on how

to provide balanced, nutritional meals and can even help patients come up with ideas for creating

menus. Dietary interventions are used to address the nutrition and hydration needs of patients.

Also, dietary interventions are implemented to normalize eating behaviors in order to put an end

to the binge-purge cycle. However, normalizing exercise behaviors among those with BN is just
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as important because those with BN typically use exercise as a form of compensation from their

excessive caloric intake. Furthermore, fully restricting exercise among stable patients would not

be beneficial because it does provide them the opportunity for them to learn how to incorporate

exercise into their lifestyle in a healthy, sustainable manner. Once patients get discharged, they

are free to exercise without any limits. This may mean that if exercise is not used therapeutically,

then patients could potentially relapse.

Exercise can be used therapeutically to improve the overall wellbeing of patients.

Nursing diagnoses related to the mental aspect of BN include: “Impaired Body Image”,

“Ineffective Coping”, “Chronic Low Self Esteem”, and “Powerlessness” (Ernstmeyer &

Christman (EDs.), 2022). As a solution, the incorporation of therapeutic exercise into the

treatment plan can be used to improve body image, motivate individuals to cope with struggles in

a healthy way, improve their self-esteem, gain confidence, and empower them to claim their

overall health. Therefore, in addition to dietary interventions, individualized exercise can be

implemented into a treatment plan based upon the clinical judgment of the nurse, along with the

patient’s condition

Nurses play a critical role in the assessment and regulation of nutrition, exercise, weight,

and the binge-purge cycle in those with BN. When nurses conduct a health history, they ask

questions relating to nutritional patterns, fluid intake, exercise patterns, sleep patterns, frequency

of menstruation, weight fluctuation, and the use of medications/laxatives/supplements. Nurses

assess the frequency of binging and purging behaviors, along with the types of purging behaviors

used. In addition, the amount and type of food consumed during a typical binge can be assessed.

Vital signs are checked, weight is monitored daily, and head-to-toe physical assessments are
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conducted by the nurse. A psychosocial can be incorporated to further investigate the thoughts,

attitudes, emotions, and behaviors of the individual with the ED.

Literature Review

Overview

A search from the databases APA Psycinfo, MEDLINE, and SPORTdiscus with Full Text

were utilized. The keywords included within the search terms include: “exercise therapy and

eating disorders,” “physical activity and eating disorders,” and “bulimia nervosa and exercise

therapy”. The articles that were chosen for this literature review are based upon the criteria of

being peer-reviewed, in the English language, full-text, and within the 5-6 year date range. Three

articles incorporated into this review specifically focus on the treatment of BN with physical

exercise and dietary therapy (PED-t) as the intervention. An additional two articles generally

focus on ED treatment as a whole with the implementation of exercise as an intervention. The

research compiled is composed of quantitative and qualitative data. Out of the five articles used

for the literature review, two articles are randomized controlled trials (RTCs). The remaining

three articles include: one exploratory descriptive qualitative research via semi-structured

interviews, a systematic review, and a quantitative-empirical study. According to Galasso et al.

(2017), the literature suggests that “specific physical activity can ensure broad beneficial results

relating to eating disorders, depression, and body mass index (BMI) in bulimia.” The following

literature review suggests that incorporating exercise into ED treatment provides psychosocial

benefits to patients and may help enhance recovery for both the short-term and long-term

posttreatment.

PED-t for BN in the Outpatient Setting

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Mathisen et al. (2018) utilized physical exercise and dietary therapy (PED-t) as an

intervention for individuals in the outpatient treatment setting diagnosed with BN and who have

a history of compulsive exercise (CE). The focused patient outcome in this study is to reduce the

thoughts, attitudes, and behaviors relating to CE (Mathisen, 2018). According to Mathisen et al.

(2018), CE is an important behavior to address because it is associated with poor treatment

outcomes and increases risk for relapse in patients with BN. However, supervised and regulated

exercise is a solution to reduce CE and its problematic effects towards recovery. In this

randomized controlled trial (RCT), all of the participants are adult females within the outpatient

treatment setting. In accordance with the BMI, these participants are either classified as

underweight, normal weight, overweight, or obese (Mathisen, 2018). Thus, a diversity of ages

and weights are accounted for. As a treatment, the group in the PED-t intervention exercised 3-4

times per week and received dietary intervention 1-2 times a week for a total of 16 weeks

(Mathisen, 2018). To break it down, they completed supervised exercise 1-2 times per week, and

they completed unsupervised exercise twice per week. The supervised exercise was resistance

training sessions, while the unsupervised exercise was composed of one session of resistance

training and one session of high intensity interval training (HIIT) (Mathisen et al., 2018). Dietary

therapy was provided for the participants after each supervised exercise session (Mathisen et al.,

2018). After the 16 weeks of treatment, it was found that those in the PED-t intervention had

reduced symptoms of CE, as indicated from the subjective measurements of the questionnaires

(Mathisen et al., 2018). To put it simply, the questionnaires measured “core ED-characteristics”

and “core features of compulsive exercise in EDs” (Mathisen et al., 2018). Therefore, PED-t can
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be considered an evidence-based treatment to provide therapeutic effects by reducing CE

symptoms in those diagnosed with BN (Mathisen et al., 2018).

