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

IDENTIFIED NURSING PROBLEMS

RATIONALE

GOALS OF CARE

The client will:

INTERVENTIONS

The nurse will:

Imbalanced Nutrition: less than body requirements r/t insufficient dietary intake as evidenced by BMI below ideal range

Healthy eating is crucial during the adolescence period as bodily changes occur that affect one’s nutritional and metabolic needs. Ginny is classified as underweight and further insufficiency in food intake may lead to health complications.

• Explain the importance of proper nutrition and adhering to the recommended diet
• Adhere to the recommended and appropriate meal plan
• Report a 24-hour food recall containing appropriate, balanced, and nutritious meals

• Assess dietary habits and recent food intake
• Educate on nutrient requirements and the importance of adhering to the recommended diet
• Guide in creating a meal plan following the client’s food preferences and nutritional requirements
• Monitor client’s food intake

Ineffective Relationship r/t ineffective communication skills as evidenced by dissatisfaction with information sharing and verbalized communication difficulty

Despite adolescents striving for freedom and autonomy, parental relationship and communication should be effective as familial help is critical for an individual in this phase of life to cope with the changes and challenges experienced. Ginny’s communication with her mother is evidently ineffective and this must be addressed to facilitate guidance and holistic support.

• Verbalize communicating stresses, feelings, and problems with the mother

The parent will:

• Encourage the child on having open communication through emotional validation with respect and understanding

• Identify communication barriers
• Educate the client on the importance of having open communication with the mother
• Educate the mother on the client’s situation and developmental stage

Stress Overload r/t stressors as evidenced by the feeling of pressure from grades and college application

Adolescence has been regarded as the phase of increasing stress in which various changes occur concurrently such as physical maturity, increased need for independence, and heightened significance of social and peer relationships. Ginny evidently feels pressured with her responsibilities and the inability to resolve these predicaments could incline her to mental health problems – anxiety and depression which are common in youth.

• Report decrease in stress through effective use of coping strategies
• Spend appropriate times for rest and leisure
• Utilize nurse-taught relaxation techniques

• Counsel on effective coping strategies to manage academic demands
• Instruct a client on nonpharmacological relaxation techniques
• Discuss the importance of rest and leisure in performance improvement and stress diminishment
• Assist in adopting proper time management to allow for rest, leisure, and academic endeavors

Ineffective Adolescent Eating Dynamics r/t changes to self-esteem upon entering puberty and excessive stress as evidenced by actions on losing lose weight

In the adolescence period, having a diminished self-perception is common as influenced by a negative body image which may result in unhealthy eating behaviors that may cause illnesses. Ginny demonstrates losing weight to enhance self-esteem and this should be addressed appropriately.

Nutritional guidance and adherence to proper diet should be instigated to support the development of healthy lifestyles and ensure optimal growth and development.

• Give insights on the importance of proper nutrition
• Report nutritional diet regimen adherence
• Verbalize increased self-confidence to boost self-esteem

• Assess current eating behaviors and identify inappropriate practices
• Educate the importance of adhering to balanced nutrition and its positive impacts on holistic development
• Counsel on self-acceptance emphasizing on diminishing the client’s negative body-image perception and low self-esteem

Risk for Situational Low Self-esteem as evidenced by increased consciousness about one’s looks

Acne breakout instigates feelings of being unattractiveness which makes one lose self-confidence and develop timidity during the adolescence period, thus, it is crucial to alleviate Ginny’s risk for low self-esteem accordingly.

• Identify methods for coping with the negative perception of self
• State acne breakout as normal during puberty
• Verbalize positive expressions on self-esteem and self-worth
• Adhere to the appropriate skincare routine

• Discuss acne breakout as a common pubertal change and its causes
• Identify an appropriate skincare routine
• Assess the severity of acne
• Counsel the client on separating physical appearance from self-worth and self-esteem
• Encourage self-affirmation through establishing a trustworthy conversation with the client’s feelings and concerns validated

ANTICIPATED NURSING PROBLEMS

Ineffective Coping

-          The stressors, appearance issues, and communication concerns with her mother should be addressed effectively as otherwise, Ginny may develop unhealthy coping mechanisms.

Disturbed Body Image

-          Adolescent changes and stressors related to being severely concerned with body image may lead to an adverse effect on Ginny’s self-worth and self-perception

Dysfunctional Family Processes

-          Communication barriers with her mother must be addressed as otherwise may inhibit her from receiving proper guidance during the adolescence phase, hence, a dysfunctional family process