Nursing Care Plan

#1
ASSESSMENT
S:
Hirap na akong
makatulog pag
nagising ako
dahil sa ingay
nila
O:
Restlessness
Irritability

DIAGNOSIS
Disturbed sleep
pattern related to
environmental
factor noise as
evidenced by
restlessness,
irritability,

PLANNING
Long term:

INTERVENTION
> Record number
of sleep hours.

>Limit fluid
intake in evening
if nocturia is a
problem.

RATIONALE
>Often, the
patients problem
may differ from
objective
evaluation.
>To reduce need
for nighttime
elimination.

>Encourage
participation in
regular exercise
program during
day.

>To aid in stress

control/ release
energy.

>Recommend
inclusion of
betime
snack(ex:Milk)

>To reduce sleep

interference from
hunger/hypoglyce
mia.

>Recommend
midmorning nap
if one is required.

>napping,
especially in the
afternoon, can
disrupt, normal
sleep pattern.

>

EVALUATION

>

ASSESSMENT
S:

O:
-Lacks of
concentration
- inattentive
-Excessive and
constant motor
activity
-Inability to
control
behavior
- speaks loudly
and rapidly

DIAGNOSIS
Risk for injury
related to
hyperactivity
as manifested
by excessive
constant motor
activity and
inability to
control
behavior.

PLANNING

INTERVENTION
>Provide an area where the
patient can move around an
release excess energy.

RATIONALE
> To decrease
hyperactivity.

>Remove harmful objects

from the patients
surrounding.(ex:sharps).

>To lessen
factors of injury
.

>minimize inviromental
stimulation (ex:bright, light,
loud noise)

>to calm the

patients
internal state
an rweuce
hyperactivity.

>engage client in daily

activities(ex:
exercise,recreational,occup
ational.

>to decrease
tension an
provide focus.

EVALUATION

>instruct the client perform

relaxation technique(ex:
deep breathing exercise)

>praise the client for the

efforts of performing
productive tasks.

>to reduce
stress.

>to increase
self esteem
and reinforce
safe adaptive
behaviors.