Need/Nursing Scientific Nursing Value

Objective Rationale Evaluation

Diagnosis/Cues Analysis Intervention Integration
Need: Sleep is required to After 6-8 hours Independent: After 6-8 hours
Physiologic need provide energy for of nursing of nursing
physical and mental intervention, the • Evaluate patient’s response • Establishes patient’s intervention, the
Nursing Diagnosis: activities. As persons patient will be to activity. capabilities or needs and patient was able
Disturbed sleep age the amount of able to: facilitates choice of interventions to:
pattern related to time spent in REM • Reduces stress and excess
difficulty or laboured sleep diminishes. The a. demonstrate a • Provide a quiet environment stimulation, promoting a. the patient was
breathing secondary to amount of sleep that measurable and limit visitors. rest. able to
disease process individuals require increase in demonstrate a
Cues: varies with age and tolerance in • Elevate head and encourage • These measures promote measurable
personal activity with frequent maximal inspiration. increase in
Subjective cues: characteristics. absence of position changes. tolerance in
“Dili ko katulog kay Disruption in the dyspnea and activity with
maglisod ko ug individual’s usual excessive • Encourage deep • Improve ventilation and absence of
ginhawa”, as diurnal pattern of fatigue. breathing exercise. promotes optimal chest dyspnea and
verbalized by the sleep and expansion. excessive fatigue.
patient. wakefulness may be b. Identify
temporary or chronic. negative factors • Encourage adequate rest • Facilitates healing process b. Identified
Such disruptions may affecting activity balanced with moderate and enhances natural negative factors
Objective cues: result in both tolerance and activity. Promote adequate resistance. affecting activity
• Frequent subjective distress eliminate or nutritional intake. tolerance and
yawning and apparent reduce their eliminate or
• Assist patient with self-care • Weakness may make
noticed impairment in effects when reduce their
needs. Keep bed in low activities of daily living
functional abilities. possible. effects when
position and assist and ambulation difficult,
• Fatigue possible.
with ambulation. further assistance is
c. Participate
needed.
• Weak-looking willingly in c. Participated
necessary /
Dependent: • Aids in reduction of willingly in
desired • Provide supplemental shortness of breathe and necessary /
• Dyspnea oxygen via nasal cannula as prevent hyperventilation.
activities. desired activities.
ordered by the physician.
• Use of
accessory
muscles in
breathing

• Restlessness

• Number of
hours of
sleeping = 5
hours.