Cues / Needs Nursing Diagnosis Rationale Goal and Interventions Rationale Evaluation

Objectives

Subjective Insomnia related to Sleep is required to After 1 hr of -Assess past patterns of -to determine the cause in After 1 hr of
data: auditory provide energy for nursing sleep in normal difficulty sleeping. nursing
“Nagpapa-iso hallucinations as physical and mental intervention, environment: amount, intervention,
po ako kasi manifested by activities the client will be bedtime rituals, depth, the goal was
hindi ako changes in affect Such disruptions may able to: length, positions, aids, and -This reduces stress and promotes met. As
makatulog at result in both subjective verbalize interfering agents. sleep. evidenced by
may bulong distress and apparent understanding verbalizations of
ako” as impairment in functional of sleep -Increase daytime physical understanding
verbalized by abilities. Sleep patterns impairment and activities as indicated.  -Napping can disrupt normal sleep of the patient
the patient. can be affected by will identify patterns; however, elderly patients regarding sleep
environment, especially appropriate -Discourage pattern of do better with frequent naps impairment and
Objective data: in hospital critical care intervention to daytime naps unless during the day to counter their identifies
-changes in units. These patients promote sleep. deemed necessary to shorter nighttime sleep schedules. appropriate
affect experience sleep meet sleep requirements intervention to
disturbance secondary to or if part of one’s usual - Obviously, this will interfere with promote sleep.
the noisy, bright pattern. inducing a restful state. Planning a
environment, and designated time during the next
frequent monitoring and -Explain the need to avoid day to address these concerns may
treatments. concentrating on the next provide permission to "let go" of
day’s activities or on one’s the worries at bedtime.
problems at bedtime.
-Experimental studies have
-Attempt to allow for indicated that 60 to 90 minutes are
sleep cycles of at least 90 needed to complete one sleep
minutes.  cycle, and the completion of an
entire cycle is necessary to benefit
-limit fluid intake in from sleep.
evening
-to reduce need for night
time elimination.
 Cues / Needs Nursing Diagnosis Rationale Goal and Interventions Rationale Evaluation
Objectives

Subjective Disturbed thought Cognitive processes After 2 hrs of -Assess attention span and -Determine ability to participate in After 2 hrs of
data: process related to include those mental nursing ability to make decisions planning of care nursing
“Si Immaculate bipolar disorder processes by which intervention, or problem solve. intervention,
Concepcion knowledge is acquired. the client will be the goal was
nagbigay ng These mental processes able to: -Reorient patient to time, -Inability to maintain orientation is met as
baby ko” include reality demonstrate place, person a sign of deterioration. evidenced by
orientation, behaviour to demonstration
comprehension, minimize -Scheduled structured -Provides stimulation while of behaviour to
awareness, and changes in activity and rest periods reducing fatigue. minimize
judgment. A disruption in mentation and changes in
Objective data: these mental processes maintain usual -maintain a pleasant, -client may respond with anxious mentation and
-Inappropriate may lead to inaccurate reality quiet environment and or aggressive behaviours if startled maintain usual
thinking interpretations of the orientation. approach client in a slow or over stimulated. reality
environment and may and calm manner. orientation.
result in an inability to -defense reactions may result
evaluate reality -present reality concisely
accurately. Wherever the and briefly and do not -enhances intake and general well
patient is encountered, challenge illogical thinking being.
the nurse is responsible
for effecting a treatment -provide for nutrionally -may aid in reducing confusion and
plan that responds to the well balanced diet. increases possibility that
specific needs of the Encourage client to eat, communication skills will be
patient for structure and understood.
safety, as well as - Communicate
effective treatment for information/instructions
the presenting in simple, short sentences.
symptoms. Repeat explanations as
necessary.