The document discusses a nursing assessment and plan of care for a patient experiencing disturbed sleep patterns due to environmental factors. The nursing diagnosis is disturbed sleep pattern related to environmental noise and light. Short term goals are for the patient to understand their sleep disturbance and verbalize their usual sleep pattern. Interventions include observing the patient's sleep habits, addressing misconceptions, and advising limiting caffeine and taking naps. The objective is to evaluate sleep quality measures and the long term goal is improved sleep and well-being.

1. ASSESSMENT
NURSING
DIAGNOSIS
PLANNING
NURSING
INTERVENTIONS
RATIONALE EVALUATION
Subjective:
Disturbed
sleep pattern
r/t
environmenta
l factors such
as giving of
medication,
vital signs
monitoring
noise and
lighting
Short Term: Independent:
>to determine usual sleep
pattern and provide
comparative baseline
>provides opportunity to
address misconception/
unrealistic expectation
>this contains ingredients that
decreases the ability to fall
asleep
>to compensate the lack of
sleep
Short Term:
“Putol-putol
ang tulog ko”
as verbalized
by the client
Within 1 hour
of adequate
nursing
intervention/
teaching the
patient will be
able to
verbalize
understanding
of sleep
disturbance
>Observe and obtain
feedback from client
regarding usual bedtime,
rituals and number of hours
of sleep
>determine client’s
expectation of adequate
sleep
>Recommend limiting of
caffeine/ alcohol use and
eating of chocolate prior to
sleep
>Advise patient to take a
nap
After 1 hour of
adequate nursing
intervention the
patient was able
to verbalized
understanding of
sleep disturbance
>Goal metObjective:
>Irritable
>lethargic
>dark circles
under eyes
>hypo
responsiveness
>less than 6
1/2 hours of
sleep
Long Term:
After the shift of
adequate nursing
intervention the
patient wasn’t
able to improve
sleeping pattern.
>Goal not met
Long Term:
Within the shift
of adequate
nursing
intervention the
patient will be
able to report
improvement in
sleep/ rest
pattern and
increase sense
of well-being
and feeling
rested