visit the hospital today, complaining of being sleepy and restless and having continuous headache for the past three (3) days. Vital Sign
• BP – 130/100 mmHg • T – 36.5° C • PR – 70 bph • RR - 18 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
• Subjective: • Difficulty of After 96 hours (4 • Suggest patient • High • The patient
“Nightshift ako sa falling asleep days) of following to rest in a percentage of verbalized trabaho so I only have because of nursing sleep “medyo room away time to rest and sleep noise in the disturbance can nakakapag intervention, the from noise during the day, pero affect the sourroundings. patient will achieve • Make sure that pahinga na nahihirapan akong patient’s matulog dahil sa ingay at • Lack of sleep amount of sleep as the patient’s recovery ako ng maayos maya’t maya ang privacy evidenced by: sleep • It is necessary compare dati” pumapasok sa kwarto • Changing • Absence of to alert people • The patient environment is tatlong araw na din sleep-wake restlessness to lessen the dose not look pleasant and sumasakit ulo ko.” as schedule • Decrease of noise to avoid weak compare verbalized by the patient • Delayed sleep- relaxing disruption of to the past presence of • Stick to a on set insomia sleep • The presence eyebags regular sleep Objective: • Help patient of eyebags • Dark circle under eye • Verbalized of schedule seven understand the feeling rested have been (presence of eyebag) days a week. main cause of minimized and • Weakness and restless • Improvement sleeping decrease of • Frequent yawning of sleeping difficulties • Headache usual yawning pattern
1. Provide comfort and support to establish effective breastfeeding.2. Assess for factors affecting breastfeeding and provide health teaching. 3. Monitor infant's ability and signs of adequate intake