Ateneo de Zamboanga University

College of Nursing
Level II
School Year 2021-2022

A. PERSONAL DATA
Patient’s Name: ____Windia H. Jamil________ Age: ___22____ Sex: ____F____
Patient’s Address: Guiwan, Zamboanga City_______ Nationality: _Filipino___
Place of Birth: Tandubas, Tawi-Tawi___ Religious Affiliation: _Muslim_______

B. DIAGNOSIS
Interview on History of present illness:

Nurse: “Good morning Ms. Windia Jamil. My name is Naiza Hassan, and I am a nursing student of
Ateneo de Zamboanga University assigned to take care of you today. What name would you
liked to be called?

Client: “You can call me Win, that’s what everyone calls me.”

Nurse: “Okay Win, I’d like to ask you several questions about why you are here today. But before
anything else., I want to ask how you are feeling today?”

Client: “I am not sure why I came to the clinic today. I just feel so tired, or should I say sluggish,
and I am having this sense of heaviness in my limbs.

Nurse: “Tell me what you mean by ‘sense of heaviness in your limbs’.”

Client: “I just notice that I move unusually slowly, have high levels of fatigue, low energy, and
drag through the day much of the time.”

Nurse: “What happened that caused you to feel so tired?”

Client: “I believed this fatigue sensation resulted from my sleeplessness. On most days, I
experience problems falling asleep and waking up multiple times in the middle of the night. I
had always liked to stay up at night and it does not interfere with my desire to sleep as I
could easily initiate sleep. However, my sleep pattern had gotten out of hand. I usually began
feeling sleepy by around 12:00 pm. However, as soon as I got into bed, I felt wide awake
despite feeling very tired. I would toss and turn for an hour or two before finally being able to
fall asleep. Once asleep, I slept fine but would then be awake for hours and it would take
another hour to fall back asleep. That’s when I started feeling down, become very sleepy,
have trouble concentrating, and irritable throughout the day. My mind has always been very
active at night, but now I just can’t seem to turn it off.”

Nurse: “How often does this happen? Is it constant or does it come and go?”

Client: “It happens most of the time. I would have difficulty sleeping for several nights, followed
by a few nights of adequate sleep before the problem returns.”

Nurse: “What have you been doing to deal with this sleeping problem? Does it help?”
Client: “In an attempt to get more sleep, I would go to bed earlier than usual and then watch
movies for a few minutes to quiet my brain, only to fall asleep 2 hours later with the Laptop
still on. This was somehow effective because I got 2 awakenings compared to 3 awakenings
which I usually have throughout my sleep cycles but there was no difference in the time for
me returning to sleep. I would also stay in bed for 2 extra hours, hoping to catch up on my
sleep. During the daytime. I would try to take a nap after class. But all of these seems to be
making my sleep issue even worse because I would stay wide awake after snacking on sleep
during the day. I later learned that it is important to remain awake through each day in order
to build up enough sleep drive to produce a full night’s sleep. I am trying to stay awake
during daytime, but it is rarely successful.”

Nurse: “do you take any prescribed medications, over-the-counter (OTC) medications, or herbal
remedies to help you sleep?”

Client: “No, I haven’t tried any sleep medication, nicotine or alcohol, and I’m also not used to
drinking caffeine.”

Nurse: “when do you think this sleep issue began?

Client: “I’ve had this problem for so long. For as long as I can remember, it began when I was in
my first year at college.

Nurse: “What do you think might be causing this problem?”

Client: “I started noticing that my sleep problems and menstruation were linked. The week
before my menstruation can be a time where I can hardly sleep it may be due to the rise and
fall of estrogen and progesterone and then my sleep improves once my period arrives. As a
medical student, I know that hormonal changes can affect the body, feeling and behavior.
But being a medical student who understands the importance of getting enough sleep,
doesn’t make me immune to fall for sleep problem and have to catch myself from time to
time. At first, this wasn’t much of a problem and I decided to ride it out, until I reached 4 th
year at college when there’s increasing academic activities and pandemic just made it worst
for me.”

Nurse: “Tell me more about that.”

Patient: “I think the main contributor to my sleeping problem is my anxiety in a variety of

situations. There are times when life gets in the way of sleep. I am busy during the day, but as
night draws near, in my quiet and safe bedroom, my anxiety comes. The worries aren’t
limited to just one or two topics. I would worry about coping during the day after a poor
night’s sleep, fear of illness and death among my loved ones during this pandemic, dwelling
on pandemic dilemmas, deadlines, or most ominously, the fact that I am not sleeping.
Pandemic has transformed nearly every aspect of life - from how we normally travel, buying
things, to education system. There’s just so many uncertainties about the future. I was just
not prepared for the sudden impact that the pandemic has brought about. The terrifying
scene on hospitals I’ve seen on TV still linger in my head during bedtime. I tried to rein in my
thoughts, but they drifted toward the many things on the to-do list and presentation that
isn’t completely finished for the morning and the following day. “
Nurse: “Go on.”

Client: “Worrying about the success of an upcoming event would propels me to prepare for it
and worrying about how to get everything on my lists accomplished while also dealing with
problems makes me seek solutions. However, sometimes I worry about things that are out of
my control, or I worry too much and freeze rather than use the worry to solve a problem. I
found himself worrying so much that I seemed to worry about everything, to the point where
the worries seemed unimaginable.”

Nurse: “Isn’t that unusual?”

