CUES NURSING RATIONALE GOALS AND
DIAGNOSIS OBJECTIVES
SUBJECTIVE: Disturbed sleep Sleep is a basic human
pattern related need. It is a universal
“Diri ako nangangaturog to environmental biological process
kay sa sobra kapaso ngan changes common to all human
maaringasa” as verbalized being. It is required for
by the patient reasons such as to cope
with the everyday
stresses, to avoid fatigue,
to conserve energy, to
OBJECTIVE: refurbish the mind and
-eye bag body, and to enjoy life
-restlessness more fully. The sleep-
wake is composed of
-yawning
different complex stages
of consciousness namely:
rapid eye movement
(REM) sleep, non-rapid
eye movement (NREM)
sleep, and wakefulness.
Amount of time spent
during the REM sleep
diminishes as person’s
age increases. Age and
personal characteristics
affects the amount of
sleep that individuals
require. Generally, the
demands for sleep
decrease with age.
Disturbance in the
patient’s sleep pattern and
wakefulness may be
temporary or chronic.
Sleep pattern may be
disturbed by the
following factors: bright
environment, frequent
monitoring and
NURSING INTERVENTION RATIONALE Expected
Output
After 8 hours of
After 8hours of Established rapport To promote trust
nursing intervention providing
the patient will Assess pattern of sleep in normal Sleep pattern are unique to each
nursing
achieve optimal environment individual
amount of sleep as interventions, the
evidenced by Identified presence of factors known To Determine appropriate interventions
patient was able
verbalization of to interfere with sleep
feeling rested and to sleep at night
improvement in Encouraged patient to void before To reduce the amount of urine in the
without
sleep pattern. going to sleep bladder therefore decreasing the
number of voiding at night. difficulty and
woken up for
Instruct to avoid heavy meal, alcohol Though hunger can also keep one
and caffeine before retiring. awake, gastric digestion, and monitoring less
stimulation from caffeine and nicotine
frequently.
can disturb sleep
After providing
Instruct to avoid large fluid intake For patient may need to void during
before bedtime. the night nursing
interventions, the
Encourage exercise at daytime. To reduce stress and promote sleep.
patient
Instruct to avoid strenuous activity Over fatigue may cause insomnia.
verbalized of
before bedtime.
being more
Discourage pattern of daytime naps Napping can disrupt normal sleep
rested and
unless deemed necessary to meet pattern.
sleep requirements or if part of one’s relaxed with
usual pattern.
increased sense
Suggest use of soporifics such as Tryptophan facilitates sleep. of wellbeing.
milk.
Recommend an environment Promote sleep.
conducive to sleep or rest (e.g. quiet,
comfortable temp., ventilation,
darkness, closed door).
treatments, traveling, jet Suggest engaging in a relaxing Reduce stress and promote sleep.
lag, sharing a room with activity before retiring, such as warm
another, use of bath, calm music, reading an
medications (especially enjoyable book, relaxation exercises.
alcohol, antihistamines,
antidepressants, beta- Explain the need to avoid This will interfere with inducing a
blockers, bronchodilators, concentrating on the next activities or restful state.
caffeine, decongestants, on ones problems at bedtime.
narcotics, steroids,
hypnotics, and anti-
anxiety drugs), changes If not able to fall sleep after 30-45 The bed should not associated with
in routines such as in, mins. Suggest getting out bed and wakefulness.
night-shift rotations that engaging in a relaxing on activity.
change one’s circadian
rhythms, acute illness, or
emotional problems such Teach about possible causes of Awareness of possible causes of
as depression or anxiety. sleeping difficulties and optimal sleeping difficulty.
The major goal for clients ways to treat them.
with sleep disturbances is
to maintain or develop a
sleeping pattern that Instruct on non-pharmacological To be able to learn techniques to
provides sufficient energy sleep enhancement techniques. enhance sleep.
for daily activities. Other
goals may relate to
enhancing the client’s
feeling of well-being or
improving the quality and
quantity of the client’s
sleep.