Mathisen et al. (2020) conducted another study to measure the effectiveness of PED-t as

an intervention to those with BN in an outpatient treatment setting. The population of

participants are all adult women who were either classified as underweight, normal weight,

overweight, or obese, in accordance with the BMI. The focused outcome of this study is the

reduction of binging and purging among those with BN. Due to high relapse rates within the BN

population, alternative interventions are being sought out. Thus, this RCT was conducted to

justify that exercise can be a safe and effective intervention that is incorporated into the treatment

plan. For this research, PED-t includes a 60 minute session of dietary therapy, followed by a 45

minutes session of either supervised resistance training or HITT running (Mathisen et al., 2020).

Patient outcomes were measured by questionnaires that examined concerns related to eating,

body weight, and body shape, binging and purging behaviors, “ED-elicited personal, social, and

cognitive impairment”, symptoms of depression, and satisfaction with personal life (Mathisen et

al., 2020). After 16 weeks of treatment, there was a reduction in binging and self-induced

vomiting (Mathisen et al., 2020) There was also a decrease in concerns related to eating, body

weight and body shape (Mathisen et al., 2020). In addition, there was a decrease in CE episodes,

an increase in remission rates, and an increase in life satisfaction (Mathisen et al., 2020). Lastly,

the intervention alleviated depression, which is a comorbidity of BN (Mathisen et al., 2020).

Therefore, it can be concluded that PED-t is a safe and effective intervention within the

outpatient setting.
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The qualitative research conducted by Pettersen et al. (2017) utilized a semi-structured

interview to gain insight into the perspectives and personal experiences of six participants who

received exercise and dietary therapy (PED-t) as an intervention for management of BN. The

duration of the interviews were for approximately one hour, and there were pre-written questions

that guided the conversation within each individualized interview (Pettersen et al., 2017). As a

result, Pettersen et al. (2017) acknowledged that the PED-t intervention helps participants with

BN develop positive attitudes towards physical activity through an increased awareness and

mindfulness of the body and its needs. Furthermore, PED-t helps shift their focus away from

their physical appearance and instead focus on how they feel through movement (Pettersen et al.,

2017). Plus, PED-t helps participants value exercise in a social setting. Importantly, dietary

therapy from PED-t influences participants to realize that food is simply fuel and energy, and it

should not be labeled as “good” or “bad”. Pettersen et al. (2017) verified that increased

knowledge and awareness of nutrition helps patients know how to fuel their bodies, reduce the

fear of food, and recognize certain triggers that bring forth the onset of binging episodes. As a

bonus, the participants value the treatment group because it is a supportive environment, and it is

a safe place to share information about their experiences.

Implementation of Exercise into ED Treatment Plan

Cook et al. (2016) conducted a systematic review of the literature about therapeutic

exercise and its impact on ED recovery within the clinical setting. To clarify, the clinical setting

can be either inpatient or outpatient. According to the 18 articles used for the systematic review,

Cook et al. (2016) identified eleven guidelines that can be used to implement therapeutic

exercise into the ED treatment plan. To begin, Cook et al. (2016) emphasized the need for a team
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of experts from multiple disciples to work collaboratively in order to ensure that safety, medical,

nutritional, and psychosocial needs are being met with the use of exercise. As mentioned earlier,

nurses are able to address safety, nutritional, and psychosocial needs within patients. Since

nurses are usually the ones that spend the most time with patients, it is essential that they

communicate and collaborate with other key stakeholders of the patient’s care. Within this

context, nurses can communicate with exercise physiologists to ensure that the exercise plan

aligns with the health and personal needs of the patient. Nurses can also communicate with the

