FOCUS
CASE: PRIMARY HYPERSOMNIA
Michelle, a 22 year-old lass who had
recently lost her job, have become
hypersomniac for almost 2 months. She
remains in her bed room the whole day
and sleeps 10-12 hrs at night. Her parents
are already worried because Michelle has
already had difficulty in walking and
standing still when she is awake. She has
almost never goes out of their house. Her
friends are also worried because they
never see Michelle as they used to be
before. Upon interview, unrefreshed look
is noticed. There is insufficient data for
diagnosis of depression.
Nursing diagnosis: Disturbed Sleep
Pattern r/t inadequate stimulation.
DATA
*10-12 hrs at night
*frequent daytime naps
*unrefreshed for most of the time
*difficulty in walking and standing still
*excessive sleepiness for 2 months
*difficulty in activities that involve going
outside the house
ACTION RESPONSE
INDEPENDENT:
After 2 weeks of implementing nursing
1. Instruct patient to follow as consistent interventions, the client showed increase
a daily schedule for retiring and arising as in alertness during daytime(ability to
possible.--This promotes regulation of perform daily activities which were
the circadian rhythm, and reduces the previously unattended), decrease in
energy required for adaptation to frequency of daytime naps from 8 to once
changes or twice a day and decrease in the length
of sleep at night from 12 hrs to 8 hours.
2. Discourage pattern of daytime naps
unless deemed necessary to meet sleep
requirements or if part of one’s usual
pattern.--Napping can disrupt normal
sleep pattern
3. Instruct to avoid sleep deprivation and
desire to catch up by excessive sleeping.
—Pattern of sleeping may be more
irregular.
4. Instruct to exercise daily but avoid
exercising before retiring.—Exercise can
increase stimulation at daytime.
5. Discourage intake of alcohol.—It may
aggravate sleep pattern irregularities.
6. Encourage client to regularly take a
bath every morning daily.—May help
increase alertness and conditions client
for daily activities. Also for client’s well-
being.
7. Encourage frequent sips of water and
intake of hard candies during stimulant
therapy—To help reduce signs of dry
mouth.
DEPENDENT:
1. Administer methylphenidate as
prescribed by the doctor in the morning
preferably 30-45 minutes before
breakfast as symptomatic treatment.—
Stimulants increase alertness during
daytime. PO-sustained release peaks at

FOCUS
CASE: PRIMARY INSOMNIA
Michelle, a 22 year-old lass who had
recently employed as a cashier in a
department store, has become
workaholic. She accepts tutorial sessions
for school children after she works the
whole day as a cashier. She is also an
independent supplement distributor and
she attends to orientation and seminars in
their main office during her day off. She
can hardly fall asleep and stay asleep (0-2
hrs) at night for 3 months since she had
her new job. Upon interview, she states
that she can’t concentrate well in her
work and is too worried because her
income can hardly support her daily
expense and matriculation for her
younger sister. History of regular alcohol
intake in attempt to sleep at night,
haggard appearance and eyebags are also
noted. She rarely drinks milk and milk
products. She prefers coffee in the
morning.
Nursing diagnosis: Disturbed Sleep
Pattern r/t excessive stimulation (working
conditions, overfatigue, caffeine and
alcohol intake)
6-8 hrs, duration for 8-12hrs.
DATA ACTION RESPONSE
*0-2 hours sleep at night INDEPENDENT:
*regular alcohol and caffeine intake 1. Instruct to avoid heavy meals, alcohol, After 2 weeks of implementing nursing
*overfatigue caffeine, or smoking before retiring.-- interventions, the client verbalized
*can hardly fall and stay asleep Though hunger can also keep one awake, increase in concentration at work,
*poor concentration gastric digestion and stimulation from participation in relaxation techniques
*haggard appearance caffeine and nicotine can disturb sleep before bedtime and decrease in frequency
of alcohol and caffeine ingestion. Sleep
2. Instruct patient to follow as consistent hours at night ranges from 4-6 hours.
a daily schedule for retiring and arising as Eyebags and haggard appearance can still
possible.--This promotes regulation of be noticed. Noncompliant to intake of
the circadian rhythm, and reduces the milk.
energy required for adaptation to
changes
3. Instruct to avoid sleep deprivation and
desire to catch up by excessive sleeping.
—Pattern of sleeping may be more
irregular.
4. Discourage intake of alcohol.—It may
aggravate sleep pattern irregularities.
5. Instruct to avoid strenuous activity
before bedtime.---Overfatigue may cause
insomnia.
6. Suggest use of soporifics such as
milk.--Milk contains L-tryptophan, which
facilitates sleep
7. Recommend an environment
conducive to sleep or rest (e.g., quiet,
comfortable temperature, ventilation,
darkness, closed door). Suggest use of
earplugs or eye shades as appropriate
8. Suggest engaging in a relaxing activity
before retiring (e.g., warm bath, calm
music, reading an enjoyable book,
relaxation exercises).
9. Explain the need to avoid
concentrating on the next day’s activities
or on one’s problems at bedtime.--
Obviously, this will interfere with
inducing a restful state. Planning a
designated time during the next day to
address these concerns may provide
permission to "let go" of the worries at
bedtime

