1. ASSESSMENT
NURSING
DIAGNOSIS
PLANNING
NURSING
INTERVENTIONS
RATIONALE EVALUATION
Subjective:
Disturbed
sleep pattern
r/t
environmenta
l factors such
as giving of
medication,
vital signs
monitoring
noise and
lighting
Short Term: Independent:
>to determine usual sleep
pattern and provide
comparative baseline
>provides opportunity to
address misconception/
unrealistic expectation
>this contains ingredients that
decreases the ability to fall
asleep
>to compensate the lack of
sleep
Short Term:
“Putol-putol
ang tulog ko”
as verbalized
by the client
Within 1 hour
of adequate
nursing
intervention/
teaching the
patient will be
able to
verbalize
understanding
of sleep
disturbance
>Observe and obtain
feedback from client
regarding usual bedtime,
rituals and number of hours
of sleep
>determine client’s
expectation of adequate
sleep
>Recommend limiting of
caffeine/ alcohol use and
eating of chocolate prior to
sleep
>Advise patient to take a
nap
After 1 hour of
adequate nursing
intervention the
patient was able
to verbalized
understanding of
sleep disturbance
>Goal metObjective:
>Irritable
>lethargic
>dark circles
under eyes
>hypo
responsiveness
>less than 6
1/2 hours of
sleep
Long Term:
After the shift of
adequate nursing
intervention the
patient wasn’t
able to improve
sleeping pattern.
>Goal not met
Long Term:
Within the shift
of adequate
nursing
intervention the
patient will be
able to report
improvement in
sleep/ rest
pattern and
increase sense
of well-being
and feeling
rested