CUES/NEEDS NURSING RATIONALE GOALS AND INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES

Subjective Data: Disturbed Sleep Sleep is required After 8 hrs of After 8 hours of
Pattern related to to provide energy nursing nursing
“Medyo hirap interruptions for for physical and interventions, the • Assess • Provide mediations, the
akong matulog kasi patient’s sleep information on
monitoring and mental activities. patient will: which to establish goals and
naninibago ako sa patterns and
hospital stimuli The sleep-wake changes, naps and a plan of care for objectives have
lugar at nagigising (noise and cycle is complex, been met, as
frequency by correction of sleep
gising ako sa lighting) consisting of disturbances. manifested by:
• Achieve means of
madaling araw secondary to non different stages of observation of the
optimal amount of
dahil sa ubo ko.” as productive cough consciousness: patient while
sleep as evidenced
articulated by Ms. rapid eye by rested sleeping and
awakening • The patient’s
E.O.P movement (REM) appearance active interaction
sleep, nonrapid with the staff
eye movement • Assess • This ensures
• Demonstrate the patient’s degree
Objective Data: (NREM) sleep, and or show of being patient for
irritability upon of sleep pattern. • The patient’s
wakefulness. The rested by increased
• Yawning awakening ability to go to
amount of sleep activity tolerance sleep without being
• Restlessness and
that individuals easily awakened
difficulty in arousal
• Presence of dark require varies with • Ensure • External
• Become more
circles under the age and personal environment is stimuli interfere
active and • The patient’s
eyes characteristics. quiet and has a with going to sleep
participative in look of being well
Sleep patterns can comfortable and increases
monitoring phases rested and
temperature by awakenings.
be affected by
providing fan, etc participative in
environment, monitoring
especially in purposes
hospital critical • Provide • Prevents
care units. These ritualistic disruption of
patients procedures of clean established pattern
experience sleep linens, and/or bath and promotes
disturbance prior to bedtime comfort and
secondary to the relaxation before
sleep.
noisy, bright
environment, and
frequent • Provide • Promotes
monitoring and backrubs, music, relaxation before
treatments. and other sleep and reduces
relaxation anxiety and
Reference: techniques tension.

Fundamentals of
Nursing; 8th • Instruct • These may
edition; Volume I; relatives to provide help to enhance the
with comfortable sleep patterns in
Kozier
bed linens and terms of good and
pillows conditioned
environment.

Reference:

Nurse’s Care
Plans; 6th edition;
Doenges,
Moorhouse, &
Murr