MCN Form 016

Lyceum of the Philippines University

College of Nursing

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Data: -Sleep Pattern After 8hrs. Review normal sleep
“nahihirapan akong makatulog ng disturbance Of nursing requirement changes -Helps identify need for
maayos” related to interventions, associated with establishing different
inability to the client will pregnancy. Determine sleep patterns (e.g.,
Objective Data: maintain comfort report increased current patterns. earlier bedtime and
V/S as follows: as evidenced by sense of well- naps).
BP-140/80 interrupted being and
HR-76 sleep, not feeling feeling rested.
RR-19 Back discomfort may
well rested and
O2sat-97 Suggest side-lying necessitate change in
dark circles
Temp-36.5 position with pillow position, use of
under eyes.
between legs for multiple pillows/body
support, or place pillow, or firmer
bed board under mattress.
mattress

Assess for Excess anxiety,

occurrence of excitement, physical
insomnia and for discomforts, nocturia,
client’s to sleep and fetal activity all
loss. Suggest aids may contribute to
to sleep such , such sleeping difficulties.
relaxation
techniques/tapes,
reading, warm bath,
 MCN Form 016

Lyceum of the Philippines University

College of Nursing
and reduced activity
just before
retiring.

Note reports of
positional breathing In a Recumbent position,
difficulties. the enlarging uterus and.
Suggest sleeping in the abdominal organs
a semi-Fowler’s compress the diaphragm,
position thereby restricting lung
expansion. Use of semi-
Fowler’s position allows
the diaphragm to descend,
fostering optimal lung
expansion