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Sex: Female
Age: 17
Nationality: Filipino
Siblings: 8
Occupation: N/A
OBSTETRICS HISTORY
Client is G1P0 with a planned pregnancy. Her labor lasted for 7 hours which was from
12am – 6am. During her labor period, she rated her pain as 8 out of 10 using the pain rating
scale since it was her first pregnancy. She had 4 prenatal visits. Her last menstrual period
was February 16, 2019 and her estimated date of delivery was November 23, 2019 but she
gave birth on November 30, 2019 via normal spontaneous vaginal delivery (NSVD).
Client had her menarche when she was 13 years old. She described her menstrual
cycle as regular that lasts for 3 days, “kada bulan ak gin-aabtan ngan tag-tulo la ka adlaw”
as verbalized by the client.
PAST HEALTH HISTORY
Client’s childhood illnesses were cough, colds, fever and Urinary Tract Infection. She
didn’t receive any immunization when she was still a child. No allergies to food or medicines
and no previous injuries or accidents.
Client’s father and mother are still alive, and experiencing Rheumatoid Arthritis. His
paternal side has a history of Hypertension while her mother has none.
Client is a 17-year-old female and single. She currently lives in Brgy. Campoyong,
Guiuan, Eastern Samar. Her highest educational attainment is Grade 9 but according to her
she will go back studying with the Alternative Learning School Program.
She described her day to be okay. Her usual activities are playing games in her
mobile phone and walking around their area with her friends.
She eats 3x a day and her usual diet is fish, rice and vegetables like carrots and
cabbage. She drinks 2 carbonated drinks like Coke and Royal each day and she also
consume 8 glasses of water daily. She estimated her urine output to be 750 ml out of 1000
ml per day. She usually voids 3-4 times a day with no difficulty.
She defecated with no difficulty, usually once or twice a day, the consistency of his
stool was formed, and its color was brown or sometimes brownish green depending on
what he eats. She has an uninterrupted sleep from 12am – 3am.
GORDON’S 11 FUNCTIONAL HEALTH PATTERNS
C. Elimination
According to the client she has no problem in urinating, she usually voids 3-4 times
daily. She estimated her urine output to be 750 ml out of 1000 ml. She usually defecates
1-2 times daily with no problems reported.
E. Cognitive-Perceptual Pattern
The client stated that she has no sensory deficits but she is experiencing pain at the
moment.
“it mal-ul-ol la haak kay tak pwerta kun ngain gumawas nak baby.” As verbalized by
the client.
F. Sleep-Rest Pattern
Client only sleeps for 3 hours from 12am-3am and do not nap during the day
because according to her, she wants to make the most of her time with her friends.
“Okay la tak katurog, waray problema, tagtulo la ka oras tikang 12 tikadto 3 kay
mapaso man haam tas nahigara-an.””mapaso man gihap dinhi.” As verbalized by the
client.
G. Self-Perception Pattern
“Para ha akon, joker ako, malakat, ngan matuyaw.”as verbalized by the client. Her
talent is singing.
“Diri man ak napacheck-up, pero kun may sakit natumar medisina bisan waray resita
hit doctor.” As verbalized by the client.
H. Role-Relationship Pattern
The client’s most important people in her life is her family. According to her they
were raised properly.
“maayos man tak relasyon ha ira, waray samok.” As verbalized by the client.