NURSING CARE PLAN of Mrs.

I with SLEEPING
DISTURBANCE

Arragged to Fulfill One of The Task of Psychosocial English

Arraged By :

Siti Nurintan Sari P17320316031

Ina Rumsyiani Ningsih P17320316038

Class :

III A

BANDUNG POLYTECHNIC of HEALTH

BOGOR NURSING DEPARTEMENT

2019
 NURSING CARE PLAN of Mrs.I with SLEEPING
DISTURBANCE

A. Assesment
1. Identity
a. Patient Identity
1) Name : Mrs.I
2) Age : 25 th
3) Sex : Female
4) Religion : Islam
5) Marital status : Married
6) Job : Housewife
7) Education : Senior High School
8) Ethnic : Sundanese
9) DOB : 24-04-1994
10) No.RM : 1400429
11) Entry Date : 4/03/2019
12) Assesment Date : 5/03/2019
13) Medical Diagnosis : Dermatitis
14) Address :Jl. Kampung Sawah blok D2 no 8
RT 07 RW 09 Kel. Bojong
b. Responsible Identity
1) Name : Mr.A
2) Age : 26 th
3) Sex : Male
4) Religion : Islam
5) Job : Private Officier
6) Address : Jl. Kampung Sawah blok D2 no 8
RT 07 RW 09 Kel. Bojong
7) Relationship with patient : Husband
2. Major Complaints
The client said it’s difficult to sleep because it’s itchy all over the
body.
3. Current History of Illness
The client entered an emergency room on March 4th 2019 at 10.30
pm, with a complaint of intense hives and signs of bruishing. The
client said the itch he suffered was repeated over and over and
would usually leave a mark that stood out. The client says an itch
on the skin area may spread. The client says the itches which suffer
are intense itchy which may disrupt a client’s activity. The client
has filed a complaint from 3 weeks ago.
4. Past History of Illness
The client has been in a Arga Makmur Hhospital with complaints
of shortness of breath, and cough for a week.
5. Family History of Illness
The client said his father had suffered from the same disease, and
his father sufferes from shortness of breath too.
6. Psychosocial History
The client said that he’s anxious because his itches not gone and
afraid of complications.
7. Drug Use History
The client says to cure his itc, he takes amoxicilin medication, and
then he doesn’t feel itchy anymore
8. Daily Activity
Before Hospitalization After Hospitalization
Nutrition The client says eat The client says eat
twice a day. He lose three times a day. The
his appetite because client eats only a
he have trouble quarter of the food,
swallowing because the client has
a nausea and trouble
 swallowing
Elimination The client says pee the client says pee
three times a day, the three times a day, the
colour thick yellow. colour thick yellow.
And the client says And hasn’t defecate
defecate once times a yet
day.
Activity/Sport The client said never The client waas just
exercised lying in bed
Sleep Patterns The client says sleep The client says sleep
at 00.00 and wake up at 00.00 and wake up
at 03.00 a.m. the client at 03.00 a.m. the
says it’s difficult to client says it’s
sleep because the itch. difficult to sleep
The client sleeps for 3 because the itch. The
hours. And the client client sleeps for 3
never at take a nap. hours. And then when
wake up the client’s
are not feeling so
fresh. And the client
never take a nap.

9. Head to Toe Assesment

a. General State : Moderate
b. Consciousness level : Composmentis
c. Vital sign
Blood pressure : 140/90 mmHg
Pulse : 98x/minutes
Respiration : 22x/minutes
Temperature : 370C
d. Weight gain : 65 kg
 e. Height : 170 cm
f. Skin : it’s got rubor (redness), it’s got bula
(scald), it’s got pain tap, it’s got edema (swellling)

B. Nursing Diagnosis
Sleeping disturbance related to pruritus
 C. Nursing Care Plan

Nursing Diagnosis Purpose Outcomes Intervention Rational

Sleeping General : After the treatment

disturbance related Client not suffer 2x24 hours we expect :
to pruritus sleeping disturbance Client not suffer
Spesific : sleeping disturbance,
Client not suffer client not suffer any
pruritus execessive stimulation
(itchy) with outcomes :
1. Client not suffer 1. Help the patient move in an orderly 1.Exercise has a beneficial effect
sleeping disturbance on sleep if carried out in the
(sleep patterns are evening.
good)
2. Bedtime is adequate 2. Keep the bedroom still has good 2. The dry air makes the skiin
ventilation and moisture itch. A comfortable environment
increases relaxation.
3. Quality sleep good 3. Prevent and heal the dry skin. 3. Nocturnal pruritus
disturbances normal sleep
4. Vital sign within 4. Encourage the client to avoid 4. Caffein has a peak effect 2-4
normal boundaries caffeinated beverages before on hours after consumption
going to bed at night

5. Monitor vital sign of client (blood

5. Find out the general
pressure, pulse, respiration,
circumstances of the client
temperature)