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Saint Joseph College Institute of Health Sciences Cavite City NURSING CARE PLAN PERSONAL DATA Name: Mary

Lyn Santos Address:Blk. 2 Lot 7 Annex, Imus Cavite ASSESSMENT Cues/Evidences Nursing Diagnosis Subjective: Hindi ako makatulog ng maayos sa gabi as verbalized by patient. Sleep pattern disturbance related to environmental changes secondary to hospitalization as evidenced by early morning awakening, difficulty in falling or remaining asleep, restlessness, complaints of not feeling rested and patients verbalizes: Hindi ako makatulog ng maayos sa gabi Scientific Rationale Predisposing Factors: Environmental Disturbances and Stressors Neurological disturbances Impaired Reticular Formation Function Manifestation of difficulty of sleeping Sleeping Pattern Disturbances Age: 27 Room No: PLANNING Nursing Objective At the end of my 8hour shift, after medical and nursing intervention, the patient achieves optimal amounts of sleep as evidenced by rested appearance, late awakening, ease in sleeping and maintaining sleep, no complaints of unrested feeling and patients verbalizes: Nakakatulog na ako ng mahimbing. Sex: F Bed No: IMPLEMENTATION Nursing Order/Action Scientific Rationale
Independent

EVALUATION
At the end of my 8-hour shift, after medical and nursing intervention, goal was partially met. The patient slightly achieves optimal amounts of sleep as evidenced by rested appearance, late awakening, ease in sleeping but difficulty in maintaining sleep, still complaints of unrested feeling and patients verbalizes: Medyo nakakatulog na ako.

Maintain environment To promote restful sleep. conducive to sleep. Assist patient in observing To promote relaxation. previous bedtime ritual. Provide nursing aids (back relaxation. rub, bedtime care, pain relief, comfortable position, relaxation techniques). Organize nursing care. Increase day time physical activities as indicated.
Collaborative To promote rest and

Objective: -early morning awakening -difficulty in falling or remaining asleep -restlessness -complaints of not feeling rested

To promote minimal interruption in sleep/rest.

To reduce stress promote sleep

and

Administer hypnotics as Use of hypnotics medications ordered and evaluate should be thoughtful and avoided if less aggressive effectiveness.
means are effective because of their potential for cumulative effects and generally limited period of benefit.

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