I.

Demographic Data

a. Clients name : Patient M
b. Sex : Female
c. Age : 45 years old
d. Birth date : May 29, 1969
e. Birth Place : Capiz, Ilo-ilo
f. Race/nationality : Filipino
g. Address : Nayon Kay- Anlog, Calamba City
h. Chief Complaint : DOB and Pallor
i. Admitting Diagnosis : CKD 2 to DM nephropathy Anemia 2
j. Final Diagnosis : CKD 2 to DM nephropathy Anemia 2
k. Date of Admission : August 6, 2014
l. Hospital : Dr. Jose P .Rizal Memorial District Hospital
I. Source and Reliability of the Information
All data and information presented in this case were collected at Dr. Jose P. Rizal Memorial District Hospital. Other
information needed in this case was gathered from the patients husband and some is from the interview and in nurse
patient interaction. Other data presented are gathered in the patients chart like laboratory results, medical findings.
II. Reason for seeking care
The patient experienced difficulty of breathing, notable pallor and she has edema on lower extremities thats why her
family decided to brought her to the hospital immediately.
III. History of Present Illness
A day prior to confinement the patient suffered on slight DOB while she was sweeping the floor thats why patient M
decided to took a rest for a while
However, easy fatigability, Pallor, DOB and swelling on her both legs worsen her condition, thus prompted her husband to
confine her at Dr. Jose P. Rizal Memorial District Hospital.
On the 6
th
day of August 2014 at around 5:15 in the afternoon the patient was admitted at Dr. Jose P. Rizal Memorial
District Hospital with a chief complaint of DOB and Pallor with an admitting diagnosis of CKD, 2 to DM Nephropathy
Anemia 2

IV. Past Medical History
According to Patient M she has diabetes since 2010 thats why she has a maintenance drug Globaxol and glimepiride.
Last 2011 she undergo amputation on her left second digit on feet. And last 2013 she undergo another amputation on her
right hand index finger.


V. Family History







VI. Functional Assessment
A. Health Perception/Health Maintenance
She used to buy some over the counter drug whenever she had a common disease, but if she dont
have money she just get some herbal medicine like: lagundi,bayabas,oregano. Shes not regularly go
to Brgy. Health Center and sometimes shes busy doing household chores.

B. Self-esteem/self-concept/self-perception pattern
The client describes herself as a jolly, calm and relaxed person. She is a sociable and friendly
person. She loves to make joke to her friend.
C. Activity/Exercise Pattern
Patient VS usually does active activities at home like cooking, clean the house, do the dishes.
Sometime she walks at morning like 3 days in a week.
D. Sleep/rest pattern
The client has no difficulty of going to sleep. According to her, she sleeps 5-6 hours.
E. Nutritional/Elimination
Patient VS love eating vegetables such as pechay, kangkong mostly green leafy vegetables.
According to her she drinks 6-7 glass of water every day. She hates junk foods.
F. Sexuality/Reproductive
Patient said that shes not active because she dont have partner.
G. Interpersonal Relationship
About her relationship with others she considered herself as friendly. She also said that shes open
whenever her friend has a problem she can help it but not in terms of financial.
H. Coping Stress Management/ Tolerance pattern
The patient is open to her family about her problems. But then, with regards to her sickness, she
never complained about it. She kept it to herself as long as she can tolerate it.
I. Personal Habits
She does some of household chores whenever her relatives go to their work, she left alone thats
why she do cooking, cleaning she house.