Cues/ Nursing Scientific Basis Goals and Nursing Actions Rationale of Evaluation

Evidences Diagnosi Outcome and Nursing Nursing

s Criteria Orders Actions

SUBJECTIVE Disturbed The soft tissues of GOAL: After eight

CUES: sleeping the upper airways After eight hours of
“ Di man ko pattern collapse during hours of nursing
katulog ug related to sleep, resulting in nursing patient
tarong dai interruptio periods of patient interaction
labi na kung n and breathing. The interaction the the patient
naa mo sulod therapeuti individual then patient will be was able to
diri na mga c, rouses enough to able to verbalize
nurse ug mga monitoring resume breathing, verbalize understandi
medtechs” laboratory interrupting normal understanding ng of
test, other sleep pattern. They of disturb sleep/rest
OBJECTIVE generated may complain of sleep/rest disturbance.
CUES: awakening persistent day time pattern
and fatigue despite
-Once shortness what seems to be SPECIFIC
awaken, of breath adequate night OBJECTIVES:
difficulty to time sleep. INDEPENDENT:
sleep again The patient 1.1Assess sleep 1.1 This is to
was observed (Daniel Ricks, will be able to: pattern disturbance acknowledge
Nursing that are associated and identify
-Frequent Fundanmentals,200 1. Verbalize with specific other causes of
awakening at 6) understanding underlying illness sleep
night time of sleep disturbance
disturbance 1.2Plan to
-Seen patient determine client’s/ 1.2 To provide
lying on bed, 2. Identify SO’s expectations of opportunity to
awake, individual adequate sleep address
conscious, appropriate misconceptions
coherent, interventions and unrealistic
afebrile, to promote expectations
tachypneic sleep (Doenges,2006)
with D5NSS 1.3 Identify
infusing well 3.Report circumstances that 1.3 This will
at his right improvement interrupt sleep and help to identify
arm regulated of rest/sleep frequency the disruptions
at 30 gtts/min pattern of sleep and
and with O2 plan
at 2L/min interventions
with the appropriate for
following vital the patient.
signs: 1.4 Evaluate (Doenges,2006)
patient’s feeling and
T: 36.5 perception to the 1.4 To know the
degrees problem extent of the
Celsius problem and
provide
P: 91 bpm therapeutic
management for
RR: 30 cpm the patient
(Doenges,2006)
BP:130/90 DEPENDENT:
21. Arrange care to 2.1 This will
-Dark circles provide for allow the
under the eye uninterrupted patient to rest
noted periods of sleep longer especially
at night. Do
-Frequent much care
yawning without
awakening the
client.
2.2 Provide the (Doenges,2006)
client with a quiet
environment and 2.2 This will
comfort measures allow the client
to rest and
2.3 Instruct the sleep
patient to do less (Doenges,2006)
activity during at
night and limit the 2.3 This will
intake of chocolate, help the client
caffeine, and to reduce night
alcoholic beverages time elimination
prior bedtime. and awakening.
(Doenges,2006)
2.4 Evaluate
patient’s
understanding the
necessity for 2.4 This will to
monitoring the vital reduce anxiety
signs and other care and stress of
when a client is the patient and
hospitalized. to promote
 cooperation
COLLABORATIVE: from the patient
3.1 Assist to develop (Doenges,2006)
schedules that take
advantage of peak 3.1 This will
performance stimulate your
patient to rest
at night and be
able to rest
3.2 Provide patient well.
his personal (Doenges,2006)
sleeping things like
instructions his SO’s 3.2 This will
to bring his own help the client
blanket or pillow to fell more
comfortable and
could stimulate
him to sleep
3.3 Instruct SO’s to (Doenges,2006)
limit visiting hours
and lower voices 3.3 This will
when sleeping. stimulate the
senses of your
patient to sleep.
3.4 Encourage the (Doenges,2006)
patient to exert less
activity at night and 3.4 This wills
try to sleep. your patient to
regain his
strength.
(Doenges,2006)