This document contains a nursing assessment, diagnosis, plan, implementation, and evaluation for a patient complaining of disturbed sleep pattern and waking up during the night. The nurse assessed eye bags, weakness and restlessness. The short term goal was for the patient to achieve optimal sleep after nursing intervention and the long term goal was improved sleep pattern after 6 hours. After interventions, the patient reported slightly longer sleep at night and not feeling as weak in the morning, meeting the short term goal.
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Disturbed Sleep Pattern
This document contains a nursing assessment, diagnosis, plan, implementation, and evaluation for a patient complaining of disturbed sleep pattern and waking up during the night. The nurse assessed eye bags, weakness and restlessness. The short term goal was for the patient to achieve optimal sleep after nursing intervention and the long term goal was improved sleep pattern after 6 hours. After interventions, the patient reported slightly longer sleep at night and not feeling as weak in the morning, meeting the short term goal.
S Subjective: Disturbed SHORT TERM GOAL: SHORT TERM “palahi akong Sleep Pattern After 2 hours of GOAL: nagigising sa related to nursing intervention, After 2 hours gabi” as waking up the patient will of nursing verbalized by during the achieve optimal intervention, the patient night amount of sleep as the patient (nocturia) evidenced by rested verbalized: Objective data: appearance, “Medyo - presence of verbalization of humaba na eye bags feeling rested, and ang tulog ko - weakness improvement insleep sa gabi. Hindi and restless pattern narin ako masyadong LONG TERM GOAL: mahina After 6 hours of saumaga.” nursing intervention, the patient will be LONG TERM able to report GOAL: improvement in After 6 hours sleep/rest pattern of nursing and increase sense of intervention, well-being and the patient feeling rested was able to improve sleeping pattern
After 1 Week of Nursing Intervention The Client Will Verbalizes of Feeling Rested Assess Past Patterns of Sleep in Normal Environment: Amount, Bedtime Rituals, Depth, Length, Positions, Aids