Name of Student: Carla Mae T.

Maravilla Sec on: C Group number: 3

NURSING CARE PLAN
Assessment Cues Nursing Diagnosis (Ra onale) Desired Out- Nursing Interven- Jus ca on Evalua on
Pathophysiologic / Schema c come on
Diagram

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 Subjective: Insomnia related to ex- Predisposing Factors: Short term: Independent: After 8 hours of nursing in-
cessive hyperactivity as - to determine usual terventions, goal met. Patient
“ Na budlayan gid ko ya mag tulog evidenced by difficulty - Biological (Genetics/biochemical) After 8 hours of ade- - observe and obtain sleep pattern and verbalized understanding of
kag 3-4 hours lang akon tulog permi” falling asleep and sleep- quate nursing interven- feedback from. Client provide compara- sleep disturbance .
as verbalized by the patient. - Physiological (Neuroanatomical tion/teaching the patient regarding usual bed-
ing only short periods at a factors) tive baseline
time. will be able to verbalize time, rituals and num- After 3 days of nursing in-
- Medication side effects understanding of sleep ber of hours of sleep terventions, goal met. Patient
Objective: disturbance. Client was able to sleep 6 to
- Recommend limiting of - This contains in-
caffeine/alcohol use gredients that de- 8 hours per night and was
- Restless able to fall asleep within 30
Precipitating factors: and eating of chocolate creases the ability
- Grandiosity prior to sleep to fall asleep minutes of retiring.
- Stress
- Hyper mood Definition:
- Sleep deprivation
- Elevated activity A disruption in amount
and quality of sleep that - Goal-attainment events
impairs functioning
Vital signs: Long Term: Dependent:
Signs and symptoms
BP- 110/80 After 3 days of nursing - Administer sedative
- elation and euphoria care, with the aid of a medications, as ordered,
PR- 82 sleeping medication, to assist client achieve
- Alteration in thought processes and client will sleep 4 to 6
RR- 15 Source/Reference communication patterns sleep until normal sleep
hours without awaken- pattern is restored.
T- 37 C NANDA - Motor activity is constant ing.

- Meager appetite
Strength:
- family support Pathophysiology
- Treatments and medications are Genetics
given

Neurotransmitter Imbalances

Abnormal Neurocircuitry

Environmental Factors

Inhibitory control of emotional cir-

cuitry