RLE FORM 002

Cebu Normal University

College of Nursing
Cebu City

Mission-Vision: Care Using Knowledge and Compassion

NURSING CARE PLAN

NCP Scoring System 10 pts Defining Characteristics 3 pts Intervention 3 pts

Nursing Dx 2 pts Outcome 1 pt Bibliography 1 pt (at least 5 eferences)

Client’s Name: ___________________________________________________ Patient Care Classification: (Please Check)

Age ._Sex: F__ Civil Status:_single _ Religion: _Roman Catholic________________
Allergies: Food: __pt has no known food allergies __________________________________
Drug: __no known drug allergies_________________________________________
Diet: _Soft Diet________________________________________________________
Date of Admission: _
Diagnosis: __
___________________________________________________________________________
__________ Wholly Compensatory: Pts. Therapeutic self-care is accomplished by
nurse
____/_____Partially Compensatory: Pts. Performs some self-care measures
__________ Supportive Educative Pts. Accomplishes self-care measures
Clinical Division and Bed No: _____________________________________
Name of Physician: __Dr. _______________________________
Name of Student: ____ENOC, MIKKO CASTILLO_____________________________

DEFINING CHARACTERISTICS EXPECTED OUTCOME CRITERIA INTERVENTION AND RATIONALE BEHAVIORAL OUTCOME
(Ideal) (Actual)
Nursing Diagnosis: Sleep deprivation
LONG-TERM: I: Ascertain usual sleep habits and
r/t to uncomfortable sleeping After 2 days of nursing changes that are occurring.
environment as evidence by
intervention the pt will report R: Determines the need for action and
verbalization of interrupted sleep and
improvement in sleep pattern helps to identify appropriate
lethargy. SHORT-TERM: interventions.
After 8 hours of nursing S: Nursing Care Plan.4th ed.
S: “Wala ko tarung tulog anhe.” As intervention the pt will identify I: Provide comfortable beddings and
verbalized by the patient individually appropriate interventions some of own possessions
to promote sleep, and to demonstrate R: Increase comfort for sleep
O: >received pt lying in bed, report of having a restful sleep. S: Nurse’s Pocket Guide.11th ed
conscious, awake and coherent and I: Encourage the pt to avoid/restrict
nondyspneic
>w/ newly hooked IV #3 D5NSS @ 30
gtts/min infusing well to the left arm
>w/ FBC attached to Urobag with
urine level of 200cc
>listlessness/lethargy noted
>patient looks tired and restless
>seen being uncomfortable
LAB RESULTS
>no significant lab results
THEORITICAL BASIS:
SLEEP DEPRIVATION means prolonged
periods of time without sleep. This
could be due to environmental,
physiologic, and psychologic factor. In
my patient’s case, the it is the
environmental factor that causes
interruption of sleep. This sleep
deprivation decreases the amount of
quality and consistency of sleep which
can be harmful to health and can
delay the healing process. Sleep in
some ways restores the normal levels
of activity , normal balance among
parts of nervous system( Guyton
1991, p.611) Studies have shown that
sleep is also necessary for protein
synthesis which allows repair process
to occur (Dorociak 1990, p.40) it has
been suggested that maintaining a
regular sleep wake rhythm is more
important than the number of hours
of actual sleep. It then follows that
reestablishing a disturbed sleep wake
cycle is important aspect of nursing.
intake of caffeine, alcohol and other
stimulating substances from the late
afternoon and evening.
R: To avoid stimulating substances in
order to have a comfortable rest
S: Nurse’s Pocket Guide.11th ed
I: investigate anxious feelings
DEPENDENT/COLLABORATIVE: R: To determine the basis and
I: Administer antihypertensives to pt appropriate anxiety reduction
as ordered techniques
R: Decrease feeling of being ill can S: Nursing Care Plan.4th ed.
induce sleep I: Provide a less disturbing
S: Nursing Care Plan.4th ed. environment.
I: Administer pain relieving R: To promote sleep
medications S: Nursing Care Plan.4th ed.
R: to decrease discomfort I: instruct relaxation techniques
S: Nursing Care Plan.4th ed. R: Help induce sleep
I: Administer sedatives, hypnotics as S: Nursing Care Plan.4th ed.
indicated I: Avoid interruptions during sleep as
R: to induce sleep possible
S: Nursing Care Plan.4th ed. R: Uninterrupted sleep is more restful
and patient may be unable to return
to sleep when awaken
S: Nursing Care Plan.4th ed.
I: Encourage the patient to position in
comfort
R: Repositioning alters the areas of
pressures thus promoting sleep
S: Nursing Care Plan.4th ed.
I: Supports continuation of bed time
rituals
R: promotes relaxation and readiness
for sleep
S: Nursing Care Plan.4th ed.
BIBLIOGRAPHY
>Brunner & Suddarth, Medical-Surgical
Nursing, 10th ed.
> Doenges, Marilyn E. et. al. 2004.Nurse’s
Pocket Guide.11th ed., Philadelphia, FA
Davis Company
>Moyet, Lynda Juall.2006.Nursing
Diagnosis: Application to Clinical
Practice.Edition 11.Lippincott Williams and
Wilkins
>Wilkinson, et. al. Prentice Hall: Nursing
Diagnosis Handbook.Singapore: Pearson
2008, p.451
> Doenges, Marilyn E. et. al. 2004.Nursing
Care Plan.4th ed., Philadelphia, FA Davis
Company
>Pilliterri A, (2007) Maternal and Child
Nursing: Care of Childbearing and
Childrearing Family (vol.1) 5th edition;
Philadelphia Pennsylvania F.A. Davis
Company
> Kozier et al (1998). Fundamentals of
Nursing, New York. Addison Wesley
Longman Inc.