XI.

NCP
NURSING DIAGNOSIS ANALYSIS GOALS & OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
Sleep deprivation r/t
prolonged discomfort
SUBJECTIVE:
dalawang oras lang tulog
o! as" nag"g"s"ng ao
da#"l sa u$o o ta%os
na#"#"ra%an naong
&aatulog' Nag""s"% d"n
ao tungol nga d"to sa
nang(ar" sa a"n a(a #"ra%
&atulog saa nasa #os%"tal
as" #"ra% &atulog')
General sleep
deprivation may be
either total (e.g., a
person has had no
sleep at all for a
period of days) or
partial (e.g., over a
period of time a
person obtains only
three or four hours
of sleep per night).
Other commonly
observed
behavioral effects
during sleep
deprivation
include fatigue,
inability to
concentrate,
and visual or
tactile illusions and
hallucinations.
These effects
generally become
intensified with
increased loss of
sleep, but they also
wax and wane in a
cyclic fashion in line
with 2!hour
fluctuations in ""G
alpha!wave (# to $2
hert%) phenomena
and with body
temperature,
becoming most
acute in the early
morning hours.
&hanges in
intellectual
GOAL:
A*t+r , da( o* nurs"ng
"nt+r-+nt"on! t#+ %at"+nt
w"ll r+%ort "&%ro-+&+nt "n
sl++% %att+rn'
OBJECTIVES:
A*t+r ,. &"nut+s o* nurs+/
%at"+nt "nt+ra0t"on t#+
%at"+nt w"ll $+ a$l+ to
ascertain duration
of current problem
and efect on
life/functional
abili ty.
Assess clients usual
sleep patterns and
current sleep
disturbance relying
upon client/S!report
of problem.
Incorporate
screening
information into in"
dept# sleep diary or
testingif needed.
D+t+r&"n+ 0l"+nt1s sl++%
+2%+0tat"ons'
L"st+n to
Usual sl++% %att+rns
ar+ "nd"-"dual! $ut
sl++% loss #as $++n
s#own to $+ t#+ &ost
0o&&on 0o&%la"nt
r+%ort+d "n %r"&ar(
0ar+ s+tt"ngs3
t#+r+*or+! s0r++n"ng
*or t#+ %ro$l+& s#ould
$+ t#+ rout"n+'Nursess
Pocket Guide 11
th

edition ! "oen#es$
%oorhouse &nd %urr '(
)*+
'ndividual may have
faulty
beliefs(attitudes
about sleep and
unrealistic
expectations.
Nursess Pocket Guide
11
th
edition ! "oen#es$
%oorhouse &nd %urr '(
)*+
$elps clarify
clients
perception of
E,,ecti-eness
,' 4as t#+ %at"+nt a$l+
to &a"nta"n %at+nt
a"rwa(5
6Y+s 6No
performance during
moderate sleep
loss can to a
certain extent be
compensated for by
increased effort and
motivation.
.E/E.ENCES:
Enc!c0o'edi&
Britt&nic& ! Je,,re!
%( Bo00en#en
A*t+r , #our o* nurs"ng
"nt+r-+nt"on! t#+ 0l"+nt w"ll
$+ a$l+ to %+r*or&
r+la2at"on t+0#n"7u+s and
#a-+ a 7u"+t
A*t+r 8 #our o* nurs"ng
"nt+r-+nt"on! t#+ %at"+nt
w"ll #a-+ 0l+ar &u0us
s+0r+t"ons'
su$9+0t"-+ r+%orts o*
sl++% 7ual"t( :+'g'!
s#ort! "nt+rru%t+d);
and r+s%ons+ *ro&la0
o* good sl++% :*++l"ng
*ogg(! sl++%(! and woo<(!
*"g#t"ng sl++%! *at"gu+!
+t0';'
Ad&"n"st+r &+d"0at"on :+'g'!
$ron0#od"lator! &u0ol(t"0!
#(dro0ort"son+! and ant"$"ot"0;
as ord+r+d $( t#+ do0tor
(DEPENDENT NURSING
INTERVENTION)
In0r+as+ *lu"d "nta+
=+r*or& 0#+st %#(s"ot#+ra%(
sleep
%uantity/%uality
and response to
inade%uate sleep.