RD to confirm that caloric intake and macronutrient/micronutrient intake is sufficient for the

exercise that the patient is participating in. From there, nurses are able to monitor dietary intake

and supervise the amount, frequency, and type of exercise that the patient participates in. In other

words, nurses ensure that the patient adheres to their dietary needs set by the RD and appropriate

exercise interventions set by the exercise physiologist. It is important for nurses to be cautious

that patients do not binge, undereat, purge, or exercise compulsively. For safety purposes, Cook

et al. (2016) stressed that exercise should not be available for patients who veer away from their

treatment plan. Also, Cook et al. (2016) confirmed that contraindications to exercise due to

medical or psychological concerns should be assessed. Nurses can collaborate with physicians to

discuss any pertinent medical needs of the patient and how that would impact nutrition and

exercise. Relating to this, nurses can collaborate with psychiatrists/psychologists to discuss

pertinent psychosocial needs of the patient and its effect on treatment. Furthermore, the

individualistic thoughts, attitudes, and behaviors relating to exercise should be assessed to gain a

better understanding of the psychological state of patients (Cook et al., 2016). Through

collaboration with other professionals, nurses will have a clear idea on how to care for each
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patient holistically. To establish consistency and accountability with the treatment expectations,

goals, and outcomes, Cook et al. (2016) strongly suggested that there should be a written contract

between the patient and treatment team relating to exercise. Exercise is initially implemented to

be short and with low-intensity and for opportunities to gradually build up (Cook et al., 2016). It

is recommended that a psychoeducational component should coincide with an exercise program

(Cook et al., 2016). Thus, dietary therapy or nutritional education meets the requirements for the

psychoeducational component because it teaches patients about how to incorporate nutrition into

their treatment plan. Nutrition has to meet the needs of the exercise, and weight must be

maintained (Cook et al., 2016). Thus, nurses can monitor daily weights. To further meet the

psychosocial needs of patients, Cook et al. (2016) advocated patients to reflect upon each

exercise session. Summarily, nurses can incorporate the information from this research to create

an individualized care plan for each patient with BN.

Within 15 years of research in the clinical setting, Danielsen et al. (2018) provided a

general framework for the safe and therapeutic use of exercise for patients admitted to inpatient

ED units. Furthermore, Danielsen et al. (2018) discovered three stages for the implementation of

exercise into the treatment plan. The researchers acknowledged that Stage 1 prioritizes the

regulation of basic necessities such as nutrition and rest (Danielsen et al., 2018). During this

stage, physical activity is used with caution and is very limited. For example, the patient may be

limited to relaxation exercises and slow-paced walks that are short in duration. The nursing

priorities for Stage 1 are to monitor the safety, physiological, and psychosocial needs of patients.

Also, nurses can encourage patients to be actively engaged within their treatment plan in order to

promote independence and accountability. According to Danielsen et al. (2018), in order for
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patients to transition from Stage 1 to Stage 2, the criteria is that they must be in Stage 1 for a

minimum of 2 weeks, and if they are underweight, then their BMI must be around 17 to progress.

During Stage 2 of treatment, Danielsen et al. (2018) acknowledged that patients gain autonomy

with physical activity. For example, patients are able to participate in exercise groups twice a

week. These exercise groups incorporate resistance training and cardiovascular training

(Danielsen et al., 2018). Being a part of a group helps patients reap the social benefits of

exercise. The nursing priorities for Stage 2 are to ensure that patients eventually reach their target

weight and meet their individualized treatment goals. is As treatment further progresses,

Danielsen et al. (2018) mentioned that Stage 3 prioritizes the transition of healthy participation

of exercise from the unit to outside of the unit in order to normalize exercise after discharge. This

in turn should facilitate long-term recovery within patients. From the information obtained in the

literature review, it can be concluded that exercise in addition to dietary interventions can be

beneficially implemented into the ED treatment plan in patients diagnosed with BN.

Implementation

Stetler Model of Research

The EBP Model that is applicable to this EBP Project is the Stetler Model of Research

because it provides guidance on how to implement EBP interventions into practice. This research

focuses on the impact that therapeutic exercise has on BN recovery, in conjunction with dietary

interventions. Accordingly, the literature review suggests that researchers, clinicians, and patients

support the use of diet and exercise into the treatment plan. The Stetler Model is appropriate for

individual nurses to utilize in order to help them navigate through their EBP project.
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Furthermore, the knowledge and evidence provided from the literature review guides nurses to

facilitate decision-making and promote education within the patients’ plan of care, through the

use of the model (Grove & Gray, 2019). The implementation of the interventions supported by

EBP research would help nurses to improve upon their clinical judgment and overall improve

patient outcomes. According to Grove & Gray (2019), the Stetler Model is composed of five

phases: preparation, validation, comparative evaluation and decision making, translation and

application, and evaluation. Within the preparation phase, the priority is to reflect upon a clinical

problem and provide justification for why an EBP change needs to occur (Grove & Gray, 2019).

Within this EBP project, the standard treatment for BN is dietary intervention. However, the

clinical problem is that individuals that receive standardized treatment for BN tend to relapse

after being discharged from the inpatient or outpatient setting. If relapse rates are high, then this

indicates that a practice change should occur and alternative treatments should be sought out.

