Case Study

Abstract
The purpose of this assignment was to perform a case study of a healthy child. Developmental considerations and data analysis were used to formulate and prioritize three nursing diagnoses. A complete health history interview was performed on a 17-year-old female. A genogram was developed to help determine potential genetic predispositions.

J.K.M. is a 17-year-old female born on May 9, 1994. The first part of the interview was done with her mother present. Her mother was then asked to leave to continue to interview. As a child she had normal childhood illnesses without complications. All of her immunizations are up to date. She had no injuries or illnesses requiring hospitalization. She started menstruating at the age of 12. She is still menstruating and has normal 3-5 day periods while on Nuva-ring and her cycle is every 28 days. She has started dating and has been sexually active off and on since the age of 16. Both her parents and one sister are alive. There is a history of alcoholism and depression on both sides of her parent’s family. Her parents are divorced. She lives with her mother and sister and states they all get along very well except for the occasional disagreement. She does not see or communicate with her father. She denies any drug or alcohol use. She states that she is usually happy but she is concerned about the depression and alcoholism that runs in her family. She has no suicidal ideation and has never been physically or sexually abused by anyone. She participates in the cheerleading program of her high school. She has a small group of friends that she socializes with a great deal. She also has a growing concern for her future and college preparation. She is interested in working with children but not sure of which direction to take – law or education. Her interest in personal appearance is also very important to her. J.K.M. spends increased time working out daily at the gym. She states that she takes in less than 1000 calories daily to manage her weight. Current weight is 124 pounds, height 5’8”, BMI 18.9 that is in the 20% percentile and falls into the healthy weight range.
Family is a critical component in the care of an adolescent. It is important for the clinician to introduce himself or herself properly to the teen and their family. Most of the visit will be spent with the adolescent alone. However, in most cases it is important for parents to be included at some point during the visit. This might be at the beginning, end, or both depending on the age of the adolescent and the complexity of the problem. It is also important to consider that the definition of a family has changed and there may be many possible family dynamics including blended families, stepfamilies, adoptive families and foster families. Family cultural and ethnic backgrounds are also critical to help understand the teen and their family. (Jarvis, 2012, Chapter 4).
During the interview process it is important to be able to communicate with the adolescent. Establishing rapport is important but not always easy with an adolescent during the first visit. Some suggestions for communicating with teens are to ask non threatening open ended questions, don’t be afraid to address sensitive issues, look for hidden agendas, assess for emotional conditions, listen and display interest, offer additional resources, and make sure their comments and concerns are taken seriously. Ensuring confidentiality with the teen is also important. The limits of confidentiality should be discussed with the teen. Parents should also be aware of these confidentiality guidelines. (Jarvis, 2012, Chapter 4).
Using a developmentally oriented approach is important when trying to obtain psychosocial information from the adolescent. The HEADSS interview is commonly used. This includes the topics of home, education, activities, drugs, sex and suicide. The teen interviewed for this assignment fell into Erickson’s adolescence stage, which is Identity vs. Role Confusion. Many things should be taken into consideration when looking at developmental considerations for the adolescent. They start to become independent and self-directed in home, school and work schedules. They search for new beliefs and begin to form their own personal philosophy of life. Many teens have frequent mood swings. Sexual curiosity, sexual activity and dating are common. At this stage, adolescence is peer-oriented and they begin to sever ties with their parents. Meal skipping is common. Fast food and unhealthy snacking become a part of their regular eating pattern. Many will experiment with smoking, alcohol, and drugs. (Jarvis, 2012, Chapter 4).
This is a time of changes for how teenagers think, feel, and interact with others. There are many changes going on within their bodies. Most girls will be physically mature by this stage, and most will have completed puberty. Boys might still be maturing physically during this time. Teens might have concerns about their body size, shape, or weight. Eating disorders are common, especially among girls. During this time, your teen is developing his unique personality and opinions. Relationships with friends are still important but will have other interests as they develop a more clear sense of who they are. They can also be overwhelmed by the possibilities of their future that may include college, work or military.
Nursing Considerations for adolescents: Adolescents consider themselves adults. Their physical assessments are the same as for an adult. Adolescents may become extremely self-conscious and embarrassed. Privacy should be provided. Areas of the body not being examined should be covered. Adolescents need simple adequate explanations. They need to be allowed involvement and decision-making regarding their care. (Jarvis, 2012, Chapter 4).
Nursing diagnosis #1: Imbalanced nutrition, less than body requirements related to an intake of nutrients insufficient to meet metabolic needs in relation to psychological and increased metabolic demand. Intervention: Assess causative factors; meet with a dietitian to help the patient plan meals that include appropriate caloric intake for her age and height. Promote wellness through emphasis of well-balanced, nutritious intake and pace consistency and quantity of meals. Properly educating the patient to help them understand that the current eating habits can be very harmful. Patient will be able to verbalize information about proper nutrition and how it relates to her health. Provide names of councilors and support groups that deal with eating disorders. Rationales for interventions: Providing information is necessary to make an accurate nutritional assessment and maintain client’s health and safety. Client may have inadequate or inaccurate knowledge regarding the contribution of good nutrition to overall wellness. (Stolte, 1996, p. 140).
Nursing diagnosis #2: Risk for unwanted pregnancy and contracting a sexually transmitted disease related to insufficient knowledge of contraception and disease prevention. Interventions: Provide information regarding disease prevention, abstinence and contraception. (Gulanick & Myers, 2011, p. 894).
Nursing diagnosis #3 - Low self esteem related to inaccurate self-perception of an ideal body image as evidenced by change in body weight, excessive exercise and fear of weight gain. Interventions and goals: Interventions and goals: Acknowledge normalcy of emotional response to actual or perceived change in body structure. Adolescent will express an understanding that current exercise patterns are self-destructive. Adolescent will consume appropriate number of calories each day. Adolescent will learn and implement new coping behaviors. Be able to identify feelings and underlying dynamics for negative perception of self. Verbalize acceptance of self as is and an increased sense of self-worth. Rationales for interventions: Adolescents and young adults may be particularly
affected by changes in of
their bodies at a time when developmental
changes are normally rapid, and at a time when
developing social and intimate relationships is
particularly important. (Stolte, 1996, p. 140).

