Defining Nursing Diagnoses Scientific Analysis Goal of Care Nursing Interventions Rationale Evaluation

Characteristics
Subjective: Disturbed Sleep During the depressed phase Short Term: Independent: Short Term:
Pattern Related to of the bipolar disorder, it's 1. Arrange care to provide 1. A silent and calm After 2 days of nursing
“Dili ko katulog Episodes common to experience After 1 hour of nursing for uninterrupted periods of environment during intervention, the patient
ug tarung , naa of Delusion insomnia, characterized by intervention the patient rest, especially allowing sleep will help to had identified individually
man koy Secondary to difficulty falling asleep, will identify individually for longer periods of sleep at lengthen the range appropriate interventions
insomnia , nakit- Bipolar Disorder A staying asleep, or waking appropriate interventions night when possible. of sleep. to promote sleep.
an nako akung s evidenced by: up too early. to promote sleep. 2. Encourage client to GOAL MET
bana , gibisita ko Bipolar depressed patients establish a bedtime routine to 2. Rituals and routines
niya , naka puti “Dili ko katulog ug are also particularly Long Term: facilitate transition from induce comfort, Long Term:
siya” tarung , naa man sensitive to hypersomnia -- After 4 days of student wakefulness to sleep. relaxation, and sleep. After 4 days of student
koy insomnia , characterized by too much nursing Intervention the 3. Encourage client to nursing Intervention the
nakit-an nako sleep, sometimes up to 18 patient will reporteliminate stressful situations 3.Stress interferes with a patient will report
akung bana , hours per day, and daytime improvements in quality of before bedtime. person’s ability to relax, improvements in quality of
Objective : gibisita ko niya , fatigue. What's especially sleep pattern as evidenced 1. A silent and calm rest, and sleep sleep pattern as evidenced
naka puti siya” problematic with bipolar by: environment during sleep will by:
● Appears patients is that sometimes ● Verbalization of help to lengthen the range •“mas naka tulog ko ug
restless deprivation of sleep for any feeling of sleep. tarung ma’am karun kaysa
● Dark reason – such as caffeine of satisfaction after2. Rituals and routines induce ni aging adlaw” as
circles consumption --could lead to walking in the comfort, relaxation, and verbalized by patient
under the a switch into mania-- which morning sleep. ● no feeling of
eyes could be a big problem. ● no feeling of3.Stress interferes with a fatigue after
fatigue afterperson’s ability to relax, rest, waking up
and sleep ● .Not restless and
● Dissatisf waking up
Reference: Psychiatric weak , no frequent
action Nursing Care Plans 5th ● No restless and Dependent:
weak, no frequent 1.Administer Chlorpromazin 1.Has a therapeutic yawning and dark
with Edition, Fortinash,
yawning and dark e as ordered. effect of sedation that eyes
sleep Holoday Worret page 185-
202 eyes may induce sleep GOAL PARTIALLY
MET
● Frequent
yawning