Client: “Yes, it was bizarre. The worry is uncontrollable to a certain degree; for example, I
understand that the worry is excessive but nevertheless find it difficult to stop worrying.

Nurse: “What changes have occurred in your sleeping pattern?”

Client: “It has only worsened with the passage of time, where each night brings fresh rebuff to
my attempts at sleep, where I now doubt my ability to ever sleep well again.”

Nurse: “How is your sleeping problem affecting you?”

Client: “Worrying about “doing it all” on a regular basis usually leaves little time for self-care. I
have a very active mind and trouble turning off my to-do-lists at night. It feels as if there’s
just too much to and there’s just not enough time to get everything done. And worst of all,
when I woke up in the middle of the night, I’m laying there on bed unable to wind back down
and drift off to supreme slumber. There are just things that can stress me out and cause me
to lose valuable shut-eye. As a result, I don’t make time for precious sleep. I would have a
daytime sleepiness, drowsiness, lethargy, and was no longer excited about the things I used
to enjoy.”

Nurse: “Next time this comes up, what might you do to handle it?”

Client: “I think I have to develop resistance from thinking about things during bedtime. Even
though it seems I have no choice but to tackle problems before bedtime, I must resist the
urge to do so. If not, it will surely be resonating in my head for hours, crowding out any
opportunity for sweet dreams. Instead, I would make a schedule to address difficult issues,
presentation or any academic activities the following day, in an earlier timeslot and start to
learn to preserve the hours before bedtime.”

Nurse: “I noticed that you’ve known how to handle it properly after going through a lot with
sleep issues. It is very important to set aside problems before bedtime because it could
interfere with our sleep. And I also noticed how well aware you are of the factors that
contributes to your sleep problem.”

Client: “Thank you. But my parents and friends are not aware about my condition. Do you think I
should tell them?”

Nurse: “What do you think about that?”

 Client: “Well, yes. I think that I probably should. Not sharing my feelings and worries with others
and keeping things to myself could fuel my sleep issues.”

Nurse: “Perhaps you can share your worries with your friends and families to help you stay in
good mental health and deal with times when you feel troubled.”

Client: “Thank you. I can now make a better choice.”

Nurse: “Is there anything else I need to know about your sleep?”

Client: “Oh, yes. I sleep 4 hours with 3 awakenings after each one.”

Nurse: “So we will end it here and we’ll be discussing it more next time. Thank you for your
cooperation (smiles and shakes hands with patient).”

C. NCP

CUES NURSING GOALS AND NURSING IMPLEMENTATIO EVALUATION

DIAGNOSIS DESIRED INTERVENTION N
OUTCOME

Subjective cues: Insomnia - No Sleep Enhancement - Implement Outcomes met

related to compromise in health teaching
“I experience - Determine the client's At the end of 8
anxiety (as sleeping
problems falling sleep and activity pattern. about sleep hours of nursing
evidenced by through the habits
asleep and intervention
difficulty falling night - Encourage to establish a
waking up the client was
consistently - Support of
multiple times in and remaining bedtime routine to able to:
with wandering facilitate transition from bedtime rituals
the middle of the asleep, fatigue,
reduced. wakefulness to sleep. which include - Acknowledge
night.” daytime her insomnia is
listening to music,
drowsiness, - No a somatic
Expresses “fear” - Encourage to eliminate reading, taking a
and “worry” over
lethargy, compromise in stressful situations before soothing bath, expression of
irritability, and feeling bedtime. her anxiety
illness and death, and praying.
decreased in regarding
not being able to rejuvenated
- Instruct the client and deadlines,
sleep, deadlines, ability to after sleep - Provision of a
significant others about presentation,
and the success function) restful success of
- No factors (e.g.,
of upcoming environment upcoming
physiological,
event and dependence on events, and fear
psychological, lifestyle, - Specific
presentation. sleep aids of pandemic
frequent work shift
measures to dilemmas.
States “I started changes, excessively long
work hours, and other promote comfort
feeling down, - Verbalize
environmental factors) and relaxation.
become very feelings,
sleepy, have that contribute to sleep Such as: perceptions,
trouble pattern disturbances. and fears
concentrating, clearly without
and irritable - Discuss with the client much tension
throughout the and his family comfort and anxiety.
day.” measures, sleep-
promoting techniques,
- Verbalize the
and lifesyle changes that
importance of
can contribute to optimal
Reports sleep getting enough
sleep.
disturbance with sleep at night.
only 4 hours sleep
- Monitor bedtime food
and 3 awakenings - Understand
and beverage intake for
after each one at sleep-promoting
items that facilitate or
night. techniques.
interfere with sleep.

Objective cues: Anxiety Reduction

- Create an atmosphere
- Pale Long term goal:
to facilitate trust.
- Drawn - States that
- Seek to understand talking with her
- weak friends has been
her perspective of a
- droopy or stressful situation. helpful.
sleepy
- Practicing
appearance of - Encourage
relaxation
the face verbalization of
techniques each
feelings, perceptions, night and sleeps
- Dark circles and fears. an average of 7
under the eyes hours a night
- Determine the client’s
Physical decision-making ability. - Expresses a
examination feeling of being
rested upon
Height: 170.18
awakening.
cm (5′7′′)

Weight: 45.6 kg - Expresses

(101 lb) having high
level of energy
Temperature: during the day
37.0°C (98.6°F) and enjoying
the things she
Pulse: 80 bpm usually does for
fun.
Respirations:
16/min
Blood pressure:
100/75 mmHg