Republic of the Philippines

CAVITE STATE UNIVERSITY

Don Severino de las Alas Campus
Indang, Cavite
(046) 415-0010 / ((046) 415-0011
www.cvsu.edu.ph
cvsu.op206@gmail.com

COLLEGE OF NURSING

RELATED LEARNING EXPERIENCE

NAME: D.B DATE: October 24, 2019

COURSE/YEAR/SECTION/GR. NO.: BSN 2-3/ GR. NO. 2 AREA: Bancod, Indang , Cavite

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective data Disturbed sleep After 2 hours of >Determine the >Sleep problems can
"Hindi ko na e-enjoy pattern related to pain rendering nursing factors known to be caused by different
yung tulog ko kasi as manifested by intervention, the client interfere sleep factors that needs to
hindi sapat, madalas feeling unrested and will be able to: be assess.
pa akong magising ng dissatisfaction with >Determine the
madaling araw dahil sleep >Verbalized the client’s sleep >Individuals may have
sa sakit ng katawan." importance of sleep. expectation faulty beliefs, attitudes
and unrealistic
Objective Data: >Discussed the >Assess the client’s expectations about
•Presence of dark negative effects of not usual sleep pattern sleep.
circles on the eye having enough sleep and compare with
•Yawning current sleep >To ascertain the
•Restlessness >Discussed the disturbance. intensity and durations
•Taking a nap when possible factors that of problems.
there is a free time. causes pain while >Assist the client to
sleeping stablish optimal >Allows for longer
Pain scale of 5/10, (1 sleep/rest pattern periods of
being the lowest and LONG TERM: uninterrupted sleep,
10 as highest) on the especially during
upper back part that >reduce the presence night.
last for 1-3 minutes of dark circles on the
every 1-3 am in the eyes.
morning
>Report optimal
 balance of sleep.

Vital Signs: >No evidence of >Conduct health >To impart new

restlessness. teaching regarding the knowledge to client
T= 36 °C importance of sleep and correct client’s
PR= 70 bpr >Verbalize feeling of and the negative misconception about
RR= 20 cpm well rested upon effects of not having sleep.
BP= 100/70 mmHg waking up enough sleep.

>Minimize number of >Provide 1 week >To monitor client’s

yawning monitoring sheet sleep pattern for the
whole week even
>Verbalize absence of without the nurse’s
pain during sleep. supervision.

>Fill up monitoring
sheet for sleep pattern
for 1 week

______________________________________
Clinical Instructor