N13 - Maternal and Child Nursing 2nd Semester AY 2021-2022

IDENTIFIED NURSING PROBLEMS (NANDA)

RATIONALE 
(Silbert-Flagg, & Pillitteri, 2018)

GOALS OF CARE
(NOC)

APPROPRIATE INTERVENTIONS
(NIC)

The nurse will:

Disturbed body image r/t trying to lose weight a.e.b. being underweight

Adolescents may be disappointed with their bodies due to an “unsatisfactory” appearance. They may want to lose weight due to being obese or overweight through low-calorie or starvation diets. Ginny was neither; she is underweight and yet tries to lose weight. Actual weight may contrast with her perceived weight.

The client will:

The mother will:

• Determine reasons for losing weight.
• Assist in separating appearance from feelings of personal worth.
• Assist in identifying an attainable healthy weight goal and creating a nutritious diet plan.
• Discuss various high-calorie nutritious foods and foods abundant in zinc, iron, and calcium while also considering client’s preferences.

Report adherence to nutritious diet plan, express comfort with own body, and have a normal BMI.

Risk for situational low self-esteem r/t facial and neck acne breakout and feeling extra conscious of looks

Acne is the most common skin disorder of adolescents due to increased sebaceous gland secretions trapped into hair shafts. Having acne has caused Ginny to be extra conscious of how she looks, especially that she has a boyfriend. She may be carrying an undesirable self-perception.

Maintain grooming and hygiene routine for acne care and express positive feelings about self-worth.

Assist the client in developing positive self-esteem.

• Discuss acne breakout as a common skin disorder for adolescents and its causes.
• Assist in creating an attainable skin care routine and encourage adherence.
• Inspect acne lesions if they are mild, moderate, or severe.
• Refer client to a physician for treatment or medications if acne breakout is abnormal.

Stress overload r/t academic grades and college application a.e.b. feelings of stress and acne breakout

Ginny is undergoing transition, preparing for college. During life-changing events, especially as an adolescent shifts to young adulthood, extreme stress may be felt. Juggling academics, relationships, and personal matters (self-perception, losing weight) may burden Ginny. Acne breakout can be caused by emotional stress.

Report decrease in stress by using effective coping patterns and perform in academics to level of ability.

Assist client to cope with stress physically, emotionally, and mentally.

• Assist in breaking down academic and college application goals into manageable tasks.
• Appraise the impact of client’s life and stressful situation on personal and relationship roles.
• Assist in practicing positive strategies to deal with limitations.

Ineffective relationship r/t ineffective communication a.e.b. keeping secrets from mother

Adolescents tend to be in conflict with their parents due to wanting autonomy. Ginny’s keeping of her relationship a secret may imply that her mother did not approve of her having a relationship this early.  This led to Ginny having ineffective communication with her mother, who finds her to be difficult to talk to and hardly knows her friends. “Parent-child friction” peaks around Ginny’s age.

Report being able to discuss feelings of distress with her mother.

Maintain open communication with client while respecting privacy.

• Listen intently to both the mother and the client individually for reasons of ineffective communication.
• Facilitate open communication between them.
• Counsel client on the importance of having a trusting and communicative relationship with the mother.
• Counsel the mother on client’s situation and developmental stage.

ANTICIPATED NURSING PROBLEMS

• Ineffective adolescent eating dynamics. Ginny may develop unhealthy eating habits to lose weight.
• Ineffective coping. If her stress and losing of weight are not managed and ineffective communication with her mother for support continues, Ginny may develop unhealthy coping strategies.