II.

NURSING ASSESSMENT

A. Demographic Data Name: A.L. Address: Tuktukan,Guiginto,Bulacan Age: 16 yrs.old Sex: female Race: Filipino Marital status: single Occupation: none Religious orientation: Catholic Health care financing and usual source of medical care: Work Date of admission: March 5,2012 Admitting Diagnosis: PU 39 2/7 AOG CIBC Gestational hypertension

B. Chief complaint or reason for visit She complains of abdominal pain C. History of present illness She experienced gestational hypertension during her labor.According to her,it is because of her phobia in needle. D. History of past illness In her childhood stage, she have measles. She has complete immunizations. She doesn,t have any allergies and didn,t experienced any accidents.Her first hospitalization was when she has problem in F.FUNCTIONAL HEALTH PATTERN 1. Health perception and health management pattern She has a history of measles in the past. They go to health centre for check-up. The client was smoking and drinking alcohol but not using any drugs. 2. Nutritional Assessment: (72 hours diet Recall) 1ST day March 5,2012 2nd day March 6, 2012 3rd day March 7, 2012

NPO BREAKFAST

Sinigang 1 cup of rice

Tahong at 1 cup of rice LUNCH

Sinigang at 1 cup of rice

DINNER

3 .Elimination Pattern The client urinates 2500ml in assessing the urine bag used. Upon assessment, It is amber in color and slightly turbid in consistency. She doesnt feel any discomfort in urinating. She defecates 2 times a day with brown in color and hard in consistency. She doesnt feel any discomfort. 4.Activity/exercise Walking is the only exercise that the client do.

5.Sleep-rest pattern . According to her, she doesnt have any problem in sleeping and shes not using any sleeping pills.Shes take nap at afternoon. 6.Cognitive-perceptual pattern She doesnt have any problem in hearing and vision. 7.Self- perception/self- concept She just want to have a good and happy family with her newly born baby. 8.Role/Relationships The client is adapted from their past maid. 9.Sexuality/Reproduction Her LMP was January 3,2011.Her first menstruation was when shes 13 yrs.old. The client stated that she already experience sexual intercourse at the age of 15 yrs.old.at one partner only.They didnt used any contraceptives.She said that during their intercourse,they do oral intercourse.

10.coping-stress She is friendly, jolly person and quite rugged. she is aware that she is pregnant and so excited to give birth. When she has a family problem, she goes to her friend to take some advise. Sometimes, she cope her problem by drinking alcohol together with her friends. 11.Values/Beliefs She value her family. Religion is important for her because it helps in her problem. E. Growth and Development

Theory Stage

Psychosocial Adolescence 12 to 20 yrs. Ego Development :Identity vs. Role Confusion Basic Strenghts: Devotion and fidelity

Cognitive

Psychosexual Latency Stage

Moral Level III: Postconventional morality.

Formal Operational Stage

Descriptions

Up to this stage, according to Erikson, development mostly depends upon what is done to us. From here on out, development depends primarily upon what we do. And while adolescence is a stage at which we are neither a child nor an adult, life is definitely getting more complex as we attempt to find our own identity, struggle with social interactions, and grapple with moral issues. Our task is to discover who we are as individuals separate from our family of origin and as members of a wider society. Unfortunately for those around us, in this process many of us go into a period of withdrawing from responsibilities, which Erikson called a "moratorium." And if we are unsuccessful in navigating this stage, we will experience role confusion and upheaval.

This stage, which follows the Concrete Operational stage, commences at around 11 years of age (puberty) and continues into adulthood.In this stage, individuals move beyond concrete experiences and begin to think abstractly, reason logically and draw conclusions from the information available, as well as apply all these processes to hypothetical situations.The abstract quality of the adolescent's thought at the formal operational level is evident in the adolescent's verbal problem solving ability. The logical quality of the adolescent's thought is when children are more likely to solve problems in a trial-and-error fashion.During this stage the adolescent is able to understand such things as love, "shades of gray", logical proofs and values. During this stage the young person begins to entertain possibilities for the future and is fascinated with what they can be. Adolescent egocentrism can be dissected into two types of

During the latent period, the libido interests are suppressed. The development of the ego and superego contribute to this period of calm. The stage begins around the time that children enter into school and become more concerned with peer relationships, hobbies and other interests. The latent period is a time of exploration in which the sexual energy is still present, but it is directed into other areas such as intellectual pursuits and social interactions. This stage is important in the development of social and communication skills and self-confidence.

Some adolescents and adults go a step further and rise above moralities based on authority to ones based on reason. Stage 5. The social contract stage means being aware of the degree to which much of so-called morality is relative to the individual and to the social group they belong to, and that only a very few fundamental values are universal. The person at this level sees morality as a matter of entering into a rational contract with one's fellow human beings to be kind to each other, respect authority, and follow laws to the extent that they respect and promote those universal values. Social contract morality often involves a utilitarian approach, where the relative value of an act is determined by "the greatest good for the greatest number." Stage 6. This stage is referred to as the stage

A significant task for us is to establish a philosophy of life and in this process we tend to think in terms of ideals, which are conflict free, rather than reality, which is not. The problem is that we don't have much experience and find it easy to substitute ideals for experience. However, we can also develop strong devotion to friends and causes. It is no surprise that our most significant relationships are with peer groups.

social thinking, imaginaryaudience that involves attention getting behaviour , and personalfable which involves an adolescent's sense of personal uniqueness and in vincibility.

of universal principles. At this point, the person makes a personal commitment to universal principles of equal rights and respect, and social contract takes a clear back-seat: If there is a conflict between a social law or custom and universal principles, the universal principles take precedence.

Findings Remarks

PASSED Positive. Because our client is aware of her role in the family.

Failed Negative .Because she dont understand what is her limitations when it comes about love .And at her age ,she is already engaged in sexual activities.

Failed Negative . Because she already experienced sexual intercourse that is not suited at her age.

PASSED Positive .Because shes aware of socializing .And know how to answer our interview in a good way.

VI.Discharge plan: MEDICATION: Instruct the patient to take home medication ordered by the doctor and encourage strict compliance. EXERCISE:

TREATMENT: This is mainly symptomatic or supportive OUT-PATIENT: Encourage for a check-up so that she can monitor her health status. DIET:

SLEEP: Instruct the client to have an adequate sleep for at least 8-10 hours. If possible, take a nap in the afternoon for better recovery.