NURSING CARE PLAN

NAME OF PATIENT: PATIENT X WARD: _______________________________________

DIAGNOSIS: - DATE: September 12, 2020

ASSESSMENT BACKGROUND NURSING OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

KNOWLEDGE DIAGNOSIS
Subjective Data: Independent:
According to the Sleep is an important Disturbed - identify - Assess and record the - Elderly people usually 1. Patient will
patient, he says component for health Sleep Pattern individually patient’s sleeping pattern, sleep less than they did verbalize an increase
that he has and wellness across the RT appropriate gathering information when they were younger in overall quality of
difficulty falling lifespan. Dissatisfaction Environmental interventions to from the patient’s and often awaken more sleep within the 3
and staying asleep with sleep and sleep Barrier AEB promote sleep significant others or frequently during at days of nursing
ever since he disturbance is common Diassatisfaction such as caregiver. night. intervention, stating
moved into the in older adults because With Sleep alterations in factors such as the
nursing home aging is associated with environment - The nurse will assess the - observation gathers environment and
recently. He states an increasing prevalence and creating a patients sleeping pattern data pertinent to the comfort
that one factor of multimorbidity, sleep schedule and help him develop a patient’s sleeping habits __met
includes that he polypharmacy, within the sleeping plan together and will help indentify __unmet
isn’t familiar with psychosocial factors session with the patient. what to eliminate and to __partially met
the environment affecting sleep, and enhance. Cooperation
and that it doesn’t certain primary sleep - Client will with the patient 2. Patient is observed
feel cozy enough. disorders. One factor report promotes adherence to to take none or less
He also has that may affect sleep is improved sleep desired regimen. than 1hr naps at
difficulty falling the environment. and increased daytime
asleep due to slight Zeitgebers are cues from sense of well - Provide a dark, quiet, - alterations in __met
loneliness, missing the environment that being and and comfortable environment promote __unmet
his family although entrain circadian feeling rested atmosphere for the sleep conditions. __partially met
they visit fairly rhythms to a 24-hour within 3 days of patient to sleep in. The Zeitgebers are cues from
often. The patient cycle length, promoting nursing nurse will discourage the environment that 3. Patient has a
describes himself normal sleep-wake interventions. caffeine or large meal entrain circadian rhythms positive increase in
as drowsy and habits. Zeitgebers may intake 2 hours before the to a 24-hour cycle length, mood observed
moody often times be light-based, but also patient goes to sleep. promoting normal sleep- through verbalization
and compensates include exercise, wake habits. Zeitgebers or ques in social
by taking daytime scheduled meals, and may be light-based, but interaction
naps. other social cues. For also include exercise, __met
socially isolated older Dependent: scheduled meals, and __unmet
adults, there may be other social cues. __partially met
Objective Data: inadequate exposure to - Administer necessary
- droopy eyelids zeitgebers, leading to medications as ordered - Administering
- irritability irregular sleep-wake provide back rub, and medications on schedule
- difficulty in daily patterns. pleasant conversation at promote continuity of
functioning sleep time. sleep. These
Source: interventions promote
Miner, B., & Kryger, M. comfort thus enhance
H. (2017). Sleep in the the sleep.
Aging Population. Sleep
Medicine Clinics, 12(1),
31–38.
https://doi.org/10.10
16/j.jsmc.2016.10.008

‌
 ASSESSMENT BACKGROUND NURSING OBJECTIVES NURSING RATIONALE EVALUATION
KNOWLEDGE DIAGNOSIS INTERVENTION
Subjective Data: Independent:
- Patient verbalizes Older adults are more Hypothermia RT - The patient’s - Monitor - This assessment will 1. Patient verbalizes
feelings of being susceptible to Age-related temperature and temperature indicate the presence of feeling comfortable
cold hypothermia than an changes in mental status will through the use hypothermia. The normal and warm after 30
average-aged person thermoregulation remain within the of a low-range temperature of an older mins of nursing
Objective Data: due to physiological and environmental normal limits, or thermometer if adult is 35.5°C (96°F). interventions
- Temp 35. 1°C changes in their exposure AEB they return to the available. For an Elderly persons have poor __met
- cold skin upon integumentary Shivering patient’s normal older adult, peripheral circulation and __unmet
palpation system. Their body's limits at a rate of refrain from decrease subcutaneous fat __partially met
- Shivering response to cold can 1°C/hr, after taking an axillary in the axillary area.
be diminished by interventions. temperature. 2. Patient’s
certain illnesses such temperature returns
as diabetes and some - Patient will feel a - Assess and - Increasing disorientation, to normal range of at
medicines, including sense of comfort record the mental altered sensorium, or least 35.5°C (96°F).
over-the-counter cold within the status of the atypical behavior may after 1hr of nursing
remedies. In addition, environment after patient. indicate hypothermia. interventions
older adults may be nurse’s alterations __met
less active and or interventions - Initiate slow - Increasing the room __unmet
generate less body rewarming if the temperature to at least __partially met
heat. This becomes patient is mildly 23.89°C (77.5°F) is one
more apparent in hypothermic. method to reverse mild 3. Signs of
colder settings as Give blankets and hypothermia. Additional hypothermia (Cold
evidenced by adjust room measures include the use of skin and shivering) are
shivering. Shivering is temperature warm blankets, head alleviated after at east
the body’s response accordingly. covers, and warm 30 mins of nursing
to cold as these circulating air blankets. interventions
muscle spasms Dependent: __met
generate a lot of heat. -Warm the - This method is done to __unmet
Hypothermia when eft patient internally reverse moderate to severe __partially met
untreated can lead to by providing hypothermia. Other
complete failure of warm oral or IV methods include warmed
the heart and fluids if the saline gastric or rectal
respiratory system. patient’s irrigations or introduction
 temperature of warmed humidified air
Source: drops below 35°C into the airway.
Hypothermia: A Cold (95°F).
Weather Risk for
Older People. (2015, Collaborative:
August 23). Retrieved - Once the - Causes aside from
September 13, 2020, patient’s environmental factors may
from National temperature fails be responsible for the
Institutes of Health to increase by hypothermia. Treating the
(NIH) website: 1°F/hr using underlying condition will
https://www.n these methods, help the patient’s
ih.gov/news- anticipate temperature to return to
events/news- laboratory normal.
releases/hypothermia request for WBC
-cold-weather-risk- count for possible
older-people#:~:text sepsis, glucose
=Older%20peopl level for
e%20also%20 hypoglycemia,
are%20at,and%20 and thyroid test
generate%20les for
s%20body%20heat. hypothyroidism.

NAME OF STUDENT: Jenny Juniora Ajoc CLINICAL INSTRUCTOR: Prof. Fe Agulan

BLOCK & YEAR: BSN 310