CHINESE GENERAL HOSPITAL COLLEGE OF NURSING
NURSING CARE PLAN
Assessment
Subjective data:
-“Mga apat na oras lng ata
ako nakakatulog sa gabi
tapos paputol-putol pa,
kumikirot parin kasi yung
sa loob eh” as verbalized
-“sa umaga paidlip-idlip
naman ako, binabawi ko
yung tulog sa gabi” as
verbalized
Objective data:
-appears restless
-pain scale of 7/10
-irritability
-frequent yawning during
assessment
Diagnosis Planning
Sleep deprivation related to pain and Short term goal:
discomfort secondary to trans-urethral After 3 hours of nursing
resection of the prostate intervention, the client will
be able to identify
Inference: appropriate interventions
Trans-urethral resection of the prostate to promote sleep as
involves a surgical removal of the inner manifested by:
portion of the prostate through an -Explaining atleast two
endoscope inserted through the urethra management in promoting
which can cause post-operative pain to sleep.
the patient. Pain can lead to anxiety, -Verbalize understanding
sleep deprivation of sleep disorder
-shows decrease in being
irritable
Reference: Long term goal:
http://www.jjs.me.uk/teaching/acutepain After 2 days of nursing
Smetltzer, S., Bare, B., Hinkle, J. and intervention, the client will
Cheever, K. 12th ed. Medical-Surgical be able to establish a
Nursing. normal sleeping pattern as
evidenced by:
-reports decrease feeling
of discomfort
-decrease of yawning
during daytime
-absence of being irritable
-reports prolonged and
continues sleeping hours
during night.
-being active during
daytime
Intervention
Independent:
-Position client in a
comfortable position
-provide comfort measures
such as quiet environment
and dim light
-assess sleep pattern
-encourage the client to
express concerns when
unable to sleep
-provide a warm bath
before the client goes to
sleep
-Suggest abstaining from
daytime naps
-investigate anxious
feelings
-limiting fluid intake before
sleeping
Rationale Evaluation
Short term goal: FULLY
-to alleviate discomfort and MET
promote sleep
To distract attention on
pain, reduce tension and to Long term goal: PARTIALLY
promote non MET. Because of time
pharmacological restriction, some of the
management outcomes wasn’t able to
be observe. The client was
only able to show absence
-to provide comparative of being irritable and also
baseline show’s decreased in
yawning.
-verbalizing concerns may
promote relaxation
-Vasodilation of the veins
provide a sleepy, lazy
effect, causing client to fall
to sleep
-because they impair ability
to sleep at night
-to help determine basis
and appropriate anxiety-
reduction techniques
-to reduce need for
nighttime elimination
CHINESE GENERAL HOSPITAL COLLEGE OF NURSING
NURSING CARE PLAN

-Discuss effective age- -To enhance client’s ability

appropriate bedtime rituals to fall asleep

Dependent:
-Prescribe sedatives as -to induce sleep
ordered