Nursing

Care Plan
By: Emma Lumerto, Kira

Case Study

Minna, 14 year old student, lost her mother and has had to move to
the capital to live with her sister.
She has been overweight all her life. Due to feelings of sorrow, she
eats a lot of sweets before going to bed. Because of poor diet she
suffers from constipation.
She drinks a lot of coffee to calm her down, which makes her sweat
and urinate often and gives her occasional diarrhea.
Her size makes it difficult to exercise and her muscles are weak.
She also has problems sleeping. Suffers from paleness, headaches and

Some thoughts (taking into consideration Roys Model)...

(But of course we cant assume all these things.)

Physiological mode:

Adaptiveness is not completely good/balanced. Basics: Oxgenation , Nutrition ,

Elimination , Activity and rest ,Protection (immune system), Complex: Senses ,
Fluids/Electrolytes , Neurological functions , Endocrine

Self concept mode:

How does she think of herself? Perhaps has bad self esteem because of weight, low in
confidence, depression and surity of who she is and what she believes because of loss of
mother. Spiritual questioning.

Role function mode:

14 yr old female student , social integrity might be disrupted because living in a new city
away from friends. (but not adapting well to changes in environment), Knowing who she is in
relation to others might not be affectively adapted to due to disruption in Mother-daughter
relationship.

Interdependence mode:
Has her sister as support but lacks the mother-daughter relationship at a sensitive period in
her life. Might lack feelings of security and affection from loss of mother.

Assessment of behaviour

Client is over weight. Clients height is 165

cm, weight 68 kg, BMI 25. Unbalanced diet.
Constipation, but occasional diarrhoea. Weak
muscles. Problems sleeping. Headaches,
pale, constantly sick. Stomach irritation.
Lives with sister. Can move.

Assessment of influencing
factors
Client is overweight due to genetics, high calorie
diet and lack of sufficient exercise. Moving to a
different city and the loss of her mother is
causing difficulties with coping emotionally and
controlling her eating. Digestion problems exist
because of poor diet and excess coffee drinking.
Excess coffee drinking to calm emotions. Lack of
appetite for real nutritious food.

Nursing Diagnosis

Overweight due to genetic factors, late night eating to ease pain (more
intake of calories than used and less activity at night). Difficulty sleeping
due to high energy intake late at night, caffeine and emotional difficulties
Her weight makes it hard for her to exercise and leads to weaker muscles.
Constipation from unbalanced diet. Excess coffee causes sweating,
urination and occasional diarrhoea.
Poor nutrition, lack of sleep and stress causes flues. (Stress from being ill,
new environment and adjusting to living without mother.)

Goals
Long term:
Maintain normal healthy weight, lifestyle and maintain goals
Readjust eating habits ( 3 meals a day, cut calories from 2500 to 1,800 a day, meals
with adequate balanced nutrition, last meal before 6 pm.)
Regular exercise every day. (30 mins -1 hour)
Moderation in coffee.
Find balance with coping with loss of mother and settling in her new place of living.
Short term:

Recognise relationship between healthy diet, exercise and her weight.

Cutting down gradually on coffee intake and sugary food intake.
Nutrition diary and exercise diary.
Reach BMI 23 and weight of 61 kg
Short term goals of weight loss

Interventions

Explain relationship between healthy diet, exercise and weight. Explain

relationship between patients actions and problems. Show and give a copy of
the food pyramid. Help with food/exercise diary.
Help from nutritionist and grief councillor. Involve the sister to aid with
motivation and keeping up the routine at home.
Take blood tests, weight, BP and other measurements.
Tailor diet and exercise to clients likes and choices, but guide in the right
direction.
Encourage client to walk daily. Walk with her; keep her company with exercise.

Evaluation

So far client has kept to her goals and has lost x amount of weight. Keeps her food and exercise
journal.
Seems to understand cause and effects of eating and weight gain. Eats balanced diet. Still
struggling with exercise and coffee, but drinks less than before. Still has trouble sleeping, still
some emotional difficulties in coping.
Less pale, less flues, less frequent headaches. Bowel functions are returning to normal. Sister is
becoming more and more involved in motivation and support.
Finds difficulty with finding enjoyable exercise. Still trying different activities. Motivated by
success so far.
Recommend continuing with grief councillor and regular check-ups until reaches target weight.
Regular check-ups.