DIVINE WORD COLLEGE OF BANGUED
Rizal Street, Zone 6, Bangued, Abra Telefax (074) 752-8003
Bachelor of Science in Nursing (BSN)
NURSING CARE PLAN
NURSING PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
ASSESSMENT
Subjective Data: After 8 hours of After 8 hours of nursing
Disturbed Sleep nursing 1. To obtain baseline
Pattern related to 1. Monitor Vital signs interventions, the patient
data
airway obstruction interventions, the reports mproved rest
patient reports difficulty
and frequent patient will and fewer sleep
falling and staying
awakenings as verbalize improved 2. Assess sleep pattern and interruptions.
asleep, feeling evidenced by a 2. Positioning the
rest and monitor oxygen saturation.
unrefreshed upon patient's report of patient in side-lying to
demonstrate fewer
waking, and frequent difficulty sleeping. reduce airway
sleep interruptions. 3. Educate patient about weight
awakenings throughout obstruction.
reduction and lifestyle
the night.
modification
3. Educate the patient
on the importance of
sleep hygiene.
Objective Data:
4. Encourage adherence to Advise them to
CPAP therapy maintain a consistent
sleep schedule,
create a relaxing
Difficulty breathing bedtime routine, and
avoid caffeine,
alcohol, and large
Temp: 36.2 meals before bed.
Pulse Rate: 98
Respiratory rate: 22 4. Assist the patient with
breaths/min the use of a
BP: 110/80 continuous positive
airway pressure
Sp02: 94%
(CPAP) machine.
Explain the purpose
and proper use of the
(+) labored breathing device, emphasizing
the importance of
consistent use for
(+) Restlessness effective treatment.
