St.

Paul University Philippines

Tuguegarao City 3500 Cagayan

School of Nursing and Allied Health Sciences

College of Nursing

Nursing Care Plan

Assessment Diagnosis Background Planning Intervention Rationale Evaluation

Knowledge
Subjective Disturbed Sleep is required NOC: Sleep NIC: Sleep GOALS MET
Data: Sleep Pattern to provide energy Enhancement
During the related to for physical and Goal:
interview the fatigue as mental activities.
client’s major evidenced by The sleep-wake After nursing Establish rapport To gain the
problem and verbalizations cycle is complex, intervention, the with the patient trust of the The client was
concern right of activities consisting of client will be able to and therapeutic patient able to
now is how and all things different stages acquire optimal communication. involved. acquire optimal
will handle her contributing of consciousness: amounts of sleep as amounts of sleep
stress on the of stress. rapid eye evidenced by rested as evidenced by
given task movement appearance, rested appearance,
such as (REM) sleep, verbalization of Monitor and To detect any verbalization of
modules and nonrapid eye feeling rested, and recorded the changes or feeling rested, and
activities and movement improvement in patient’s vital deterioration improvement in
all the things (NREM) sleep, sleep pattern. signs. on vital signs. sleep pattern.
contributing to and wakefulness.
her stress The amount of
resulting her sleep that
not to get individuals SHORT TERM: Assess client's Information After nursing
enough sleep require varies sleep patterns and about this topic intervention the
After an hour of
at night. with age and nursing intervention provides client was able to:
personal the client will be usual bedtime baseline data
Objective characteristics. able to: rituals and for evaluating
Data: incorporate these means to
Noticed that into the plan of improve the  Opened
the mother  Open about care. patient’s sleep. about her
was not her current current
getting enough situation and situation
sleep share her and shared
experiences. her
For short term experience
Assess patient’s problems, s.
perception of patients may
cause of sleep have insight
difficulty and into the  Verbalize
 Verbalizes possible relief etiological d plan to
plan to measures to factors of the implement
implement facilitate problem. bedtime
bedtime treatment. Knowing the routines.
routines specific
etiological
factor will  Performed
 Perform guide proper
proper appropriate technique
technique of therapy. of sleep
sleep relaxation.
relaxation.

Most people
Provide adequate need at least
knowledge patient six hours sleep
LONG TERM: about their sleep for normal
 memory and The client was
After a week of requirements. brain function. able
nursing
interventions, the  Maintain
client will be able positive
Teach patient To divert outlook
 Maintain proper sleep attention from towards
positive relaxation such stress. health and
outlook as: Deep health
towards Breathing care.
health and Techniques.
health care.

Consistent
Instruct the schedules
patient to follow a facilitate
consistent daily regulation of
schedule for rest the circadian
and sleep. rhythm and
decrease the
energy needed
for adaptation
to changes

To promote
Encourage the sleep by
client to establish therapeutic
a bedtime routine activities.
to facilitate
transition from
wakefulness to
sleep.