NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective Short term goal: 1. Assess past patterns 1. Sleep Patterns are unique to Short term goal:
cues: of sleep in normal each individual
Disturbed Within 4 hours of After 4 hours of nursing
Sleeping Pattern environment: amount,
“Nahihirapan nursing interventions the patient
ako related to interventions the bedtime rituals, depth, was able to verbalize
makatulog, Anxiety patient will be able length, positions, aids, concerns and reasons
secondary to and interfering agents.
parang laging to verbalize towards difficulty with
Panic Disorder
gumagana concerns and sleeping as evidence by “I
yung utak ko.” reasons towards 2. Assess patient's 2. Knowing the specific etiologic had a disturbing
difficulty with perception of cause of factor will guide appropriate experience back then.”
sleeping sleep difficulty and therapy.
Objective possible relief
cues: measures to facilitate 3. Knowledge of its role in Long term goal:
Long term goal: treatment. health/wellness and the wide
- Verbali- After 4 days of nursing
variation among individuals may
zations of dis Within 4 days of interventions the patient
satisfaction nursing 3. Identify factors that allay anxiety, thereby promoting was able to achieve
with sleep interventions the may facilitate or rest and sleep. optimal amounts of
pattern patient will be able interfere with normal sleep as evidenced by
to achieve optimal patterns. Decreased tiredness and
- Problems
amounts of sleep  having 8 hours of sleep
with 4. This promotes regulation of
each day
concentration 4. Instruct patient to the circadian rhythm, and
and memory follow a consistent daily reduces the energy required for Goal met
- Interrupted schedule for retiring adaptation to changes.
sleep and arising as possible

- Decreased 5. Provide nursing aids

quality of life (e.g., back rub, bedtime 5. To promote rest.
care, pain relief,
- Awakening
comfortable position,
earlier or later
than desired relaxation techniques).

6. Introduce relaxing 6. These activities provide

activities such as warm relaxation and distraction to
bath, calm music, prepare mind and body for sleep.
reading a book, and
relaxation exercises
before bedtime.

7. Encourage daytime
7. In insomnia, stress may be
physical activities but
reduced by therapeutic activities
instruct the patient to
and may promote sleep.
avoid strenuous
However, strenuous activities
activities before
may lead to fatigue and may
bedtime.
cause insomnia.

8. Prevent the patient

8. Providing a designated time
from thinking about
for these concerns allows the
next day’s activities or
patient to “let go” of these
any distracting
problems at bedtime.
thoughts at bedtime.
 9. Evaluate timing or
effects of medications
9. In both the hospital and home
that can disrupt sleep.
care setting, patients may be
10. Document findings following medication schedules
on the client records that require awakening in the
early morning hours.
Dependent Nursing
Interventions:
10. For baseline purposes
1. Administer the
appropriate
medications prescribed
by the attending
physician In order to lessen the difficulty
with sleeping
Collaborative Nursing
Interventions:

1. Collaborate with the

healthcare team to
monitor prescribed
medical needs and to
In order to attain a good
formulate psychosocial
treatment plans prognosis for the patient
befitting for the patient