Blank Care Plan Clinical PDF

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Summary

Clinical care plan for Nursing school...

Description

Nursing Care Plan (Disturbed Sleep Pattern) Assessment

Diagnosis

Planning

Implementation

Evaluation

Objective and Subjective Data

Nursing Diagnosis Sleep homeostasis, alterations of the circadian timekeeping system and/or a misalignment between endogenous circadian rhythm and exogenous factors that affect sleep timing.

Outcome Goal After 24 hours or nursing interventions, patient will be able to achieve optimal amount of sleep as evidenced by rested appearance, verbalization of feeling rested and improvement in sleep pattern.

3 Nursing Interventions with Rationale - Assess client’s sleep patterns and usual bedtime rituals and incorporate these into the plan of care. - Observe client’s medication, diet, and caffeine intake. Look for hidden sources of caffeine, such as over- the counter medications. - Provide measures to take before bedtime to assist with sleep.

Outcome Result Usual sleep patterns are individual, data collected through a comprehensive and holistic assessment are needed to determine the etiology of the disturbance.

Subjective Data: “I find it difficult to sleep at night and difficult getting to sleep at night”

Objective Data: Dark circles under the eyes Yawing Restlessness Irritability

FA2021

Difficulty sleeping can be a side effect of medications such as bronchodilators; caffeine can also interfere with sleep. Simple measures can increase quality of sleep.

9/14/2021 MHP

FA2021

9/14/2021 MHP...