Our Lady Of Fatima University

Valenzuela Campus

Valenzuela City Emergency Hospital

Delivery Room

A Case Study:
Normal Spontaneous Delivery

Submitted by:
Villa alva, Mateth

Submitted to:
Ms. Sharon Cajayon RN, MAN

General Objectives:

Specific Objectives:

INTRODUCTION

Patients Profile
Name of Patient: VC
Age: 18
Gender: Male
Birthday: 11/29/1995
Birthplace: Sta. Cruz Laguna
Address: San Isidro Heights, Banlic, Cabuyao, Laguna
Admitting Diagnosis: Hematemesis
Latest Diagnosis: Severe Pneumonia
Religion: Roman Catholic
Civil Status: Single
Nationality: Filipino
Language/Dialect Spoken: Tagalog, English
Date and Time of Admission: 09/24/2014 02:00 PM
History of Present Illness

History of Past Illness

PHYSICAL ASSESSMENT

GORDONS FUNCTIONAL HEALTH PATTERN

A. HEALTH PERCEPTION & HEALTH MANAGEMENT PATTERN

Patient is 18-year old, male and single. He was admitted due to

his chief complaint of hematemesis and was diagnosed with
Pneumonia
B. NUTRITIONAL AND METABOLIC PATTERN
Before and Now: Patient has a complete meals (breakfast,
lunch, and dinner) and has usual fluid intake of 8-10 glasses/day. He
eats meats, vegetables and fruits.
C. ELIMINATION PATTERN
Bladder habits
Before and Now: He can void 3-4 x a day without any pain felt.
Bowel habits
Before and Now: He can defecate once a day with a formed
stool.
D. ACTIVITY EXERCISE PATTERN
Before: He is a college student. And rarely exercises because of
getting ill.
Now: He was confined to SLH for severe pneumonia and
ordered for bed rest.
E. SLEEP REST PATTERN
Before and Now: He has a good sleep-wake cycle. He usually
sleeps 6-8 hours and during afternoon, he takes a nap for an hour. .
F. COGNITIVE PERCEPTUAL PATTERN
Before and Now: According to the significant others, he has no
deficit in his sensory perception (hearing and sight) and hes able to
read and write. He can hear and answer to questions being asked. He
is aware of the conversations. He can see people that surrounds him.

G. SELF PERCEPTION & SELF CONCEPT PATTERN

According to the significant others, the patient is a good brother
and son. He is not a smoker and drinks occasionally. He wants to reach
his goals in life later on.
H. ROLE RELATIONSHIP PATTERN
According to significant others, patient is very responsible and
dedicated to his studies. He always said that he wants to attain his
goals or dreams for his family and future family.
I. SEXUALITY REPRODUCTIVE PATTERN
He has no sexual experience.
J. COPING STRESS TOLERANCE PATTERN
He said that, whenever he has a problem, he shares it to the
family and solve the problems by himself and of course, listens to the
advices of his family.
K. VALUE BELIEF PATTERN
He is a Roman Catholic. He attended masses together with the
family every Sunday.

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGY

DIAGNOSTIC EXAMINATION

DISCHARGE PLANNING

What Have You Learned?