Nursing Care Plan

Assessment Nursing Analysis Goals Interventions Rationale Evaluation

Diagnosis
Subjective: Sleep Deprivation Prolonged periods of Short Term Independent Short Term :
“di ako makatulog related to pain time without sleep. After 3 hours of nursing • Identify • To identify After 3 hours of
kasi puro na lang and discomfort on intervention, the client presence of causative/ nursing intervention,
sakit sa katawan perineum will: related factors contributing the short term goal
yung secondary to • report decreased that can factors. was met as evidenced
nararamdaman labor and delivery feeling of discomfort as contribute to by:
ko” manifested by verbalizing sleep deprivation. • Reported pain
feeling of comfort (5 out relief (5 out of
Objective: of 10) • Position client in • To alleviate 10)
• 1hr of sleep • Achieve at least 5-6 a comfortable discomfort • Pt was able to
per day PTA hours of continuous sleep position achieve 6 hours
• 30 mins of per day of continuous
sleep per day • Show signs of • Provide comfort • To distract sleep that day
upon decreased yawning at measures (touch, attention on pain, • decreased
admission daytime quiet reduce tension yawning at
• frequent • Report decreased body environment, dim and to promote daytime
yawning at malaise light, light music) non • reported
daytime pharmacological decreased
during Long Term pain overall body
assessment After 3 days of nursing management malaise
• overall body intervention the client will:
malaise • Be able to • Assess sleep • To provide
• pain(8 out of reestablish and maintain pattern comparative
10) normal sleep pattern baseline Long Term
• dark circles • achieve 7-8 hours After 3 days of nursing
around the of continuous sleep per • Provide a quiet • To help in intervention the short
eyes day and peaceful providing better term goal has been
• report absence of environment sleep/rest fully met as evidenced
 body malaise during sleep by:
• report further periods • reported
T: 37.2 alleviation of pain (3 out increased periods
P: 67 beats/min. of 10) • Encourage the • Verbalizing of sleep of 8
R: 22 cycles per • absence of client to express concerns may continuous hours
BP: 100/60 mmHg frequent yawning concerns when promote relaxation per day
unable to sleep
• absence of
• Provide a warm • Vasodilation of frequent yawning
bath before the the veins provide a
client goes to sleepy, lazy effect, • established
sleep causing the client to sleep pattern
fall right to sleep
• reported pain
• Expose • To provide scale of 3 out of 10
perineum on comfort
perilight bid for 15 • reported
mins absence of body
malaise

Dependent
• Prescribe • To induce sleep
sedatives
(Valium) as
ordered

Collaboration • Relieves and

•Encourage to helps the
position well patient to sleep
and to divert and to remove
her attention to stressor for
pain for better better resting.
sleep