Nursess Pocket Guide
11
th
edition ! "oen#es$
%oorhouse &nd %urr '(
)*+
To tr+at t#+ und+rl("ng
0aus+ and "&%ro-+
-+nt"lat"on
Nursess Pocket Guide
11
th
edition ! "oen#es$
%oorhouse &nd %urr '(
*1+
4(drat"on 0an #+l%
l"7u+*( -"s0ous
s+0r+t"ons and "&%ro-+
s+0r+t"on 0l+aran0+
Nursess Pocket Guide
11
th
edition ! "oen#es$
%oorhouse &nd %urr '(
23
To dra"n t#+ s+0r+t"ons
and %ro&ot+ 0#+st
+2%ans"on
Nursess Pocket Guide
11
th
edition ! "oen#es$
>' ?as t#+ %at"+nt a$l+
to #a-+ "n0r+as+
o2(g+nat"on as
+-"d+n0+ $( o2(g+n
saturat"on a$o-+ @.A5
6Y+s 6No
8' ?as t#+ %at"+nt a$l+
to #a-+ 0l+ar &u0us
s+0r+t"ons5
6Y+s 6No
=+r*or& su0t"on"ng as n++d+d
%oorhouse &nd %urr '(
**3
To 0l+ar a"rwa( w#+n
+20+ss"-+ or -"s0ous
s+0r+t"ons ar+ $lo0"ng
Nursess Pocket Guide
11
th
edition ! "oen#es$
%oorhouse &nd %urr '(
**3
E,,icienc!
,' ?+r+ t#+
"nt+r-+nt"ons +**"0"+nt
to &++t t#+ %at"+nt1s
n++ds5
6Y+s 6No
Acce't&i0it!
,' ?+r+ t#+
"nt+r-+nt"ons a00+%t+d
and us+d $( t#+
%at"+nt5
6Y+s 6No
Ade4u&c!
,' ?+r+ t#+ r+s%"rator(
d+-"0+s and
"nt+r-+nt"ons us+d
ad+7uat+ to &++t t#+
n++ds o* t#+ %at"+nt5
6Y+s 6No
A''ro'ri&teness
,' ?+r+ t#+
"nt+r-+nt"ons
a%%ro%r"at+ to &++t t#+
n++ds o* t#+ %at"+nt5
6Y+s 6No
XII. &isc#arge Plan
M '&ICA(I!NS
Advise signi)cant ot#ers to give t#e follo*ing medications at t#e rig#t time
rig#t dose rig#t fre%uency and rig#t route.
Name of Drug Frequency &
dosage
Route Curative
efects
Side efects
+.
C#loramp#enic
ol
+ tsp b.i.d. P.!. Antibiotic
Stomac# upset
&iarr#ea
$eadac#e
Nausea and
,omiting
-. Ambro.ol /.0 ml b.i.d. P.!.
1i%ue)es viscous
secretion
2ild 3I efect
P 4','N(I!NS
Instruct patient to stop smo5ing and alco#ol misuse because it increases t#e
ris5 of #aving pneumonia
Instruct signi)cant ot#ers to perform #and *as#ing before and after contact
to t#e client in order to prevent infection.
Instruct signi)cant ot#ers to maintain cleanliness of t#e #ouse and
surrounding.
'ncourage signi)cant ot#ers to provide *ell ventilated areas.
Inform t#e signi)cant ot#ers to maintain safe #ome free from any #ealt#
#a6ards suc# as s#arp ob7ects c#emicals and matc#es.
T 4'A(2'N(S
Advise signi)cant ot#ers to perform c#est p#ysiot#erapy (I&.
Advise to 5eep clean t#e trac#eostomy and s5in surrounding it.
'ncourage follo* up for c#est X"ray.
H 'A1($ ('AC$IN3
Advise signi)cant ot#ers to continue ta5ing full course of antibiotics as
prescribed.
Instruct signi)cant ot#ers about t#e symptoms t#at re%uire contacting t#e
#ealt# care provider8 di9culty of breat#ing *orsening coug#
recurrent/increasing fever and medication intolerance.
'ncourage signi)cant ot#ers to provide c#ild a good sleeping time and
ade%uate nutrition.
Instruct signi)cant ot#ers to observe proper #ygiene suc# as #and *as#ing
clean trac#eostomy site.
Instruct signi)cant ot#ers not to ta5e t#e patient in cro*ded areas.
Instruct signi)cant ot#ers to avoid any allergens t#at mig#t #ave in contact
*it# t#e patient.
O :("PA(I'N( ;!11!< :P
4emind signi)cant ot#ers for a follo* c#ec5 up on August +- -/+=.
D I'(
Advise to follo* rig#t ,itamin C and multivitamin supplements to be ta5en.
'ncourage increase in >uid inta5e at least ? glasses of *ater per day.