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Client’s Name: Somonia,, Ina Age: 38 years old

Gravida- 2, Para- 1, Abortion- 0 MMPerez Lying-In


Clinic

Date Cues Nee Nursing Goal and Nursing Interventions Evaluation


and d Diagnosis Objectives of
Time Care
Subjective Data: S Sleep pattern That within my 8- 1.) Establish rapport September 14, 2006
Client verbalized, L disturbance related hour span of care, my ® To gain cooperation with the client. @ 7:00 AM in the morning
S 2.) Monitor Vital signs
E “Dili ko ka E to inability to patient will be able to
tarung tulog kay E maintain comfort have enhanced sleep ® To have a baseline data GOAL MET
P 3.) Review normal sleep requirement changes
T mag sige ko ug P secondary to and rest pattern as
associated with pregnancy. Determine current
E mata-mata kay - pregnancy. evidenced by: At the end of my 8-hour span
sleep pattern.
M mo sakit akong R ® Helps identify need for establishing of care, the patient was able to
B tiyan” E ® Time-limited a.) identification of different sleep pattern. enhance her sleep and rest
E S disruption of sleep individually 4.) Suggest side-lying position with pillow pattern as evidenced by:
R Objective Data: T amount and quality. appropriate between legs for support, or place bed board
During last interventions to under mattress. a.) report of improvement in
13, - irritability P trimester of promote sleep. ® Back discomfort may necessitate change in sleep/rest pattern as
- restlessness A pregnancy, most of position, use of multiple pillows/body pillow, verbalized, “Hay salamat!
- lethargic T pregnant mother b.) report of or firmer matteress. Nakatulog jud ko ug tarong.”
2006 5.) Evaluate level of fatigue; encourage client
@ - mild fleeting T have difficulty in improvement in
to rest 1-2 hr daily and obtain 8 hr of sleep at
11:00 PM nystagmus E maintaining a good sleep/rest pattern. b.) identification of specific
night. Give information about normalcy of
- ptosis of eyelids R sleep and rest interventions to promote sleep
moderate fatigue. Reassess commitments to
- frequent N pattern, most c.) report of increased work and family. as verbalized, “Mas maayo
yawning especially during sense of well-being ® Increase fluid retention, weight gain, and diay kung nay unlan sa akong
- dark circle pre-labour. and feeling rested. fetal growth all contribute to feelings of tiil banda tapos nakatagilid
under eyes fatigue, especially in the multipara with other ko.”
- changes in Bibliography: children and demands.
posture Doenges, Marilyn. 6.) Assess for occurrence of insomnia and for c) report of increased sense of
- RR= 28 cpm Nurses clients response to sleep loss. Suggest aids to well-being and feeling rested
Pocketguide. sleep, such as relaxation techniques/tapes, as verbalized, “Mas nag-okey
readings, warm bath and reduced activity just
Diagnosis, akong paminaw run kay
before retiring.
Interventions, and tarong akong tulog.”
® Excess anxiety, excitement, physical
rationales. F.A. discomforts, nocturia, and fetal activity all
Davis company. may contribute to sleeping difficulties.
Philadelphia © 7.) Note reports of positional breathing GASATAN, MA, St. N
2003 p472 difficulties.
Suggest sleeping in a semi-fowlers position.
® In a recumbent position, the enlarging
uterus and the abdominal organs compress the
diaphragm, thereby restricting lung
expansion. Use of semi-fowlers position
allows the diaphragm to descend, fostering
optimal lung expansion.
8.) Do a chronological chart
® To determine peak performance rhythm.
9.) Determine clients/SO’s expectations of
adequate sleep.
® Provides opportunity to address
misconceptions/unrealistic expectations.
10.) Refer client for counseling if sleep
deprivation/ fatigue is interfering with
activities of daily living.
® Additional support/guidance may be
necessary for client to cope with alterations in
sleep-wake cycle, identify appropriate
priorities, and modify commitments.
Criteria:
Nursing Care Plan Cues and Needs 10%
Nursing Diagnosis 15%
Objective of care 10%
In Partial Fulfillment Nursing Interventions 50%
Evaluation 5%
Of the Requirements Bibliography 5%
In PHC-RLE Promptness 5%
100%

Submitted to:
Ms. Alma M. Perez, RN
Clinical Instructor

Submitted by:
Mark Anthony E. Gasatan, St. N
BSN3R-Group 4

September 15, 2006