Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Disturbed Sleeping After 1 day of nursing  Determined  Each individual has After 1 day of nursing
Pattern Related to interventions, the patterns of sleep in different patterns of interventions, the
“Di na naman ako overthinking of patient will obtain the past in a normal sleep. Information patient obtained optimal
nakatulog nang Distracting Thoughts optimal amounts of environment: about this topic amounts of sleep and
maayos kagabi dahil sa and Ideas sleep and improvement amount, bedtime provides baseline improvement of sleep
kung anu-anong of sleep pattern. routines, depth, data for evaluating pattern as evidenced by
pumapasok sa isip ko.” length, positions, means to improve the rested appearance, and
aids, and other patient’s sleep. verbalization of feeling
Objective: interfering factors. rested and relaxed.

-Vital Signs taken as:  Noted physical or  The patient’s

BP=110/50 mmHg psychological perception of the
T=36.2◦C circumstances that insomnia may differ
P=63 bpm hinder sleep. from objective
R=20 cpm evaluation.
-Dark eye bags noted
-Frequent yawning  L-tryptophan is a
observed  Prepared patient component of milk
-Restlessness and with milk to drink which promotes
weakness noted sleep.
-Observed taking naps
when there is a chance  These activities
or capability to do so  Introduced relaxing provide relaxation
activities such as and distraction to
warm bath, calm prepare mind and
music, reading a body for sleep.
book, and
relaxation exercises
to be done before
bedtime.
 Providing a
 Prevented the designated time for
patient from these concerns
thinking about next allows the patient to
day’s activities or “let go” of these
any distracting problems at bedtime.
thoughts at bedtime
through providing
her techniques that
will help in setting
her a peaceful
 mind.  A lot of people can
able to sleep better in
 Provided an cool, dark, quiet
environment environment.
conducive to rest or
sleep.  Promoting rest and
sleep can help regain
 Promoted rest and lost energy and make
sleep. up the restless and
sleepless night
experienced.

 Having full meals just

 Educated the before bedtime may
patient on the produce
proper food and gastrointestinal upset
fluid intake such as and hinder sleep
avoiding heavy onset. Coffee, tea,
meals, alcohol, chocolate, and colas
caffeine, or smoking which contain
before bedtime. caffeine stimulate the
nervous system. This
may interfere with the
patient’s ability to
relax and fall asleep.
Alcohol produces
drowsiness and may
facilitate the onset of
sleep but interferes
with REM sleep.