NURSING CARE PLAN FORMAT

Name:_________________________________ Medical Diagnosis: __________________________________ Date:

_________________
Nursing Assessment Nursing Interventions
Subjective Objective Interventions Rationale
Difficulty falling Dark shadows under 1. Consider the ten rights of patients. To ensure safety.
sleep. the eyes
Appears tired in the
morning
Lack of energy in the 3. Identify circumstances that interrupt To prevent disturbance because of
morning. sleep interruptions.

5. Limit fluid intake in the evening. To reduce need for nighttime elimination/
sleep disruption.
Nursing Diagnosis 7. Assure the patient that occasional Worrying about not sleeping can perpetuate
Insomnia sleepiness should not threaten health or exacerbate the problem.
Problem
9. Encourage participation in regular to aid in stress control and release of
related to inadequate sleep exercise program during daytime. energy.
Related
hygiene.
factor
11. Assist the client to develop an For effective sleep promotion.
As evidenced by look of individual program relaxation.
tiredness and lack of energy in
Defining
the morning.
characteri
13. Assist in Develop sleep relaxation Employing both physical and mental
stics
program such as self-hypnosis progressive relaxation can help minimize anxiety and
muscle relaxation imagery promote sleep.
Nursing Inference 15. Recommend inclusion of bedtime To reduce sleep interference from hunger
Biological, physical, psychological, and snack such as milk or hypoglycemia.
environmental factors that would lead to 17. Administer medication as prescribed. To relieve discomfort and take maximum
Prolong period of stress which development of advantage of sedative effect.
conditioned arousal to stimuli that would 18. Monitor the adverse effect if may To prevent risk of resistance.
normally be associated with sleep and it could occur
turn into repeated difficulty with sleep
initiation, maintenance, consolidation
(insomnia) as evidence by look of tiredness
and lack of energy in the morning.
After 1 week of nursing interventions, patient will be able to develop an interrupted sleep pattern 5-8 hours at
Nursing Plan/Goal night, report feelings of rejuvenated after sleep and establish an effective sleep routine.

After 1 week of nursing intervention, the goal is partially met. Patient was ables to practice relaxation techniques
Nursing before bedtime to promote sleep.
Evaluation
Prof. AltroyVanAgtang