Name: Civil Status: Date Admitted:
Age: Religion: Diagnosis:
Sex: Occupation: Attending Physician:
ASSESSMENT DIAGNOSIS PATTERN PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Disturbed sleeping Within my 8 hours span Assessed sleep pattern - High percentage of Goal met. Patient was
“Mag-lisod ko ug tulog pattern r/t interruptions of care, the patient will disturbances that are sleep disturbances are able to sleep for 6
kay permi ko pukawon for therapeutics, achieve optimal associated with specific affected by illnesses. hours within 11:00 pm-
sa mga nurse”. As monitoring, other amount of sleep as underlying illnesses. 7:00am.
verbalized by the pt. generated awakening, evidenced by rested
and excessive appearance, Observed and obtained - To determine usual
stimulation (noise and verbalization of feeling feedback from clients sleep pattern and
Objective: lighting) rested, and regarding usual provide appropriate
-Dark circles under improvement in sleep bedtime, routines, # of intervention.
eyes-Restlessness- pattern hours of sleep, and
Irritability-Dozing- environmental needs.
Yawning-Difficulty in
arousal-Change in Did as much care as - To avoid disturbances
possible without during sleep, and to
waking the client, and maximize sleeping
did as much care as process.
possible while the
patient is still awake.
Explained necessity of -So that patient will
disturbances for have an understanding
monitoring VS and care of the importance of
when hospitalized. care being done to her.
Minimizes complaints.
Encouraged wearing -To enhance ability to
eye cover, drinking fall asleep
warm milk, and
sleeping at the same
time