G.

NURSING CARE PLAN

ASSESSMENT Subjective: Hindi po ako nakatulog ng maayos, nagigising po ako pag madaling araw tapos nahihirapan na po ako makatulog ulit saka maaga pa po kame ginigising. as verbalized by the client. Objective: >frequent yawning >low energy >cannot focus NURSING DIAGNOSIS Disturbed Sleeping Pattern related to frequently changing sleep-wake schedule as evidenced by the working hours of the client. PLANNING Short Term Outcome: After 2 hours of nursing interventions, the client will state two ways to improve sleep pattern such as providing a quiet environment (straightening sheets) and comfort measures (back rub). Long Term Outcome: After 1 week of nursing interventions, the client will report improvement in quality of sleep pattern. IMPLEMENTATION Independent: Provide quiet environment Provide comfort measures (back rub). Arrange care to provide uninterrupted sleep. Recommend Limiting intake of caffeine and chocolate prior to sleep. Explore other sleep aids. (warm bath or milk) SCIENTIFIC RATIONALE -this provides a conducive environment for the client to relax. -this soothes and relaxes the client. -to promote wellness. EVALUATION Outcome Achieved. After 2 hours of nursing interventions, the client stated two ways to improve sleep pattern such as providing a quiet environment (straightening sheets) and comfort measures (back rub). Goal met After 1 week of nursing interventions, the client will report improvement in quality of sleep pattern. Goal met

-Caffeine inhibits sleep

-to promote wellness.

NURSING DIAGNOSIS Subjective: Disturbed -----thought process Objective: related to >short mental attention span disorder as >distractibility evidenced by >disordered altered thought attention sequencing span >cannot maintain eye contact

ASSESSMENT

PLANNING Short Term Outcome: After 5 hours of nursing interventions, the client will recognize changes in thinking / behaviour such as (focusing and being attentive.) Long Term Outcome: After 1 week of nursing interventions, the client will be able to identify interventions to deal effectively with situation, demonstrate behaviors/lifestyle changes to prevent/minimize changes in mentation and maintain usual reality orientation

IMPLEMENTATION >Identify factors present

SCIENTIFIC RATIONALE >To assess causative/contributing Factors

EVALUATION

>Assess attention span/distractibility and ability to make decisions or problemsolve. >Interview SO(s)

>Note occurrence of paranoia and delusions, hallucinations. Assess clients anxiety level in relation to situation >Maintain a pleasant, quiet environment and approach in a slow, calm manner. Client may respond with

Short Term Outcome: After 5 hours of nursing >Determines ability to interventions, the participate in planning client recognized /executing care. changes in thinking / behaviour such as (focusing and >to determine usual being attentive.) thinking ability, changes Goal met. in behavior, length of time problem has Long Term existed, and other Outcome: pertinent information to After 1 week of provide baseline for nursing comparison interventions, the client was able to >To assess degree of identify impairment interventions to deal effectively with situation, demonstrate behaviors/lifestyle >To create therapeutic changes to milieu prevent/minimize changes in mentation and maintain usual reality orientation.

anxious or aggressive behaviors if startled or overstimulated >Give simple directions, using short words and simple sentences >Maintain realityoriented relationship and environment. Present reality concisely and briefly and do not challenge illogical thinking. >Refrain from forcing activities and communications >Allow more time for client to respond to questions/comments and make simple decisions. >Encourage participation in resocialization activities/groups when available.

Goal Partially met. >to allow patient process things one at a time >to provide awareness.

>to avoid conflicts between the nurse and patient >to allow the patient to process what is happening or the question >to develop the sense of socialization of the patient and to assist client coping strategies