10. If unable to fall asleep after about 30

to 45 minutes, suggest getting out of bed
and engaging in a relaxing activity.--The
bed should not be associated with
wakefulness.

DEPENDENT:
1. Suggest using hypnotics or sedatives as
ordered; evaluate effectiveness.--Because
of their potential for cumulative effects
and generally limited period of benefit,
use of hypnotic medications should be
thoughtfully considered and avoided if
less aggressive means are effective.
Different drugs are prescribed depending
on whether the patient has trouble falling
asleep or staying asleep. Medications that
suppress REM sleep should be avoided.
 FOCUS
CASE: NARCOLEPSY
Michelle, a 23 year-old lass who was left
by her boyfriend because of being
workaholic, has experienced excessive
sleepiness characterized by irresistible
attacks even during her shift (9am-5pm)
in her work. She was recently warned by
her supervisor about her poor
performance. Upon interview, she states
that she frequently experience brief
paralysis of her limbs during attack
intervals and dreams that somebody is
calling her upon awakening from naps.
Michelle also complained of frequent
awakenings at night because of leg jerks
and frequent nightmares.
Nursing diagnosis: Disturbed Sleep
Pattern r/t abnormal physiological
symptoms.
DATA
* Excessive daytime sleepiness, even
during active states
* Cataplexy
*Brief episodes of brief paralysis
*Dreamlike hallucinations when
awakening from sleep.
*Disturbed nighttime sleep such as leg
jerks, nightmares
ACTION RESPONSE
INDEPENDENT:
After 2 weeks of implementing nursing
1. Instruct patient to follow as consistent interventions, the client showed
a daily schedule for retiring and arising as participation in behavioral restructuring
possible.--This promotes regulation of and compliance in medication but attacks
the circadian rhythm, and reduces the are just decreased and cataplexy are still
energy required for adaptation to apparent.
changes
2. Schedule daytime naps at convenient
times such as after work..--Napping can
disrupt normal sleep pattern.
Rescheduling naps decreases attacks
during working hours.
3. Instruct to avoid sleep deprivation and
desire to catch up by excessive sleeping.
—Pattern of sleeping may be more
irregular.
4. Instruct to exercise daily but avoid
exercising before retiring.—Exercise can
increase stimulation at daytime.
5. Discourage intake of alcohol.—It may
aggravate sleep pattern irregularities.
6. Encourage client to regularly take a
bath every morning daily.—May help
increase alertness and conditions client
for daily activities. Also for client’s well-
being.
7. Encourage frequent sips of water and
intake of hard candies during stimulant
therapy—To help reduce signs of dry
mouth.
DEPENDENT:
1. Administer methylphenidate as
prescribed by the doctor in the morning
preferably 30-45 minutes before
breakfast as symptomatic treatment.—

