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Assessment Diagnosis Background Knowledge Planning Intervention Rationale Evaluation Subjective

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Angela

The patient was experiencing insomnia related to anxiety as evidenced by difficulty falling and staying asleep, fatigue, and irritability. After one week of nursing interventions including creating trust, determining sleep patterns, encouraging expression of feelings, eliminating stress, educating on sleep factors, discussing comfort measures, and administering medications as needed, the patient was able to obtain optimal amounts of sleep as seen in rested appearance, feeling rejuvenated, and improved sleep patterns.

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Assessment Diagnosis Background Knowledge Planning Intervention Rationale Evaluation Subjective

Uploaded by

Angela
433 views3 pages
The patient was experiencing insomnia related to anxiety as evidenced by difficulty falling and staying asleep, fatigue, and irritability. After one week of nursing interventions including creating trust, determining sleep patterns, encouraging expression of feelings, eliminating stress, educating on sleep factors, discussing comfort measures, and administering medications as needed, the patient was able to obtain optimal amounts of sleep as seen in rested appearance, feeling rejuvenated, and improved sleep patterns.

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NCP for Insomnia

Original Title

NCP-FOR-TONY-STARK

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The patient was experiencing insomnia related to anxiety as evidenced by difficulty falling and staying asleep, fatigue, and irritability. After one week of nursing interventions including creating trust, determining sleep patterns, encouraging expression of feelings, eliminating stress, educating on sleep factors, discussing comfort measures, and administering medications as needed, the patient was able to obtain optimal amounts of sleep as seen in rested appearance, feeling rejuvenated, and improved sleep patterns.

Copyright:

© All Rights Reserved
Download as DOCX, PDF, TXT or read online from Scribd
Download as docx, pdf, or txt
433 views3 pages

Assessment Diagnosis Background Knowledge Planning Intervention Rationale Evaluation Subjective

Uploaded by

Angela
The patient was experiencing insomnia related to anxiety as evidenced by difficulty falling and staying asleep, fatigue, and irritability. After one week of nursing interventions including creating trust, determining sleep patterns, encouraging expression of feelings, eliminating stress, educating on sleep factors, discussing comfort measures, and administering medications as needed, the patient was able to obtain optimal amounts of sleep as seen in rested appearance, feeling rejuvenated, and improved sleep patterns.

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ASSESSMENT DIAGNOSIS BACKGROUND PLANNING INTERVENTION RATIONALE EVALUATION

KNOWLEDGE
SUBJECTIVE Insomnia related Biological, physical, After 1 week of 1. Create an -Trust is an After 1 week of
Patient stated to anxiety as psychological, and nursing atmosphere to essential first step nursing
increased difficulty evidenced by environmental interventions, the facilitate trust. in the therapeutic interventions,
in falling asleep difficulty falling factors patient will obtain relationship. GOAL MET. Patient
and sometimes and remaining optimal amounts was able to obtain
staying asleep asleep, fatigue, of sleep as 2. Determine the -The amount of optimal amounts
since his and irritability. Prolonged period evidenced by client’s sleep and sleep an individual of sleep as
promotion and of stress rested appearance, activity pattern. needs varies with evidenced by
expressed concern verbalization of lifestyle, health, rested appearance,
over the danger of feeling rested, and and age. verbalization of
his occupation and Development of improvement in feeling rejuvenated
his desire to do conditioned sleep pattern. 3. Encourage -Open expression after a good night’s
well in his new arousal to stimuli verbalization of of feelings sleep, and
position. He also that would feelings, facilitates improvement in
complained of normally be perceptions, and identification of sleep pattern.
waking up feeling associated with fears. specific emotions
tired and irritable. sleep such as anger or
helplessness,
distorted
OBJECTIVE Repeated difficulty perceptions, and
V/S with sleep unrealistic fears.
BP: 140/90 mmHg initiation,
Temp: 37°C maintenance, 4. Encourage him -Stress interferes
PR: 80 bpm consolidation to eliminate with a person’s
RR: 18 cpm (insomnia) stressful situations ability to relax,
Pallor and drawn before bedtime. rest, and sleep.
appearance with
dark circles under
eyes Look of tiredness
and lack of energy
in the morning
5. Instruct about -Knowledge of
factors (e.g., causative factors
physiologic, can enable the
psychologic, client to begin to
lifestyle, frequent control factors that
work shift changes, inhibit sleep.
excessively long
work hours, and
other
environmental
factors) that
contribute to sleep
pattern
disturbances.
-Knowledge of
6. Discuss with the factors that affect
client comfort sleep enables the
measures, sleep client to
promoting implement
techniques, and changes in lifestyle
lifestyle changes and prebedtime
that can contribute activities.
to optimal sleep.
Feelings of safety
7. Assist him to use and security
coping responses increase when an
that have been individual
successful in the identifies
past. previously
successful ways of
dealing with
anxiety-provoking
or fearful
situations.
8. Administer -To relieve
sedative-hypnotics, discomfort and
anti-anxiety drugs take maximum
as ordered. advantage of
sedative effect.

GROUP MEMBERS

AUTOR, ANDREA
CAMPOS, KZYL ZAKI
CHUA, KATE JOMAGELL
GUANZON, MICHAELA MARIE
GULAPA, LYANNA JOZETH
MATIAS, JASMINE JOY
PERALTA, GENNELIE AILA
TAN, BIANCA NICOLE
TAPURO, MHARC EDWARD
YABUT, DARLENE

BSN 1-Y0-4

MRS. ROSANNA SUVA

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