ASSESSMENT NURSING PLANNING (WITH RATIONALE AND IMPLEMENTATION EVALUATION

DIAGNOSIS REFERENCE)

Assess past
SUBJECTIVE CUES: DISTURDED GOAL OF CARE After 1 week of

After 1 week
The patient SLEEPING nursing intervention
verbalized that “DI PATTERN the client has been

patterns of
AKO MAKATUG able to:

of
MARAYAW BANG
DUM” she has a - achieves
hard time sleeping
during night
nursing sleep in optimal
amounts of
sleep as

intervention normal
evidenced by
rested
appearance

OBJECTIVE CUES: the environment: -

-
verbalizes of
feeling rested
Improve in his
- Restlessness
noted
client will amount, -
sleep pattern
reports

bedtime
- Dark circle improvement
under eye After 1 week of nursing intervention the of quality in
- Insomia client will: his sleep

rituals,
- achieves optimal amounts of pattern
-V/S taken as sleep as evidenced by rested -
follows appearance
T: 36.7
P: 60
R: 15
verbalizes depth, length,
BP:130/90
of feeling positions,
rested aids,
verbalizes and
of feeling interfering
rested agents.
- verbalizes of feeling rested - Assess past patterns of sleep in
- Improve in his sleep pattern normal environment: amount,
- reports improvement of quality in bedtime rituals, depth, length,
his sleep pattern positions, aids, and interfering
agents.

- Insomnia is a complicated - Document nursing or caregiver

condition and may be observations of sleeping and
temporary or chronic. Short wakeful behaviors. Record
number of sleep hours. Note
term insomnia may occur in
physical (e.g., noise, pain or
response to variations in
discomfort, urinary frequency)
work schedules, overnight and/or psychological (e.g., fear,
stressors, or travel beyond anxiety) circumstances that
different time zones. Long- interrupt sleep
term insomnia is linked
to substance abuse such as - Provide quite environment
drugs and alcohol, and other
factors like chronic pain,
chronic depression, obesity,
and aging.

- Each individual has different

patterns of sleep.
Information about this topic
 provides baseline data for
evaluating means to improve
the patient’s sleep.

- The patient may have insights

about the existing problems
(e.g., anxiety or fear about a
certain situation in life). 

- The patient’s perception of

the insomnia may differ from
objective evaluation.

- https://nurseslabs.com/insomnia/