ASSESSMENTNURSING

DIAGNOSISPLANNING

NURSING INTERVENTIONS

RATIONALE EVALUATION

Subjective:

Disturbed sleep pattern

r/t environmental factors such as giving of medication, vital signs monitoring noise and

lighting

Short Term: Independent:>to determine usual sleep pattern and provide comparative baseline

>provides opportunity to address misconception/ unrealistic expectation>this contains ingredients that decreases the ability to fall asleep

>to compensate the lack of sleep

Short Term:“Putol-putol ang tulog ko” as verbalized by the client

Within 1 hour of adequate nursing intervention/ teaching the patient will be able to verbalize understanding of sleep disturbance

>Observe and obtain feedback from client regarding usual bedtime, rituals and number of hours of sleep>determine client’s expectation of adequate sleep>Recommend limiting of caffeine/ alcohol use and eating of chocolate prior to sleep >Advise patient to take a nap

After 1 hour of adequate nursing intervention the patient was able to verbalized understanding of sleep disturbance>Goal metObjective:

>Irritable>lethargic>dark circles under eyes>hyporesponsiveness>less than 6 1/2 hours of sleep

Long Term:After the shift of adequate nursing intervention the patient wasn’t able to improve sleeping pattern.>Goal not met

Long Term:

Within the shift of adequate nursing intervention the patient will be able to report improvement in sleep/ rest pattern and increase sense of well-being and feeling rested