ASSESSMENT NURSING N PLANNING/ INTERVENTION EVALUATION

DIAGNOSIS E SPECIFIC OUTCOME

E
D
S
Subjective: Disturbed sleep S After the nursing 1. Monitor the patient’s Vital GOAL MET
Patient verbalized pattern related to L interventions patient signs.
“Dili ko katarong noisy environment. E will be able to RATIONALE: Patient’s vital
E demonstrate;
tulog kay mag signs will indicate significant
Rationale: P
sabay hilak ang Goal: changes to the patient that
mga bata.” Sleep patterns can  Improvement of needs immediate attention.
be affected by E sleep pattern
Objective: environment, N  Absence of 2. Encourage daytime physical
VITAL SIGNS especially in the H activities but instruct the
hospital setting A restlessness.
BP: 100/70 patient to avoid strenuous
where noise, N activities before bedtime.
RR: 25/min Objectives:
lighting, frequent C RATIONALE: Disturbed sleep
PR: 88 monitoring, and E  Verbalization of may be reduced by
Temp: 36C treatments are M feeling rested. therapeutic activities and may
always E  Decrease promote sleep. However,
2. O2 sat: 97% N presence of eye strenuous activities may lead
T bags. to fatigue and may cause
3. Capillary reffil insomnia.
test: <2 secs.
3. Instruct the patient to follow
a consistent daily schedule for
4. Yawning noted
rest and sleep.
RATIONALE: Consistent
5. Restlessness
schedules facilitate regulation
of the circadian rhythm and
6. Appear weak. decrease the energy needed
for adaptation to changes.
7. Patient’s eye References:
bags are visible. 4. Remind the patient to avoid
taking a large amount of fluids
8. Dark circles before bedtime.
Doenges, M.,
around the RATIONALE: This will refrain
Moorhouse, M.
patient’s eyes are the patient from going to the
and Murr, A.
noted. bathroom in between sleep.
(n.d.). Nurse's
pocket guide.
5. Encourage patient to take a
bath and other relaxing
activities.
Gulanick, M., & RATIONALE: These activities
Myers, J. L. provide relaxation and
(2010). Chapter distraction to prepare mind
1Ingestion. In and body for sleep.
Nursing Care
Plans: Diagnoses, 6. Do as much care as
Interventions, and possible without waking up the
Outcomes (7th patient and so care as much
ed., p. 199). St. as possible when the patient is
Louis, MO: awake.
Elsevier Health RATIONALE: To avoid
Sciences disturbances during sleep and
to maximize sleep.

7. Encourage patient to use

eye mask/ cover.
RATIONALE: A lot of people
sleep better when it is dark.
8. Attempt to allow for sleep
cycles at least 90 minutes.
RATIONALE: Research
shows that 60 to 90 minutes
are necessary to complete
one sleep cycle and that
completion of an entire sleep
cycle is beneficial.

9. Render bedtime nursing

care such as back rub and
other relaxation techniques.
RATIONALE: These kinds of
activities facilitate relaxation
and promote the onset of
sleep.

10. Eliminate any activities

that are not important.
RATIONALE: This measure
facilitates minimal interruption
in sleep or rest.
References:

Doenges, M., Moorhouse, M.

and Murr, A. (n.d.). Nurse's
pocket guide.

Gulanick, M., & Myers, J. L.

(2010). Chapter 1Ingestion. In
Nursing Care Plans:
Diagnoses, Interventions, and
Outcomes (7th ed., p. 199).
St. Louis, MO: Elsevier Health
Sciences