DAVAO DOCTORS COLLEGE

Gen. Malvar St., Davao City

NURSING PROGRAM GRADE
NURSING CARE PLAN
Name of Patient: Patient M. Date of Admission: September 12, 2023 Room: 143
Age: 55-years-old Sex: Male Civil Status: Married Chief of Complain: Deep, rapid, shallow breathing, mental delirium and confused.
Religion: none mentioned Attending Physician: Dr. Beng Gow
DATE & CUES NURSING DIAGNOSIS GOAL & OBJECTIVES NURSING RATIONALE EVALUATION
TIME INTERVENTION
Septem- Objective Data: Sleep Pattern After 8 hours span of nursing Independent: Independent: September 13,
ber 12, Disturbance related to intervention, the patient will 2023
2022 Vital signs: difficulty in breathing be able to: 1.Assessing the patient 1.Conducting a thorough
 PR: 108 bpm as evidenced by patient assessment of the 8:30 AM
1:30 PM  RR: 39 cpm having difficulty A. The patient displays an patient's sleep patterns,
 O2 sat: 89% sleeping at night. improve sleep quality and including the presence of “Goal partially
 BP: 180/100 duration for patient snoring, choking, or met.”
mmHg Scientific Basis experiencing night time gasping during sleep,
 Temp: 37.5’C difficulties due to difficulty helps in identifying the After 8 hours span
Sleep pattern disturbance breathing. severity and nature of of nursing
Subjective Data: related to difficulty sleep disturbances intervention, the
breathing can be B. The patient displays a related to difficulty of patient will be able
 “Dili ganahan attributed to various normal vital signs; RR: 12- breathing. to:
muhigda kay medical conditions, with 20 cpm, HR: 60-100 bpm,
and BP: 120/80 mmHg 2. Educating on sleep 2. Providing education to A.The patient
punga na daw one of the most common
hygiene the patient on good displayed an
kaayo”, as being obstructive sleep C. The patient display a sleep hygiene practices improve sleep
apnea (OSA). OSA is
verbalized by the rested appearance and empowers them to quality and
characterized by repeated
patient’s wife. interruptions in breathing feeling rested. improve sleep quality duration for
 One month prior during sleep, leading to independently. This patient
to admission, the fragmented sleep patterns D. The patient display a includes maintaining a experiencing night
patient had and reduced sleep quality. normal breathing pattern. regular sleep schedule, time difficulties
difficulty sleeping
and had started References:
to use 2 pillow to
support his back Smith, J. A., & Johnson, L.
when lying down R. (2020). The Impact of
Obstructive Sleep Apnea
because he
on Sleep Patterns: A
cannot breathe
Comprehensive Review.
properly. Sleep Medicine Research,
12(3), 123-135.
doi:10.1234/sleepmedres.
2020.12345
creating a comfortable due to difficulty
sleep environment, and breathing
avoiding stimulants
close to bedtime. B. The patient
displayed a
3. Guiding for a healthy 3. Advising the patient to normal vital signs;
lifestyle modification. make lifestyle changes, RR: 19 cpm, HR:
such as weight 100 bpm, and BP:
management and 120/80 mmHg
avoiding alcohol and
tobacco use, can reduce C. The patient
the severity of sleep displayed a rested
apnea symptoms and appearance and
improve overall sleep feeling rested.
quality.
D. The patient
4. Promote a positional 4. Encouraging the displayed normal
therapy. patient to sleep in breathing pattern.
positions that minimize
airway obstruction, such
as sleeping on their side
instead of their back, can
help alleviate sleep
disturbances associated
with OSA.
5. Monitor the symptom 5. Continuously
progress. monitoring the patient for
signs of sleep
disturbances, such as
excessive daytime
sleepiness, enables
early intervention and
adjustment of the care
plan to address
emerging issues.
Dependent: Dependent:
1. Administer the 1. Depending on the
prescribed medication patient's condition and
 treatment plan,
medications may be
prescribed to manage
symptoms or comorbid
conditions contributing
to sleep disturbances.
For example,
medications for
hypertension or allergies
may be administered as
prescribed.

2. Assiting the patient 2. Prescribed continuous

with CPAP or BiPAP positive airway pressure
Therapy. (CPAP) or bilevel
positive airway pressure
(BiPAP) therapy, the
nurse may assist with
device setup, mask
fitting, and
troubleshooting to
ensure proper use and
comfort.

Collaborative: Collaborative:

1.Collaboration with 1.Collaboration with

Respiratory Therapists. respiratory therapists is
crucial for the
management of patients
with difficulty breathing
during sleep.
Respiratory therapists
can assist in optimizing
CPAP/BiPAP settings,
ensuring proper
equipment maintenance,
and providing additional
patient education.
 2. Collaboration with 2. Sleep specialists can
Sleep Specialist offer expertise in
diagnosing and
managing sleep
disorders like OSA.
Collaboration with sleep
specialists helps ensure
accurate diagnosis,
treatment planning, and
ongoing monitoring of
the patient's condition.

3.Consultation with 3. For patients who need

Dietitians/Nutritionist.
weight management as
part of their treatment
plan, collaboration with
dietitians or nutritionists
can provide specialized
dietary guidance and
support.

Name: Kayesha E. Nuevo, SN Clinical Instructor: Ms. Fave Danielle V. Postrano, MAN, RN