BULACAN STATE UNIVERSITY

COLLEGE OF NURSING
City of Malolos, Bulacan

INDIVIDUAL NURSING CARE PLAN

Patient’s Initial: XYZ Age: 28 Gender: FemaleDate Handled: October 11, 2021 Medical Diagnosis: 36 weeks AOG and OB scoring of G2P1-T1P0A0L1.

Chief Complaint: Difficulty in sleeping Hospital: Bulacan State University Medical Center Ward/Clinical Area: OB WARD

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:  Disturbed sleeping
The patient verbalized
“Madali ako magising
pag may
naririnig akong ingay
at nahihirapan na
akong makatulog ulit”.
Objective:
 Frequent
urination at night
 Pain on near
client buttocks
 Chest pressure
 Easily wake up
due to noises
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Short Term Goal: Independent: Short Term Evaluation:
pattern r/t  After 30-60  Assess client’s usual sleep  To ascertain
incontinence and minutes of health patterns and compare with intensity and  After doing the
environmental teaching the client current sleep disturbance, duration of nursing intervention
barriers as will verbalize relying on client/significant problems. the goal to make the
evidence by understanding on other (SO) report of patient verbalize
frequent sleep disturbance. problem. understanding on
awakenings, pain As well as sleep disturbance. As
discomfort and interventions that well as interventions
chest pressure. will promote sleep.  Minimize sleep-disrupting  To promote that will promote sleep
factors (e.g., shut room readiness for was:
door, adjust room sleep and
Long Term Goal: temperature as needed, improve sleep _/_Met
 After 1-2 weeks of reduce talking and other duration and __Partially met
continuos nursing disturbing noises such as quality. __Unmet
intervention the phones, beepers, alarms).
client will be able
to sleep  Teach the client to elevate  Elevating the
consistently the head of the bed by head will
without any adding some pillows in promote chest
disturbances. head or position the client in expansion, and
semi-fowlers position. semi-fowlers
position can be
used when the
patient faces
difficulty in
breathing. Long Term Goal:
  After doing the
 Provide bedtime care such  To promote nursing
as straightening bed physical comfort intervention the
sheets, changing damp goal to make the
linens or gown, back client sleep
massage. consistently
 Voiding before without any
 Promote voiding on the bedtime can disturbances was:
client before sleeping. limit the
_/_Met
disturbance in __Partially met
sleeping as __Unmet
related to
urinary
frequency at
night.
Dependent:
 Give medications if  Following
prescribed by the physician. physician order
it will help the
patient to
recover easily.

 Administer relaxation  .Relaxation

therapies as the doctor therapies will
prescribes. help the client to
sleep
comfortably.

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 Interdependent/
Collaborative:  For specific
 Refer to sleep specialist as interventions and/or
indicated. therapies, including
medications,
biofeedback.
 The client can do some
therapy or medications by  For specific
the help of sleeping interventions
specialist or pharmacist. and therapies,
including
medications and
biofeedback that
helps the
betterment of
client.

Student’s Name: Kervin Jude D. Manahan Yr &Sec/Group No. 2B/G4 Clinical Instructor: Mrs. Charmaine Dale Robles

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