Name: K.A.

Age: 58 years old

College Department: CAIS Sex: M

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENT EVALUATION

Subjective Cues: After the Nursing
Intervention the client
“nahihilo po ako at will be able to:
nakaka experience ng
nosebleed”  Explain what
he had
“kumakain po ako ng learned about
kanin, isda, at gulay” Elevated Platelet Count elevated After the nursing
1. Assess the
as evidenced by high platelet count interventions, the client
understanding on
“natutulog po ako platelet count from lab  Outline the will be able to
elevated platelet count
atleast 8 hours per day” test and frequent different understand the
2. Provide health
headache, bleeding causes of his concepts and ways to
teaching
from nose condition deal with his condition
Objective Cues:
 Identify
H - 1.68 cm various
W – 75 kg preventions
BMI – 26.6 and
(Overweight) treatment on
BP: 126/70 mmHg his condition
1. Assess the client’s
Bone Marrow Lab diet and lifestyle
After the nursing After the nursing
Results: 2. Assess client’s food
interventions, the client intervention, the client
Overweight intake for the whole day
will have improved has improved health
641 platelet count 3. Provide counseling
lifestyle and nutrition lifestyle
and health teaching

Name: S.DG. Age: 31 years old

College Department: CAIS Sex: F

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENT EVALUATION

Subjective Cues:
The client sleeps a
maximum of 5 hours
daily. After the nursing 1. Assess the client’s
Fatigue related to After the nursing
interventions, the client physiological state
activity intolerance as interventions, the client
will be able to change 2. Assess the client’s
The client mentioned evidence by sedentary has improved lifestyle
their lifestyle and food intake
having headaches lifestyle and health
improve their health 3. Provide counselling
The client also
mentioned that she
gets tired from doing
Disturbed Sleep Pattern After the nursing 1. Assess the client’s After the nursing
small work
related to lack of sleep interventions, the client sleep pattern intervention, the client
as evidenced by will be able to sleep 2. Encourage the client will have improved
The client mentioned
sleeping only 5 hours properly. to express concern sleep pattern and is
that she has no time to
per day when unable to sleep able to get enough
exercise because she
3. Provide health sleep.
is too busy
teaching

Objective Cues:
The client looks
fatigued

BP: 100/70
P: 80