“DISTURBED SLEEP PATTERN”

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Disturbed After 1 week of Independent: After 1 week of
“Kapag sleep nursing > Assess past patterns of > Sleep patterns nursing
umaatake pattern as intervention the sleep in normal environment: are unique to intervention
yung sakit ng manifested client will: amount, bedtime rituals, each individual. the client has
likod niya, di by eye bags depth, length, positions, aids, been able to:
na sya halos related to > achieves and interfering agents.
makatulog attack of optimal > achieved
dahil sa back pain amounts of > Document nursing or optimal
sobrang during night sleep as caregiver observations of > Often, the amounts of
sakit.” As evidenced by sleeping and wakeful patient’s sleep as
verbalized by rested behaviors. Record number of perception of the evidenced by
the patient’s appearance sleep hours. Note physical problem may rested
wife. (e.g., noise, pain or differ from appearance
> verbalizes discomfort, urinary objective
Objective: of feeling frequency) and/or evaluation. > verbalized
> rested psychological (e.g., fear, of feeling
restlessness anxiety) circumstances that rested
> eyebags > Improve in his interrupt sleep
sleep pattern. > This can > Improved his
> Provide quite environment provide sleep pattern.
> reports conducive
improvement of environment to > reported
quality in his sleep with. improvement
sleep pattern of quality in his
>Provide comfort measures > it soothes and sleep pattern
(back rub). relaxes the client.

> Give medications such as > to relieve pain

sedatives and pain reliever and provide the
 as prescribed by the patient to sleep
physician before bedtime. during night.
Submitted by: Agoyaoy, Leah G. BSN 3Y3-5A Submitted to: Ms. Norilyn
Limchanco

NURSING CARE PLAN

“IMPAIRED PHYSICAL MOBILITY”
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Impaired After 3 days of Independent: After 3 days of
“Di pa din sya physical nursing nursing
nakakalakad mobility as intervention the > Determine the diagnosis > To identify the intervention
ng maayos manifested patient will: that contributes to immobility causative/ the patient has
hanngang by contributing been able to:
ngayon.” As inability to > demonstrates factors
manifested by perform and verbalizes > Provide safety measures >
the patient’s gross/fine proper exercises (Side rails up, using pillows to > To provide demonstrated
wife. movement of his lower support the body part) safety and verbalized
and skills extremities proper
Objective: such as > Assisted with normal ROM exercises of his
> Body walking > perform ADL’s exercise and proper function > Necessary to lower
weakness related to with minimal of lower extremities. regain normal extremities
> Inability to tumor in his assistance mobility of leg to
perform spine. > Encourage progressive speed recovery > performed
gross/fine activities according to level ADL’s with
movement of fatigue. > Increase minimal
and skills patient’s assistance
such as use of affected
walking. leg