Soriano, Patricia Marie Ann A.

NR-41

Nursing Diagnosis: Sleep deprivation related to orbital mass on the left eye.
Inference: It all starts in a simple hordeolum, and got infected to dirty water with staphylococcal aureus to cause an orbital mass. The sleep-rest pattern of
the patient is affected because of the of this orbital mass.

Assessment
Subjective cues:
Di ako masyadong
makatulog dahil sa bukol ko
as verbalized by the patient.

Expected Outcome
Long term goal: After 2-3
days of nursing intervention
patient will able to have an
adequate sleep pattern.

Objective cues:
General survey: alert,
coherent not in distress
Physical exam: Eye- orbital
mass on the left side
Usually sleep for about 4 to
5 hrs not continuously.

Short term goal: After 8

hrs of nursing intervention
patient will able to verbalize
plan that provides adequate
time for sleep.

Intermittent sleep and

lethargic
Usually opens his eyes
and closes after a few
minutes.

Intervention
Independent:
Obtain a sleep history
bedtime routines and
sleep patterns. From
the history, assess
factors leading to
sleep deprivation.
Assess for chronic
insomnia
Minimize factors that
disturb the clients
sleep.
Keep the sleep
environment quiet.
Encourage napping as
a way to compensate
for sleep deprivation.
Set a regular schedule
for napping.
Dependent:

Collaborative:

Rationale

Evaluation

Soriano, Patricia Marie Ann A.

NR-41

Sleep/Rest

Concept Mapping

Activity
intolerance r/t
mass on left eye

Needs
assistan
ce in
performi
ng
activities
of daily
living
(ADLs)
such as
eating

Medical Dx: Neglected

Carcinoma

Activity
Exercise

P.A: Eye- Orbital mass

Blurred vision
Proptosis
Laboratory result:
WBC- 13.3

Sleep deprivation r/t

orbital mass on left
eye
Ineffective community
therapeutic regimen
management r/t
difficulty modifying
personal habits

Intermittent
sleep and
lethargic
Usually
opens his
eyes and
closes after a
few
minutes.

Health
Perception and
Health
management

Hx of
smoking
Hx of
Alcohol
beverang
e drinker
Hx of
used
marijuan