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

IDENTIFIED NURSING PROBLEMS

RATIONALE 

GOALS OF CARE

APPROPRIATE INTERVENTIONS

The nurse will:

The client will:

The mother will:

Disturbed body image r/t changes in self-esteem and perceived need to lose weight a.e.b. being underweight

As their own worst critics with respect to their bodies, adolescents may be affected by developmental changes in body structure, especially during this stage when building social and intimate relationships is significantly important. They may perceive a need to lose weight to fit the standard of their peers or of society, resorting to low-calorie or starvation diets. Even though Ginny is underweight, her perceived weight may contrast with her actual weight, especially as she is already in a relationship. Improving her body image and providing health teaching on proper diet and nutrition may also address the unhealthy eating habits that Ginny has developed to lose weight (i.e. undereating) and prevent it from worsening to eating disorders like anorexia nervosa. 

• Express positive feelings of self-worth, including comfort and security with own body image and structure. 

• Maintain a normal BMI.

• Report adherence to balanced dietary plans that meet recommended nutritional requirements appropriate for age, sex, and development.

• Provide emotional support and assist client in developing positive self-esteem and self-worth. 

• Determine reasons for losing weight.

• Acknowledge verbal expression of feelings on body changes as normal and guide client in separating appearance from self-esteem and personal worth.

• Discuss significance of healthy eating for optimal adolescent development. 

• Assist in identifying realistic and attainable healthy weight goal. 

• Discuss various high-calorie nutritious foods and foods abundant in required vitamins and minerals while also considering client preferences.

• Guide client in creating sample nutritious diet plan.

Risk for situational low self-esteem r/t facial and neck acne breakout a.e.b. verbalization of being extra conscious of her looks

Facial beauty matters a lot to adolescents who often associate physical appearance as the foundation upon which popularity is achieved and lasting relationships are built. Their body awareness may cause them to become overly conscientious about personal hygiene and appearance. Acne is the most common skin order of adolescents resulting from increased secretion of sebaceous glands which are trapped in hair shafts. The outbreak of acne in her face and neck has made Ginny overly conscious of her looks, particularly because she already has a boyfriend. Aside from correcting a potentially  undesirable self-perception, therapeutic management of this health problem is also important to establish hygienic practices and prevent the breakout from worsening. 

• Demonstrate increased self-confidence and self-esteem.

• Verbalize that acne does not affect self-image.

• Maintain therapeutic management through accurate execution of grooming and hygiene regimen for acne care. 

• Provide emotional support and assist client in developing positive self-confidence, esteem, and self-worth. 

• Facilitate discussion of and respect client’s feelings and concerns about condition. 

• Explain and emphasize acne breakout, its disease process &  causes, as a common skin disorder for adolescents.

• Assist in creating an attainable skin care routine and encourage adherence to reduce - if not prevent - acne outbreaks. Emphasize the need for washing face and other affected areas daily with mild soap and water. 

• Advise against picking or squeezing acne lesions which may only increase inflammation. 

• Encourage a balanced diet, adequate fluids, exercise, and adequate rest. 

• Inspect acne lesions if they are mild, moderate, or severe.

• Refer client (and parents) to a physician for medical treatment and medication regimen  if acne breakout is abnormal or severe.

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

As an adolescent, Ginny is undergoing a transition between childhood and young adulthood. Extreme stress may be felt during life-changing events such as preparing for college and making a career decision, especially in the face. In Ginny’s case, juggling academics, relationships, personal matters and body image, in addition to the constant pressure of the environment or of her peers to excel, may become a burden. These emotional stressors may also be behind the flare-ups of acne and  at the same time, may also contribute to increasing her stress levels as she may perceive them as  hindrances to achieving “perfection” and maintaining her relationship. It’s important to address this problem as it may impact others aspects of her life.

• Appy effective coping mechanisms and patterns to manage stressors and perform in academics to the level of her capabilities. 

• Report a decrease in stress levels. 

• Provide emotional support and assist client to cope with stress physically, emotionally, and mentally

• Assist client to establish self-awareness to begin dealing with problems. 

• Provide counseling regarding positive and  effective coping strategies to manage stressors and deal with limitations. 

• Assist client in creating attainable academic and college application goals, breaking them down into  manageable tasks to reduce overwhelming feelings.

• Appraise impact of client’s lifestyle practices and stressful situation on personal and relationship roles. Promote self-awareness and alternatives to maintain balance in life.

Ineffective relationship r/t ineffective communication skills  a.e.b. withholding information from her parents, especially mother

The relationship between adolescents and their parents is often fraught with conflict and tension as the former desires autonomy from the latter. In fact, the more parents create rules, the more adolescents try to rebel. Ginny’s attempt to keep her relationship a secret from her mother may result from knowing that her parents would not approve of her having a boyfriend at such an early age. This led to ineffective communication between the two, as Ginny’s mother describes how difficult it is to talk to her daughter  and how she hardly knows her daughter’s friends. Nevertheless, while it is natural for adolescents to be closer to their friends than family, the parent-child dynamic must not suffer. 

• Report open communication with her mother/parent daily. 

• Express safety and comfort in confiding her feelings with her mother, whether it be distress or infatuation, and the like. 

• Maintain open communication with client while respecting privacy.

• Validate adolescent’s feelings  and provide emotional support to encourage information sharing. 

• Gently but firmly establish balance between freedom and responsibility. 

• Facilitate open and healthy communication between mother and client characterized by respect and understanding. 

• Help adolescent and parent understand the responsibilities of managing individual roles and responsibilities that are constantly changing. 

• Counsel client on the significance and benefits of maintaining an honest and trusting  relationship with her mother.

• Counsel the mother on client’s developmental stage and personal situation, and the importance of providing support, care, and love to her daughter.