Saint Joseph College

Institute of Health Sciences

Cavite City

NURSING CARE PLAN

PERSONAL DATA
Name: Mary Lyn Santos Age: 27 Sex: F
Address:Blk. 2 Lot 7 Annex, Imus Cavite Room No: Bed No:

ASSESSMENT PLANNING IMPLEMENTATION

Cues/Evidences Nursing Diagnosis Scientific Rationale Nursing Objective Nursing Order/Action Scientific Rationale EVALUATION

Subjective: Sleep pattern Predisposing Factors: At the end of my 8- Independent At the end of my
“Hindi ako disturbance related hour shift, after Maintain environment To promote restful sleep. 8-hour shift, after
Environmental medical and
to environmental medical and conducive to sleep.
makatulog ng Disturbances and nursing
changes secondary nursing
maayos sa Stressors intervention, goal
gabi” as to hospitalization as ↓
intervention, the Assist patient in observing To promote relaxation. was partially met.
evidenced by early patient achieves previous bedtime ritual. The patient
verbalized by Neurological optimal amounts of slightly achieves
patient. morning disturbances To promote rest and
sleep as evidenced optimal amounts
awakening, Provide nursing aids (back relaxation.
↓ by rested of sleep as
difficulty in falling or rub, bedtime care, pain relief, evidenced by
Impaired Reticular appearance, late
remaining asleep, Formation Function comfortable position, rested
restlessness, awakening, ease in relaxation techniques). appearance, late
↓ sleeping and awakening, ease
Objective: complaints of not
Manifestation of maintaining sleep, Organize nursing care. To promote minimal in sleeping but
-early morning feeling rested and difficulty in
difficulty of sleeping no complaints of interruption in sleep/rest.
awakening patient’s verbalizes: maintaining
↓ unrested feeling
-difficulty in “Hindi ako sleep, still
Sleeping Pattern and patient’s Increase day time physical To reduce stress and complaints of
falling or makatulog ng
Disturbances verbalizes: activities as indicated. promote sleep unrested feeling
remaining asleep maayos sa gabi” and patient’s
“Nakakatulog na
-restlessness ako ng mahimbing.” Collaborative verbalizes:
-complaints of “Medyo
Administer hypnotics as Use of hypnotics medications nakakatulog na
not feeling rested ordered and evaluate should be thoughtful and ako.”
effectiveness. avoided if less aggressive
means are effective because
of their potential for
cumulative effects and
generally limited period of
benefit.