Assessment Nursing Diagnosis Planning Implementation Rationale Evaluation

Subjective Data: Body Image After 8hrs. of Nursing  Establish a therapeutic  Adolescent client needs a After 8hrs. of Nursing
 The patient Disturbance related Interventions and nurse- client relationship. caring, nonjudgmental adult Interventions and
complained to biophysical Health Teachings:  Assess use of with whom to talk. Important to Health Teachings the:
of abdominal changes. terms/language used by establish trust and cooperation
pain and  Patient will the client/significant so that the client is free to hear  Patient was
uterine identify feelings other(s). the information available. able to identify
contractions and methods  Identify client’s self-  Terminology may be specific to feelings and
for coping with perception as positive or the adolescent culture, and methods for
Objective Data: negative negative. words may have different coping with
Vital Signs perception of  Elicit the client’s feeling meanings for client and nurse. negative
taken as follows: self/abilities. about sexual identity/roles  Helps clients become aware perception of
 Temperature-  Patient will  Discuss concerns and how she views herself and to self/abilities.
37. 3 verbalize fears about body image begin to increase her self-  Patient was
centigrade increased and transitory changes esteem. able to
 Pulse rate- sense of self- associated with  May have difficulty seeing verbalize
63 beats per esteem in pregnancy; discuss value herself as a mother. The increased
relation to system. adolescent must take a role sense of self-
minute.
current  Discuss ways to promote transition from child/daughter to esteem in
 Respiratory situation. relation to
positive self-image and adult/mother, which can create
rate- 21  Patient will current
recognition of positive conflicts for the client and
breaths per demonstrate significant other(s). situation.
aspects of the situation.
minute. adaptation to  Establishes a basis for future  Patient was
 Discuss appropriate
 Blood changes/event adaptation techniques and learning. Conflicts may exist able to
pressure- s as evidenced the communication skills to regarding how client has demonstrate
125/80 by setting implement these previously seen herself, what adaptation to
mmHg realistic goals techniques. her expectations of pregnancy changes/events
and active had been, and what are the as evidenced
participation in reality of pregnancy are. by setting
meeting own  Assists in coping with changes realistic goals
needs. in appearance and presenting a and active
positive image. participation in
 Role playing and active meeting own
listening can be used to learn needs.
skills of communication and
adaptation. Helps client learn
information necessary to
development of improved self-
esteem.