Maslow’s Hierarchy of Needs

(Cherry, 2011, figure 1)
Maslow’s Hierarchy of Needs was used to prioritize and rationalize the nursing diagnoses for this adolescent. Nursing diagnosis #1- Impaired nutrition – less than body requirements, falls under the first level of needs which is physiological. Meeting our basis needs. We need to properly nourish and maintain a healthy body. Nursing diagnosis #2 - Risk for unwanted pregnancy and contracting a sexually transmitted disease falls under safety but also is part of love and belonging. By properly using birth control and using condoms will help to prevent unwanted pregnancy and help prevent the spread of sexually transmitted diseases. This is part of keeping her body safe and healthy. Nursing diagnosis #3 – Low self esteem falls under Maslow’s fourth level, which is esteem. Low self-esteem means poor confidence that can cause negative thoughts. These negative thoughts tend to make a person give up easily rather than face challenges. In addition, it has a direct bearing on a person’s happiness and wellbeing.

GENOGRAM

Grandfather 68
Grandfather 68
Grandmother 64
Grandmother 64
Grandmother
65
Grandmother
65

Grandfather 79
Grandfather 79

Hyperthyroidism Alcoholism, Depression Lung Cancer Dementia, Diabetes Chemical Dependency, Bipolar, Hypertension

Father
51
Father
51
Aunt
40
Aunt
40
Mother
43
Mother
43

Alcoholism Alcoholism, Depression, Anxiety & Depression Anxiety & Depression Chemical Dependency

Sister
23
Sister
23
JKM 17
JKM
17

MALE Celiac

FEMALE

DIVORCE Celiac disease, anxiety, depression

DEATH

References
Cherry, K. (2011). Heirarchy of Needs. Retrieved from http://psychology.about.com/od/theoriesofpersonality/a/heirarchyneeds.htm
Gulanick, M., & Myers, J. L. (2011). Nursing care plans (7th ed.). St. Louis, Missouri: Elsevier.
Jarvis, C. (2012). Physical examination and health assessment (6th ed.). St. Louis, Missouri: Elsevier Saunders.
Stolte, K. M. (1996). Wellness nursing diagnosis for health promotion. Philadelphia, PA: Lippincot-Raven Publishers.