FOCUS
CASE: OSAS
Michelle, a 35 year-old female who
stands 5’2’’ and weighs 80 kgs,
complains of excessive urination at
night , frequent headaches, malaise and
fatigue. Upon interview, she states that
her husband confront her about periods of
loud snoring and gasping of air. She also
notices that she’s becoming forgetful.
Polysomnography showed blockage of
airflow last 10 seconds to 1 minute and
arouses the patient from sleep as the brain
responds to decreased blood oxygen
levels.
Nursing diagnosis: Disturbed Sleep
Pattern r/t abnormal physiological
symptoms.
Stimulants increase alertness during
daytime. PO-sustained release peaks at
6-8 hrs, duration for 8-12hrs.
DATA ACTION RESPONSE
*Age : 35 y/o INDEPENDENT: GOAL MET:
*Height: 5’2’’ After 1 week of implementing nursing
*Weight: 80 kgs 1. Encourage client to lose weight by interventions, the client verbalized
*complains of excessive urination at exercising daily and eating balance diet. improvement in sleep at night as
night — Most patients with OSAS are manifested with soft snoring and absence
*frequent headaches, malaise and fatigue. overweight with a short, thick neck and of episodes of gasping for air. The client
*loud snoring and gasping of air. fat infiltration around the pharynx that showed compliance in exercise program
*forgetfulness increases the risk of airway blockage. and diet modification. There is marked
* blockage of airflow last 10 seconds to 1 decrease in frequency of headache,
minute 2. Encourage client to sleep on the side malaise and fatigue.
rather than in a supine position-- may
reduce apneic episodes
3. Instruct to avoid sleep deprivation and
desire to catch up by excessive sleeping.
—Pattern of sleeping may be more
irregular.
4. Instruct to exercise daily but avoid
exercising before retiring.—Exercise can
increase stimulation at daytime.
5. Discourage intake of alcohol.—It may
aggravate sleep pattern irregularities.
6. Encourage client to regularly take a
bath every morning daily.—May help
avoid early morning depression.. Also for
client’s well-being.
DEPENDENT:
1. Put client in positive airway pressure
as ordered by the doctor.—It increase O2
levels and prevent devt of further
complications such as dysrrhythmias,
cardiovascular problems, hypercapnia
resulting to acidosis.
 FOCUS
CASE: CIRCARDIAN RHYTHM
PATTERN
Michelle, a 14-year old high school
student has recently had her new
Samsung touch screen celfone, usually
stays up late at night. She goes to her bed
room only after viewing all the teleseryes
in primetime not to lie down in bed but to
write something on her diary until around
1am. Afterwhich, she still remains busy
in texting her buddies and her boyfriend.
She would just fall asleep at around 4-
5am. Her mother complains difficulty in
awakening Michelle by 6 in the morning
for her preparation for school. Upon
interview, Michelle states that she
remains active at night and is difficult to
fall asleep. She feels that she is being
deprived for sleep by her parents that’s
why it’s hard for her to concentrate in
school. There is no hx of alcohol or
coffee intake.
Nursing diagnosis: Disturbed Sleep
Pattern r/t poor sleep hygiene measures.
DATA
* Inability to fall asleep before 2 am to 6
am
*difficulty awakening in the morning
*Feeling of being sleep-deprived
*Significant social or work impairment
*Need for multiple means to awaken
ACTION RESPONSE
INDEPENDENT:
After 1 week of implementing nursing
1. Instruct client to follow as consistent a interventions, the client verbalized
daily schedule for retiring and arising as improvement in sleep at night as
possible.--This promotes regulation of manifested by compliance in sleep
the circadian rhythm, and reduces the hygiene measure, normal length of sleep,
energy required for adaptation to absence of difficulty in falling asleep and
changes awakening in the morning.
2. Instruct to avoid heavy meals before
retiring.—It may cause active movements
in GIT causing client to be physically
active.
3. Instruct to avoid sleep deprivation and
desire to catch up by excessive sleeping.
—Pattern of sleeping may be more
irregular.
4. Instruct to exercise daily but avoid
exercising before retiring.—Exercise can
increase stimulation at daytime.
5. Discourage intake of alcohol.—It may
aggravate sleep pattern irregularities.
6. Encourage client to regularly take a
bath every morning daily.—Help client in
reconditioning oneself for activities in the
day. Also for client’s well-being.
7. Suggest use of soporifics such as
milk.--Milk contains L-tryptophan, which
facilitates sleep
8. Recommend an environment
conducive to sleep or rest (e.g., quiet,
comfortable temperature, ventilation,
darkness, closed door). Suggest use of
earplugs or eye shades as appropriate
9. Suggest engaging in a relaxing activity
before retiring (e.g., warm bath, calm
music, reading an enjoyable book,
relaxation exercises).

