ASSESSMENT DIAGNOSIS BACKGROUND PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective Data: Disturbed sleep Change in sleep- SHORT TERM  Establish rapport  To promote trust. Goal met as evidenced
Client verbalized pattern related to wake schedule. GOALS: by interventions
that she gets to physiological  After 20-30  Assess the patient’s  Sleep patterns may identified by the
sleep just a little interruption such minutes of sleep pattern and take vary for each patient to increase and
because of her as frequent Decreased REM nursing note of the following: individual. promote her duration
frequent urination urination. intervention, the the amount of sleep, Evaluating these of sleep.
of at least 5times patient will position, sleep patterns will provide
per night before Impaired identify at least routine, position, general information
hospitalization. processing of one individual depth, extent, and and details on
information in the appropriate interferences. certain areas of sleep
brain intervention to that need to be
promote sleep. addressed or
 After 2 hours of improved.
Decreased nursing
oscillations interventions,  Observe for any signs  To attain baseline
the client will of sleep-wake information for the
state two ways problems. Note the investigation of
to improve sleep patient’s hours of insomnia.
Disturbed sleeping pattern such as sleep.
pattern. providing a
quiet  Take note of the  To aid with
REFERENCE: environment physical (e.g., insomnia evaluation
Fundamentals of (straightening background noise, and help with its
Nursing by Taylor, sheets) and discomfort, frequent management.
Page 1178 comfort urination during
measures (back bedtime, pain) that
rub). hinders sleep.
LONG TERM GOAL:  Adhering to a
 After 1 week of  Encourage the client consistent sleep and
nursing to adhere to a rest schedule helps
interventions, dedicated and regulate and manage
the client will consistent sleep and circadian rhythm.
report rest schedule. Meanwhile, drinking
improvement in Suggest drinking less a glass of milk has
quality of sleep water few hours been correlated with
pattern. before going to bed, sleep promotion,
voiding before going mainly because of its
to bed and taking a L-tryptophan
glass of warm milk component.
before bedtime.

 Provide quiet  This provides a

environment conducive
(straightening environment for the
sheets). client to relax.

 Provide comfort  This soothes and

measures (back rub). relaxes the client.

 Arrange care to  To promote

provide uninterrupted wellness.
sleep.

 Explore other sleep  To promote

aids such as warm wellness.
baths.