ASSESSMENT NURSING N PLANNING/ INTERVENTION EVALUATION

DIAGNOSIS E SPECIFIC OUTCOME

E
D
S
Disturbed sleep S After the nursing 1. Monitor the patient’s Vital GOAL MET
pattern related to L interventions patient signs.
Subjective: noisy environment. E will be able to RATIONALE: Patient’s vital
Patient verbalized E demonstrate;
signs will indicate significant
Rationale: P
“Dili ko katarong changes to the patient that
Goal:
tulog kay mag Sleep patterns can  Improvement of needs immediate attention.
sabay hilak ang be affected by E sleep pattern (at
mga bata.” environment, N least 4-6hrs) 2. Encourage the patient to
especially in the H encourage foods that are high
 Absence of
Objective: hospital setting A in iron.
where noise, N restlessness. RATIONALE:
VITAL SIGNS
lighting, frequent C Lack of sleep may affect the
BP: 160/100 monitoring, and E Objectives: hemoglobin levels, eating iron
T: 37.9 treatments are M  Verbalization of rich food boosts the
RR: 20 rpm always E feeling rested.
production of hemoglobin.
HR: 110 bpm N  Decrease
T presence of eye
bags. 3. Encourage the patient to
2. Low Hgb – 85.0
close the eyes or use eye
(normal: 115-155)
mask.
RATIONALE:
3. Capillary reffil
Some people sleep better at
test: <2 secs. the dark.

4. O2 sat: 97% 4. Advice the patient not to

drink too much fluids at night
5. Restlessness time.
 References: RATIONALE:
6. Yawning noted Less fluid intake at night also
lessens the patient’s urge to
7. Patient’s eye Doenges, M., void.
bags are visible. Moorhouse, M.
and Murr, A. 5. Advice tha patient to drink
8. Dark circles (n.d.). Nurse's milk before sleeping.
around the pocket guide. RATIONALE:
patient’s eyes are Milk contains tryptophan.
noted. Tryptophan is an amino acid
that can help the human body
Gulanick, M., &
9. Appear weak. produce serotonin, a brain
Myers, J. L.
chemical that can induce
(2010). Chapter
deeper and more restful sleep
1Ingestion. In
by creating melatonin.
Nursing Care
Plans: Diagnoses,
6. Encourage the patient to
Interventions, and
change her diaper and take a
Outcomes (7th
bath or clean up before bed
ed., p. 199). St.
time.
Louis, MO:
RATIONALE:
Elsevier Health
Cleaning the body promotes
Sciences
comfort and relaxation to the
patient.

7. Teach the patient about

relaxing breathing methods.
RATIONALE:.
Breathing methods that
promotes calmness and
relaxation.

8. Encourage the patient to

avoid or lessen caffeine
intake. RATIONALE:
Caffeine is a stimulant that
can keep a person palpitate
and stay awake.

9. Advice the patient to lessen

electronic use at night time.
RATIONALE:
Using electronic devices late
at night is terrible for sleep.

10. Eliminate any activities

that are not important.
RATIONALE: This measure
facilitates minimal interruption
in sleep or rest.

References:

Doenges, M., Moorhouse, M.

and Murr, A. (n.d.). Nurse's
pocket guide.

Gulanick, M., & Myers, J. L.

(2010). Chapter 1Ingestion. In
Nursing Care Plans:
Diagnoses, Interventions, and
Outcomes (7th ed., p. 199).
St. Louis, MO: Elsevier Health
Sciences