Ncp 1
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NURSING CARE PLAN Assessment
Nursing Diagnosis
S: “hindi siya makatulog sa gabi” as verbalized by the SO.
Disturbed Sleep Pattern r/t change in the environment (noise, lighting) 2o to confinement
O: Conscious and coherent drowsy on appearnace c sunken eyeballs c body weakness restless c poor appetite; consumed ¼ of the food served ambulatory c assistance
Scientific Explanation
Planning
Interventions
Rationale
Evaluation
The patient will demonstrate an optimal balance of rest and activity A.E.B. at least 2-3 hours of uninterrupted sleep
establish rapport place the client in a comfortable position take and record vital signs
to facilitate NPI. to prevent backaches or muscle aches. to note any significant changes that may be brought about by the disease to determine usual sleep pattern and provide comparative baseline.
Patient demonstrated an optimal balance of rest and activity A.E.B. at least 2-3 hours of uninterrupted sleep within the shift
Assess past patterns of sleep in normal environment: amount, bedtime rituals, depth, length, positions, aids, and interfering agents Evaluate timing or effects of medications that can disrupt sleep
In both the hospital and home care settings, patients may be following medication schedules that require awakening in the early morning hours.
Determined client’s / SO’s expectation of adequate sleep Instruct to avoid heavy meals, alcohol, caffeine, or smoking before retiring
Instruct to avoid large fluid intake before bedtime Discourage pattern of daytime naps unless deemed necessary to meet sleep requirements or if part of one’s usual pattern
provides opportunity to address misconceptions / unrealistic expectations Though hunger can also keep one awake, gastric digestion and stimulation from caffeine and nicotine can disturb sleep This helps patients who otherwise may need to void during the night Napping can disrupt normal sleep patterns; however, elderly patients do better with frequent naps during the day to counter their shorter nighttime sleep schedules
Nursing Diagnosis
S: “hindi siya makatulog sa gabi” as verbalized by the SO.
Disturbed Sleep Pattern r/t change in the environment (noise, lighting) 2o to confinement
O: Conscious and coherent drowsy on appearnace c sunken eyeballs c body weakness restless c poor appetite; consumed ¼ of the food served ambulatory c assistance
Scientific Explanation
Planning
Interventions
Rationale
Evaluation
The patient will demonstrate an optimal balance of rest and activity A.E.B. at least 2-3 hours of uninterrupted sleep
establish rapport place the client in a comfortable position take and record vital signs
to facilitate NPI. to prevent backaches or muscle aches. to note any significant changes that may be brought about by the disease to determine usual sleep pattern and provide comparative baseline.
Patient demonstrated an optimal balance of rest and activity A.E.B. at least 2-3 hours of uninterrupted sleep within the shift
Assess past patterns of sleep in normal environment: amount, bedtime rituals, depth, length, positions, aids, and interfering agents Evaluate timing or effects of medications that can disrupt sleep
In both the hospital and home care settings, patients may be following medication schedules that require awakening in the early morning hours.
Determined client’s / SO’s expectation of adequate sleep Instruct to avoid heavy meals, alcohol, caffeine, or smoking before retiring
Instruct to avoid large fluid intake before bedtime Discourage pattern of daytime naps unless deemed necessary to meet sleep requirements or if part of one’s usual pattern
provides opportunity to address misconceptions / unrealistic expectations Though hunger can also keep one awake, gastric digestion and stimulation from caffeine and nicotine can disturb sleep This helps patients who otherwise may need to void during the night Napping can disrupt normal sleep patterns; however, elderly patients do better with frequent naps during the day to counter their shorter nighttime sleep schedules
