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

 IDENTIFIED NURSING PROBLEMS

 GOALS OF CARE

After the nursing interventions, the client will,

 INTERVENTIONS

     The nurse will,

Imbalanced Nutrition: Less than the body requirements related to inadequate dietary/food intake as evidenced by BMI below the 5th percentile for age, sex and height.

Balanced nutrition is essential for her body in order to function properly. These foods provide the energy we need every day. Also, having proper nutrition is important because it helps reduce disease, improve well-being and ability to fight off illnesses. Additionally, a balanced diet is extremely important to maintain optimal metabolism and overall health.

• Identify nutritious food based on the food pyramid.

• Identify proper caloric and nutritional intake

• Follow a proper and healthy diet

• Report BMI within the normal range for age, sex and height.
  • Discuss the different nutritional guidelines such as Pinggang Pinoy, food pyramid and the 10 kumainments.

• Educate the client regarding the appropriate caloric and nutrient intake for her.

• Create a meal plan together with the client.
• Monitor the client’s dietary intake using a 24-hour food recall.

• Explain how to compute BMI

Ineffective Adolescents Eating Dynamics related to changes to self-esteem upon entering puberty as evidenced by trying to lose weight despite being underweight

Adolescents need to eat well because their bodies are changing, which affects their nutritional and dietary needs. During this time, they are most likely conscious of their weight and tend to lose weight without a clear plan and supervision, resulting in a poor diet. This is probably the case with Ginny.

• Identify appropriate caloric and nutritional intake.
• Identify healthy eating habits

• Adhere to healthy eating
• Report improvement to her self-esteem
• Discuss the appropriate caloric and nutrient intake for her.

• Discuss various healthy eating habits

• Monitor the client’s dietary intake

• Explain the importance of self esteem to her physical, mental and emotional health

Disturbed Body Image related to breakout (facial and neck pimples) as evidenced by the feeling of being extra conscious of her looks.

Body/facial image is important to the development of adolescence. Teens may become self-conscious about their bodies as they continue to grow and change during their formative adolescent years. Many of them will also become overly conscious of flaws such as blemishes, pimples, or excess weight. With this, they are at a higher risk of developing negative body image

• Report improved self – esteem

• Verbalizes positive body image and increased confidence.

• Discuss the different normal physiologic developmental changes during adolescence

• Teach parents the importance of their responses to the child’s body changes and future adjustment, as appropriate

• Assist patient to identify actions that will enhance appearance

• Monitor for statements that identify body image perceptions concerned with body shape and body weight

Stress overload related to stressors as evidenced by the pressure of keeping her grades up so she can apply to her choice of college

Maintaining or exceeding average grades is extremely stressful, especially when it comes to college applications. During this time, they are more likely to work harder in order to achieve their goals. With this stress, they are more likely to develop bad eating, exercise, and even life habits. In Ginny's case, she is stressed out because she is under pressure to maintain her grades and meet her expectation of applying to the college of her choice.

• Demonstrate healthy coping mechanisms

• Report ease and decreased stress due to her grades

• Identify relaxation techniques

• Discuss the different coping mechanism
• Promote stress reduction
• Encourage expression of feelings
• Explain the importance of time management
• Discuss various relaxation techniques
• Explain the importance of rest in order to relieve stress
• Assist the client to identify ways on how she can relieve her stress.

ANTICIPATED PROBLEMS

Anxiety

ü  if the client continues to experience stressors and pressure as well as consciousness with her facial/body image.

Ineffective coping

ü  if the client will be unable to resolve her current stressor.

Dysfunctional family processes

ü  if the client will not be able to communicate properly, build trust and rapport with her parents.