Ncp Normal Spontaneous Delivery Disturbed Sleeping Pattern

Nursing Care Plan Age: 26 y/o

Patient’s Name: XY Assessment Subjective: “di ako makatulog kasi puro na lang sakit sa katawan yung nararamdaman ko” Objective: • 1hr of sleep per day PTA • 30 mins of sleep per day upon admission • frequent yawning at daytime during assessment • overall body malaise • pain(8 out of 10) • dark circles around the

Nursing Diagnosis Disturbed sleeping pattern related to pain and discomfort on perineum secondary to labor and delivery

Diagnosis: NSVD

Inference

Goals

Interventions

Because of the pain at the perineum r/t episioraphy, normal body relaxation is hindered leading to prolonged period of time without sleep or sleep deprivation

Short Term After 3 hours of nursing intervention, the client will: • report decreased feeling of discomfort as manifested by verbalizing feeling of comfort (5 out of 10) • Achieve at least 5-6 hours of continuous sleep per day • Show signs of decreased yawning at daytime • Report decreased body malaise

Independent • Position client in a comfortable position

References: Wikipedia: http://en.wikipedia. org/wiki/Sleep

Expected Outcome Long Term After 3 days of nursing intervention the client will: • Be able to reestablish and maintain normal sleep pattern

• Provide comfort measures (touch, quiet environment, dim light, light music)

• Assess sleep pattern • Provide a quiet and peaceful environment during sleep periods • Encourage the client to express concerns when

Rationale

Evaluation

• To help in providing better sleep/rest

Short Term : After 3 hours of nursing intervention, the short term goal was met as evidenced by: • Reported pain relief (5 out of 10) • Pt was able to achieve 6 hours of continuous sleep that day • decreased yawning at daytime • reported decreased overall body malaise

• Verbalizing concerns may promote relaxation

Long Term After 3 days of nursing intervention the short term goal

• To alleviate discomfort

• To distract attention on pain, reduce tension and to promote nonpharmacolo gical pain management • To provide comparative baseline

eyes

•

achieve 7-8 hours of continuous sleep per day • report absence of body malaise • report further alleviation of pain (3 out of 10) • absence of frequent yawning

unable to sleep

• Provide a warm bath before the client goes to sleep • Expose perineum on perilight bid for 15 mins

Dependent • Prescribe sedatives (Valium) as ordered

• Vasodilation of the veins provide a sleepy, lazy effect, causing the client to fall right to sleep • To provide comfort

has been fully met as evidenced by: • reported increased periods of sleep of 8 continuous hours per day • absence of frequent yawning • established sleep pattern

• To induce sleep References: Fundamentals of Nursing, 11th edition

• reported pain scale of 3 out of 10 • reported absence of body malaise