Disturbed Sleep

Need/Nursing Diagnosis/Cues Need: Physiologic need

Scientific Analysis Sleep is required to provide energy for physical and mental Nursing Diagnosis: activities. As persons Disturbed sleep age the amount of pattern related to time spent in REM difficulty or laboured sleep diminishes. The breathing secondary to amount of sleep that disease process individuals require Cues: varies with age and personal Subjective cues: characteristics. “Dili ko katulog kay Disruption in the maglisod ko ug individual’s usual ginhawa”, as diurnal pattern of verbalized by the sleep and patient. wakefulness may be temporary or chronic. Such disruptions may Objective cues: result in both subjective distress • Frequent and apparent yawning impairment in noticed functional abilities. • Fatigue •

Weak-looking

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Dyspnea

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Use of accessory muscles in breathing

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Restlessness

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Number of hours of sleeping = 5 hours.

Objective After 6-8 hours of nursing intervention, the patient will be able to: a. demonstrate a measurable increase in tolerance in activity with absence of dyspnea and excessive fatigue. b. Identify negative factors affecting activity tolerance and eliminate or reduce their effects when possible. c. Participate willingly in necessary / desired activities.

Nursing Intervention Independent: •

Evaluate patient’s response to activity.

• Provide a quiet environment and limit visitors. •

Rationale

• Establishes patient’s capabilities or needs and facilitates choice of interventions • Reduces stress and excess stimulation, promoting rest.

Elevate head and encourage frequent position changes.

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These measures promote maximal inspiration.

• Encourage deep breathing exercise.

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Improve ventilation and promotes optimal chest expansion.

Encourage adequate rest balanced with moderate activity. Promote adequate nutritional intake. Assist patient with self-care needs. Keep bed in low position and assist with ambulation.

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Facilitates healing process and enhances natural resistance.

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Dependent: • Provide supplemental oxygen via nasal cannula as ordered by the physician.

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Weakness may make activities of daily living and ambulation difficult, further assistance is needed. Aids in reduction of shortness of breathe and prevent hyperventilation.

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Evaluation After 6-8 hours of nursing intervention, the patient was able to: a. the patient was able to demonstrate a measurable increase in tolerance in activity with absence of dyspnea and excessive fatigue. b. Identified negative factors affecting activity tolerance and eliminate or reduce their effects when possible. c. Participated willingly in necessary / desired activities.

Value Integration