10. Explain the need to avoid

concentrating on the next day’s activities
or on one’s problems at bedtime.--
Obviously, this will interfere with
inducing a restful state. Planning a
designated time during the next day to
address these concerns may provide
permission to "let go" of the worries at
bedtime

11. If unable to fall asleep after about 30

to 45 minutes, suggest getting out of bed
and engaging in a relaxing activity.--The
bed should not be associated with
wakefulness.
 FOCUS
CASE: SLEEP DISORDER R/T
MEDICAL CONDITION AND
SUBSTANCE ABUSE
Michelle, a 40-year old widow who
weighs 85 kgs, states “I sleep during the
day because I have nothing to do.” She
also reported use of 5 servings of alcohol
daily, reported use of a pack of cigarettes
daily and verbalization of “I like to sit
here and watch TV” while describing her
bedroom activities. Analysis of client’s
medications revealed medical diagnoses
of GERD, hypertension, diabetes mellitus
II, and obesity.
Nursing diagnosis: Disturbed sleep
pattern r/t inadequate stimulation, poor
sleep hygiene, and substance use
DATA
*history of alcohol and nicotine abuse
*history of medical conditions: DM,
GERD, HTN, and obesity
*inadequate stimulation
ACTION RESPONSE
INDEPENDENT:
1. Obtain a sleep-wake history including After 2 weeks of implementing nursing
history of sleep problems, changes in interventions, the client showed
sleep patterns, and use of medications compliance in nonpharmacologic
and stimulants.--Assessment of sleep interventions but remained noncompliant
behavior and patterns are an important in cessating alcohol and nicotine intake.
part of any health status examination Sleep ranges from 4-6 hours at night.
2. Assess for use of alcohol or cigarettes
prior to use of sleep medication or
retiring for the evening.--Alcohol and
nicotine should be avoided for several
hours prior to sleep
3. Assess for underlying physiological
illnesses as a potential cause for
nighttime sleep loss and daytime
sleepiness (including, but not limited to
pulmonary, cardiovascular and
gastrointestinal conditions).--
Symptomatology of disease states can
cause insomnia
4. Initiate nonpharmacologic
interventions for improved sleep
including:
• Sleep restriction
• Increasing sunlight exposure
• Educational interventions to
promote beneficial sleep hygiene
(Including the impact of substance
use on sleep quality, keeping regular
waking and sleeping times, avoiding
naps, refraining from caffeine,
impact of exercise on sleep and
environmental adjustments to
promote sleep)
• Provide diversional activities to
provide stimulation (painting
projects, scrapbooking/life review
activities)
--Nonpharmacologic interventions have
been found to improve sleep efficiency
and increase satisfaction with sleep
pattern while decreasing use of hypnotics
5. Evaluate learning outcomes using
patient verbalizations of following the
treatment recommendations and
experiencing enhanced sleep.--
Evaluation serves as an assessment of the
effectiveness of care and allows
opportunity for adjustments to the plan of
care.