NURSING CARE PLAN

ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTIONS RATIONALE EVALUATION

DATA

Subjective: Disturbed sleeping An altered health status Short Term Goal: Independent:
“Hindi siya pattern related to can affect one’s peace After 30 minutes of 1. Identify factors -Sleep problems can arise
nakakatulog sa gabi” as apprehension regarding of mind. Time-limited nursing interventions, known to interfere with from internal and external
verbalized by the S.O. abnormalities in health interruptions of sleep the client will state sleep include current factors and may require
and hot and noisy amount and quality due ways to improve sleep illness and assessment overtime.
“Irritable siya minsan environment as to internal and external pattern such as hospitalization.
dahil masakit yung evidenced by factors. providing a quiet
mga mga medisina na diaphoresis, body environment and 2. Provide a quiet -Provides a conducive
ineinject sakanya” as malaise, and Source: different comfort environment. atmosphere to relax.
verbalized by the S.O. verbalization of Manual of Nursing measures.
complaints. Diagnosis by Marjory 3. Minimize sleep -To promote readiness for
Objective: Gordon After 3 days of disturbing factors such sleep, and improve sleep
-Body malaise noted. nursing interventions, as: duration and quality.
the client will report a). loud talking
improvement in b). alarms
quality of sleep and c). shutting the door
increased sleeping loudly
periods. d.) beepers

4. Instruct SO to -This soothes and relaxes

provide comfort the client.
measures such as back
rub.

5. Provide bedtime care -To promote physical

such as straightening comfort.
bed sheets & changing
dump linens.

6. Encourage to listen to -To enhance relaxation

peaceful music.

7. Encourage to avoid -To enhance the clients

drinking caffeinated and ability to fall asleep.
alcoholic drinks during
the night.

8. Explore other sleep -To promote wellness.

aids such as warm baths
or milk as indicated.

Collaborative:
- Administer - Antagonizes the effects of
Diphenhydramine 50 histamine at H1-receptor
mg 1 amp now sites; does not bind to or
inactivate histamine.
Significant CNS
depressant and
anticholinergic properties.

Source: Nursing Care

Plans: Guidelines for
Individualizing Client Care
Across the Life Span, 9th
Edition by: Marilynn E.
Doenges, Mary Frances
Moorhouse, and Alice C.
Murr.