NURSING CARE PLAN

CUES AND CLUES DIAGNOSIS SCIENTIFIC RATIONALE OBJECTIVES INTERVENTIONS RATIONALE

(ASSESSMENT)
Subjective: Disturbed During stage 1, which is light sleep, Short Term: Educate on techniques that Promotes relaxation and
“Dalawang araw sleep we drift in and out of sleep and can On the night of January 27 promote bedtime comfort drowsiness and help to address
na na wala akong pattern be awakened easily. Our eyes move until discharge, the patient: regimens such as an evening skin-care needs. Milk and protein
matinong tulog very slowly and muscle activity slows. snack, warm milk, warm bath, foods contain tryptophan, a
dahil sa suction People awakened from stage 1 sleep a. Must sleep from reading, back rub or general precursor of serotonin which is
machine. Masyado often remember fragmented visual 9pm or 10pm -6am. massage with lotion at thought to induce and maintain
siyang maingay. images. Many also experience bedtime. sleep.
Sinabi na naming sudden muscle contractions called b. Appears energized
na papalitan pero hypnic myoclonia, often preceded by and attentive to
wala pa raw atang a sensation of starting to fall. These carry out daily tasks Advice the use of soft music or Reduces sensory stimulation by
available.” sudden movements are similar to the upon waking hours. “white noise” during blocking out other environmental
"jump" we make when startled. relaxation. sounds that could interfere with
Objective: When we enter stage 2 sleep, our eye c. Must wake up restful sleep.
 Has droopy movements stop and our brain waves without droopy eyes
eyes. (fluctuations of electrical activity that and eyebags.
 Appears tired. can be measured by electrodes) Advice the reduction of noise Provides an atmosphere
 Eyebags become slower, with occasional and light. Encourage conducive to sleep. Increases
evident. bursts of rapid waves called sleep Long Term: comfortable bedding. comfort for sleep and
 Appears weak spindles. In stage 3, extremely slow After a week of practicing physiologic/ psychological
upon waking brain waves called delta waves begin early sleeping interventions support.
hours. to appear, interspersed with smaller, patient should develop an
faster waves. By stage 4, the brain involuntary habit of sleeping Instruct in relaxation measures Active thinking of problems and
produces delta waves almost at the right time for at least or sleep-inducing techniques depression during times of sleep
exclusively. It is very difficult to wake 6-8 hours a day and must such as guided imagery, deep must be decreased to allow
someone during stages 3 and 4, habitually abide to it every breathing, or progressive patient focus of attaining sleep to
which together are called deep sleep. other day after. muscle relaxation and advice regain energy.
There is no eye movement or muscle consumption of time
activity. People awakened during productively before sleep.
deep sleep do not adjust immediately
and often feel groggy and disoriented Encourage adherence to Reinforces that it is bedtime and
for several minutes after they wake regular bedtime schedule and maintains stability of
up. Some children experience rituals. Encourage family environment. Later than normal
bedwetting, night terrors, or members at home to tell client bedtime may be indicated to
sleepwalking during deep sleep. that when it is time to sleep. allow client to dissipate excess
When we switch into REM sleep, our energy and facilitate falling
breathing becomes more rapid, asleep.
irregular, and shallow, our eyes jerk
rapidly in various directions, and our
limb muscles become temporarily
paralyzed. Our heart rate increases,
our blood pressure rises, and males
develop penile erections. When
people awaken during REM sleep,