Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Data: Insomnia related to Short-term goal: Independent: To prevent Patient practices
“Hindi ako metabolic disease as After 4 hours of Identify sleep relaxation
makatulog pag evidenced by look of Nursing circumstances that disturbance techniques
gabi.” as tiredness and lack of intervention, interrupt sleep. because of before bedtime
verbalized by the energy in the patient will be Limit fluid intake interruptions. to promote
patient. morning. able to identify in the evening sleep. Patient is
and do Encourage To reduce need involved in daily
Patient reports Inference: appropriate participation in for night time activities thus
difficulty falling Insomnia is most interventions to regular exercise elimination To inducing sleep
and staying asleep often defined by an promote sleep. program during release energy. during night
individual's report of daytime Develop Exercise in time.
Objective Data: sleeping difficulties. Long-Term goal: behavioral bedtime may
Dark shadows Insomnia is most Patient will report program for stimulate rather
under the eyes often thought of as improvement in insomnia such as than relax.
Appears tired in both a sign and a sleeping pattern not napping in
the morning symptom that can such as feeling bedtime, For effective
Sleeping most of accompany several rested after sleep establishing sleep
the day sleep, medical, and after a week of routine bedtime promotion.
psychiatric disorders, continued sleep- and arising, and
characterized by promoting not reading or To relieve
persistent difficulty interventions. watching TV in discomfort and
falling asleep and/or bed take maximum
staying asleep or Dependent: advantage of
sleep of poor quality. Administer sedative effect.
or marked distress for medications if
more than 1 month. ordered 1 hour
before sleep