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

Identified Nursing Problems

Rationale

Goals of Care

Interventions

Imbalanced nutrition: less than body requirements r/t insufficient dietary intake as evidenced by BMI below 5^th percentile and verbalized trying to lose weight

Adolescence is a transitional stage to adulthood that requires a lot of nutrients to support the still developing body. Inadequate nutrition can lead to various imbalances damaging their body perception and negatively affect self-esteem, both of which are vital at this stage.

• Explains relationship between diet, exercise, and weight

• Identifies optimal personal weight range

• Identifies appropriate caloric and nutrient intake

• Discuss relationship between food intake, exercise, and weight loss
• Determine individual motivation for changing eating habits
• Determine ideal body weight
• Discuss risks with being underweight
• Encourage individual to chart weekly weights as appropriate

Ineffective adolescent eating dynamics r/t changes in self-esteem as evidenced by BMI below 5^th percentile and still trying to lose weight

Adolescent eating habits change based on trends and self-perception. Improper weight loss diets compromise health due to undereating decreasing total energy and ability to deal with daily activities. Changes may be due to unrealistic body/beauty standards

• Explains relationship between diet, exercise, and weight

• Identifies caloric intake requirements

• Monitors body weight

• Discuss relationship between food intake, exercise, and weight loss
• Determine individual motivation for changing eating habits
• Discuss risks with being underweight

• Instruct on how to increase calorie intake and select nutritious food

• Chart weight gain progress until return to appropriate range

Disturbed body image r/t alteration in view of one’s body as evidenced by desire to further lose weight despite being underweight and client verbalization of pimples breakout making her extra conscious of her looks”

Client verbalizes still wanting to lose weight despite being below their IBW hence the need to address client’s self-perception and return to adequate nutrition. May be due to having a boyfriend and misconceptions about beauty standards.

• Verbalize realistic self-image

• Adjustment to changes in body function
  
  

• Satisfaction with body appearance often positive

• Determine how family behavior affects patient
• Encourage expression of thoughts, feelings, and concerns
• Provide privacy and ensure confidentiality
• Provide health counseling and guidance to adolescent client

• Establish therapeutic response based on warmth and respect

Impaired parenting r/t ineffective communication skills as evidenced by  Jennifer’s verbalization of “having a hard time talking with Ginny” and deficient parent-child interactions

Jennifer is unsure of how to communicate with her child worrying that Ginny is with the wrong crowd, not knowing her friends and staying out late, indicating insufficient parent-child interactions affecting ability to manage and communicate, possibly as conflict with expectations between parent and child.

• Interacts positively with child and maintains open communication

• Assists adolescent to cope with stress

• Ask client to identify what they can/cannot do about what is happening
• Facilitate role rehearsal by having patient anticipate others' reaction to enactment

• Determine how family behavior affects patient
• Assist patient identify usual role in family and role transition periods throughout the lifespan
• Assist patient identify positive strategies for managing role changes

Stress overload r/t pressure as evidenced by verbalization of stressing to keep grades up

Client is stressed about keeping grades up to get into their target college while also managing social pressures.

• Identifies effective coping patterns

• Reports decrease in level of stress

• Encourage verbalization of feelings, perceptions, and fears
• Assist patient to list and prioritize all possible alternatives to a problem
• Assist patient to identify strengths and reinforce these