Name: C.GAge: 27, FWard & Room No.: St.

Mary, 254
Chief complaint: Post- CSAttending Physician: Dr. Fuentes
Final Diagnosis: G2P1 (1012), pregnancy uterine, term, 37 weeks by Ballard score, cephalic-transverse lie in presentation, delivered
to a live twin A baby boy, and twin B baby boy by primary low segment transverse cesarean section for malpresentation; multifetal
gestation (dichorionic/diamniotic)

DAT CUES NEE NURSING DIAGNOSIS PATIENT INTERVENTION IMPLEME EVALUATION

E D OUTCOME NTATION
M SUBJECTI S Disturbed sleep pattern Within 2 INDEPENDENT: MARCH 4,
VE: related to hospital routines days of 2020 @ 3 PM
A L
as evidenced by verbal nursing
“Taod-taod
R E reports of not feeling care, the Establish rapport with the 1
naay naga
rested. patient will: client. GOAL
C sulod, mu- E
PARTIALLY
mata pud R: Good therapeutic
H P MET
ko.” relationship can improve
RATIONALE: a. Report
general state of well-being.
improveme
Being admitted in the
3 nt in a. The patient
hospital would mean
sleep/rest reported, “Mas
“Graveyard / frequent monitoring of the Provide comfortable
pattern arang-arang na
shift man patient which is necessary bedding such as extra
2 2 akong tulog
gud ko, so to provide care for the pillows or blankets.
karon kaysa
inganing clients. Health workers of
0 R b. Verbalize R: Increases comfort for gahapon”
orasa tulog different areas make this
increased sleep providing
2 pa ko E possible, such as
sense of physiological and
usually.” administering medications,
0 S well-being. psychological support. b. The patient
monitoring vital signs
every four hours, and verbalized,
T
drawing blood to monitor “Worth it
“2 hours
7 the patient’s condition. c.Be able to Encourage light activities gihapon ni
palang
express that such as reading, watching maam kung
akong
she is TV, or socializing and stop makagawas
A tulog” satisfied activities several hours nako kay maka
with her before bedtime, as bonding na ko
M REFERENCE: 3
rest. appropriate. sa akong mga
Ubel, P. (2015). Sleep anak.”
R: daytime activity can help
Deprivation in Hospitals Is
expend energy and be
A Real Problem. Retrieved
ready for night time sleep.
from c. The patient
https://www.theatlantic.co expressed that
OBJECTIV m/health/archive/2015/06/ she is still not
E: Encourage to have a
sleep-deprivation-in- satisfied with
roommate or watcher who
-Grimaced hospitals-is-a-real- the interrupted
have similar patterns and
face problem/276960 on March rests she has
nocturnal needs.
8, 2020. been
R: Decreases the likelihood experiencing
that “night owl” roommate because of
-visible
may delay client’s falling frequent
fatigue
asleep. monitoring and
4 administration
of medications.
-restless
Promote bedtime comfort
such as massage.
-not using R: To promote relaxing and
pillows. soothing effect.

Reduce noise and light

during bedtime.
R: To provide atmosphere
conductive for sleep. 5

Encourage position of
comfort and assist in
turning, if needed.
R: Repositioning reduces
pressure on tissues,
enhance muscle relaxation 6
and promotes rest.

Limit interruptions such as

awakening for medications.
R: Uninterrupted sleep is
more restful, client may be
unable to return to sleep
when awakened. 7

Limit the amount of visitors

within late afternoon or
night time.
R: Frequent visiting can
interrupt with the promotion
of sleep or rest.

8
DEPENDENT:

Administer sedative or
hypnotics with caution, as
indicated.
R: May be given to help
client sleep or rest during
transition period from home
to new setting.

MA. CHELIZ
FELICIA M.
TUPAZ, ST.N

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