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

Identified Nursing Problems

Rationale

Goals of Care

Interventions

Imbalanced nutrition: less than body requirements related to insufficient dietary intake as evidenced by BMI below the 5^th percentile for age, sex, and height

An adolescent requires adequate nutritional intake to sustain her metabolic needs that are essential for her development. Imbalanced nutrition may contribute to stress, tiredness, and our capacity to work, and over time, it can contribute to the risk of developing some illnesses and other health problems such as malnutrition

•  Steadily gain weight towards the ideal weight for height and age
• Recognize the importance of sufficient dietary intake
• Identify factors causing weight loss 
• Adherence to a healthy diet

• Provide health teaching on the importance of adequate dietary intake and the adverse effect of being underweight
• Discuss the possible factors causing weight loss related to her current situation
• Coordinate with the client and create a meal plan that consists of a high caloric diet

Ineffective adolescent eating dynamics related to changes in self-esteem upon entering puberty as evidenced by trying to lose weight despite being underweight

Eating habits may be subjected to change during the adolescent years due to consciousness in appearance and changes in self-esteem.  Adequate nutritional intake is important in this stage because the body needs sufficient nutrients to support growth and development.  Ginny needs to establish a healthy eating habits to sustain her growth and  improve her BMI

• Establish healthy eating patterns
• Identify appropriate nutritional intake
• Identify factors that cause low self-esteem
• The client will verbalize acceptance of body image with stable body weight.

• Discuss the necessary nutritional component in a meal
• Explain the benefits of having an optimal weight
• Determine factors that cause low self-esteem

Stress overload related to stressors as evidenced by pressure to maintain a high grade in relation to college application

The college application process is potentially the most stressful time of a student’s high school career. Stressors like this can affect your body, thoughts and feelings, and behavior.  In Ginny’s case, she is experiencing pressure due to expectations and fear.

• Manage the stressors and choose a healthy coping mechanism

• Assist the client to identify or verbalize her thoughts and feelings
• Provide suggestions on how to overcome the problems
• Demonstrate and encourage the use of stress reduction activities such as deep breathing technique, guided imagery, and yoga

Interrupted family process related to developmental transition as evidenced by poor communication between parent and child

Interrupted family process occur as a result of poor communication within the family. Also, her mother lacks knowledge in dealing with the developmental transition of Ginny. Her mother verbalizes her difficulty talking to Ginny and expresses her concern about Ginny’s possible involvement in the wrong crowd.

• Maintain open communication within the family

The parent will

• Expresses understanding and affirmation of the problem
• Displays attentive, supportive parenting behaviors

• Encourage the client to communicate to her parent her concerns and emotions
• Explain to the parent the developmental transition she is experiencing and the need to provide constant support

ANTICIPATED NURSING PROBLEMS

• Disturbed Body image – The client exhibits low self-esteem; she is conscious of her physical appearance. If she will not be able to attain her ideal mental picture of herself, this problem may occur.
• Ineffective coping – If the client is unable to appropriately manage her stressors
• Dysfunctional family process – If open communication is still not facilitated and the lack of understanding and support are not evident in the family.