Within this project, exercise is suggested to be used as intervention because those diagnosed with

BN tend to have negative thoughts, attitudes, and behaviors towards exercise that are

unaddressed during treatment. Not to mention, excessive exercise or compulsive exercise can be

considered a form of purging. The idea is to expose BN patients to exercise in a strategic manner

in order to teach them to incorporate a healthy amount of exercise for them in their lifestyle for

both the short-term and long-term. The goal is for patients to stop using exercise as a form of

purging and instead use it for enjoyment. Diet and exercise are lifestyle factors that complement

each other and impact one another. Therefore, if patients do not develop a healthy relationship

with exercise, despite their dietary needs being met, then there is still an issue. However, when

dietary and exercise interventions are both incorporated into the treatment plan, then this should
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increase the remission rate and decrease the relapse rate in BN patients. Within the validation

phase, the type of research, amount of evidence, and the findings from the studies within the

literature are analyzed (Grove & Gray, 2019). The type of research for this EBP project is

considered credible because the studies included consist of a systematic review and two RCTs,

which are rated as a high level of evidence. Thus, three out of the five articles from the literature

review provide strong evidence of exercise therapy as an additional intervention. During Phase

III, comparative evaluation is used to compare the benefits with the risks of the intervention

(Grove & Gray, 2019). From this, a decision can be made on whether or not to implement the

intervention to the treatment plan. In accordance with the research, exercise and dietary

interventions are beneficial because it has been found to reduce compulsive exercise, promote

remission, decrease binging and purging behaviors, and alleviate comorbidities associated with

BN, such as depression. It is important to note that exercise can be a contraindication in those

who are severely underweight, who have severe nutritional deficiencies, or who have severe

fluid & electrolyte imbalances. Also, even though exercise may reduce CE, it could still trigger

CE in some individuals. This is why it is important to monitor the physiological and

psychosocial status of patients, depending on the level of treatment or care that they need. In

Phase IV, the selected evidence from the research is actually implemented into practice (Grove &

Gray, 2019). An individualized, patient-centered care approach is considered during

implementation to facilitate health promotion and patient education. Lastly, during the evaluation

phase, the practice change can be assessed through various methods to determine its

effectiveness and credibility (Grove & Gray, 2019). The intervention can be evaluated by

assessing how engaged patients are with their treatment plan, especially towards their dietary
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needs and regulation of exercise. The thoughts, attitudes, and behaviors of BN patients can be

assessed pretreatment and posttreatment to determine if improvement in psychosocial status have

been achieved. Weight is monitored to make sure that the individual patient is within their

targeted range that has been set for them.

Plan of Care:

The purpose of this EBP project is to carefully implement therapeutic exercise into the

standardized treatment for those diagnosed with BN. The goal is to use exercise to improve

patient outcomes within physical and psychological recovery from BN. These outcomes can

include: improved mental status, improved relationship with food and exercise, increased

physical and psychological strength, increased self-confidence, weight-maintenance, and

improved body-image. Implementation should be used with careful considerations and strategic

planning towards each individualistic case since exercise burns calories and can alter weight.

Also, a consideration to keep in mind is that exercise is typically used as an BN behavior to

compensate for food intake. The objective is for patients to experience the therapeutic effects of

exercise. This can help them shift their focus from how they look to how they feel. A goal would

be to teach patients to incorporate exercise into their routine in a healthy way, while breaking the

habit of the use of exercise for a compensatory mechanism to eating. This can help patients

prevent future relapse.

An exercise physiologist would be a key stakeholder for this project since they are the

experts that are qualified to develop personalized exercise plans. In turn, the nurse will observe

and encourage patients to exercise as recommended. If absolutely necessary, nurses can conduct

a physical assessment on each patient prior to exercise to ensure that it is safe for them. Also, if
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necessary, a psychosocial assessment can be conducted to ensure that patients are in a stable state

to participate in activity. Based upon the nurse’s judgment, they can determine whether exercise

is appropriate or not. Also, a physical and psychosocial assessment can be conducted post

workout to monitor for any changes in the patient’s status. Nurses can weigh patients once a day

in the morning, assess vital signs once a day and PRN, and complete a pain assessment

pre-workout and post-workout. Nurses can provide a focus assessment to ensure that perfusion,

range of motion, and hydration status is adequate. If patients are deficient in fluid and

electrolytes, then they should not be able to exercise until lab values are restored and they feel

better. The RD is another stakeholder because they create and adjust the meal plan for the

patients as necessary. Nurses will monitor the nutritional intake of patients in order to ensure that

they follow their meal plan. Nurses will provide a supportive yet strict environment to encourage

adherence to treatment. Outcomes can be measured by evaluating weight, energy level, mood,

and adherence to the treatment plan.

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