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Bancure BSN3A Nursing Care Plan Assessment Subjective: “di ako makatulog kasi puro na lang sakit sa katawan yung nararamdaman ko” Objective: • 1hr of sleep per day PTA • 30 mins of sleep per day upon admission • frequent yawning at daytime during assessment • overall body malaise • pain(8 out of 10) • dark circles around the Nursing Diagnosis Sleep Deprivation related to pain and discomfort on perineum secondary to labor and delivery Analysis Prolonged periods of time without sleep. (NANDA, 11th edition , pp. 630) Goals Short Term After 3 hours of nursing intervention, the client will: • report decreased feeling of discomfort as manifested by verbalizing feeling of comfort (5 out of 10) • Achieve at least 5-6 hours of continuous sleep per day • Show signs of decreased yawning at daytime • Report decreased body malaise Long Term After 3 days of nursing intervention the client will: • Be able to reestablish and maintain normal sleep pattern • achieve 7-8 Interventions Independent • Identify presence of related factors that can contribute to sleep deprivation. • Position client in a comfortable position • Provide comfort measures (touch, quiet environment, dim light, light music) Rationale • To identify causative/ contributing factors. Evaluation Short Term : After 3 hours of nursing intervention, the short term goal was met as evidenced by: • Reported pain relief (5 out of 10) • Pt was able to achieve 6 hours of continuous sleep that day • decreased yawning at daytime • reported decreased overall body malaise
• To alleviate discomfort • To distract attention on pain, reduce tension and to promote non pharmacologic al pain management • To provide comparative baseline • To help in providing better
• Assess sleep pattern
Kristine Rielly L. Bancure BSN3A eyes hours of continuous sleep per day • report absence of body malaise • report further alleviation of pain (3 out of 10) • absence of frequent yawning • Provide a quiet and peaceful environment during sleep periods • Encourage the client to express concerns when unable to sleep • Provide a warm bath before the client goes to sleep • Expose perineum on perilight bid for 15 mins • To induce sleep Dependent • Prescribe sedatives (Valium) as ordered sleep/rest After 3 days of nursing intervention the short term goal has been fully met as evidenced by: • reported increased periods of sleep of 8 continuous hours per day • absence of frequent yawning • established sleep pattern • reported pain scale of 3 out of 10 • reported absence of body malaise
T: 37.4 P: 86 beats/min. R: 20 cycles per BP: 110/70 mmHg
• Verbalizing concerns may promote relaxation • Vasodilation of the veins provide a sleepy, lazy effect, causing the client to fall right to sleep • To provide comfort
Kristine Rielly L. Bancure BSN3A