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

Identified Nursing Problems

Rationale

Goals of Care

The client will:

Interventions

Imbalanced nutrition: less than body requirements r/t insufficient dietary intake as evidenced by client’s attempt to lose weight and the client being underweight with BMI below the 5^th percentile

A teenager who is underweight might not be getting the nutrients their body needs such as vitamins, iron and calcium, protein, or dietary fat from food to support a healthy and growing body

- Identify nutrients their body needs

- Identify foods containing essential nutrients

- Express intent to have a balanced diet

- Health teaching on nutrients an adolescent need

- Suggest keeping a food diary

- Health teaching on a balanced diet

Ineffective adolescent eating dynamics r/t changes to self-esteem upon entering puberty as evidenced by client’s attempt to lose weight and the client being underweight with BMI below the 5^th percentile

During puberty, teenagers tend to stress out on their weights leading to a high incidence of dieting behaviors that can contribute to nutritional inadequacies and to the development of eating disorders

- Establish a dietary pattern with caloric intake adequate to regain/maintain an appropriate weight

- Demonstrate weight gain toward the individually expected range

- Learn what consists of a healthy diet

- Develop a meal plan suited to their weight status and preference

- Health teaching on proper eating habits

- Identify the risks of being underweight

- Health teaching on a balanced diet that promotes weight gain

Ineffective relationship r/t ineffective communication skills as evidenced by client’s mother having a hard time talking to her

Teenagers usually spend more time with friends than with family as they share more similar interests and they feel that they have more freedom and are more accepted than when they are with their own family. Teenagers also feel pressure from their family and feel like they don’t understand them

- Establish rapport with their parent

- Start to openly communicate with their parent

- Discussion on what compromises a healthy communication

- Encourage client and their parent to allot time for talking and catching up

- Promote mutual understanding between the client and their parent

Stress overload r/t stressors as evidenced by client expressing that she’s stressed with trying to keep her grades up so she can apply to her choice of college

College is an important milestone of an individual’s life. One can be stressed with maintaining their grades and with reviewing to obtain high scores in the entrance examinations. This is normal, but a healthy coping mechanism should be implemented for it to not affect ones academic performance and health

- Express reduced stress levels

- Identify relaxation techniques

- Properly demonstrate relaxation techniques 

- Develop a healthy coping mechanism

- Assess client’s stress level

- Listen to the client’s concerns

- Assist clients to identify feelings and begin to deal with problems

- Demonstrate relaxation techniques on client (Deep breathing exercises, progressive muscle relaxation, guided imagery, and meditation)

- Instruct client on performing relaxation techniques

Anticipated Nursing Problems:

• Disturbed body image: The client might perceive that they are “fat” that might cause further dieting and weight loss
• Risk for situational low self-esteem: Changes in weight and prevalence of acne during puberty might affect the client’s self-esteem
• Ineffective coping: If healthy coping mechanisms are not established, the client might end up with maladaptive coping mechanisms that might affect their health negatively