DAVAO DOCTORS COLLEGE

General Malvar St., Davao City

Nursing Program

NURSING CARE PLAN

Name of Patient: Patient N. Date of Admission: October 01, 2022 Room: Postpartal Unit
Age: 29 y.o Sex: Female Civil Status: N/A Chief Complaint: experience contractions for the past 6 hours
Religion: N/A Attending Physician:

GOALS/OBJECTIVES NURSING
PROBLEM SCIENTIFIC BASIS RATIONALE EVALUATION
CRITERIA INTERVENTIONS
October 01, 2022, Nursing Diagnosis After 8 hours of INDEPENDENT October 1, 2022,
1:00 AM rendering nursing 1. Identify presence of 1. Sleep problems can 8:00 AM
Disturbed sleep pattern intervention, the patient factors known to arise from internal and
Subjective Data: related to situational will be able to: interfere with sleep. external factors and “Goal Partially Met”
I was in labor for more crisis as evidenced by may require
than 10 hours verbalization of a. Identify individually assessment over timeAfter my 8 hours span
and “I had no sleep at inadequate rest. appropriate to differentiate specifictime of care, the patient
all last night.” I need interventions to cause. has partially met the goal
sleep” as verbalized by promote sleep. as the patient was able
the patient. 2. Note environmental 2. These factors canto:
b. Report improved factors, such as reduce client’s ability to
Objective Data: Scientific Basis sleep. uncomfortable room, rest and sleep at a time a. Identify individually
• appears pale and excessive noise and when more rest is appropriate
sleepy Disturbed Sleep pattern c. Report increased light, frequent needed. interventions to
• tired and is a time-limited sense of medical and promote sleep.
exhausted after awakenings due to Well- being monitoring
following childbirth external factors, such andfeeling interventions. b. Verbalized
• experienced a as checking and rested. “nakatulog na jud
great deal of monitoring of vital 3. Observe for physical 3. Information collected kog way putol-
anxiety and pain signs, administering of signs of fatigue. from a comprehensive putol”
• postpartum medication, noises of assessment may be
complication was the room and lighting needed to evaluate the c. Reported a light
addressed that will lead her to type and etiology of increased sense of
• sleep disturbance have an inadequate sleep disturbance and well-being and
• conscious though rest. identify useful treatment feeling rested.
weak to get out of options.
bed to go to the
 bathroom 4. Assess client’s usual 4. To determine usual
sleep patterns and sleep pattern and
Vital Signs: REFERENCES: compare with current provide comparative
Herdman,H., Kamitsuru, sleep disturbance. baseline.
• HR: 105 bpm S., & Lopes, CT. (2021).
• Temperature: 35.3 NANDA international,Inc. 5. Request visitors to 5. To provide privacy
C Nursing Diagnosis: leave, close room and promote readiness
Definition and door, post “Quiet, for sleep and improve
Classifications 2021-2023 patient sleeping” sign. sleep duration and
(12th edition). Thieme quality.
Medical Publishers, Inc.
Doenges, M., 6. Provide bedtime care 6. To promote physical
Moorhouse, MF., & Murr, such as straightening comfort.
A. (2019). bed sheets, changing
Nurses Pocket Guide : damp linens or gown,
Diagnosis, Prioritized and back massage.
Interventions, and
Rationales (15th edition). 7. Perform monitoring 7. Allows for longer
F. A. Davis Company and care activities periods of uninterrupted
without waking client sleep, especially during
whenever possible. night.

8. Assure client that 8. Knowledge that

occasional occasional insomnia is
sleeplessness should universal and usuallynot
not threaten health harmful may promote
and that resolving relaxation and relief
time-limited situation from worry, which can
can restore healthful perpetuate theproblem.
sleep.

DEPENDENT
9. To relieve pain and
9. Administer promote rest.
medications, as
needed, by the
appropriate route and
optimal dosage.
 REFERENCES: COLLABORATION

Herdman,H., Kamitsuru, S., & Lopes, CT. (2021). NANDA international, Inc. 10. Refer to physician or 10. For specific
Nursing Diagnosis: Definition and Classifications 2021-2023 (12th edition). sleep specialist as interventions and/or
Thieme Medical Publishers,Inc. indicated. therapies, including
medications,
Doenges, M., Moorhouse, MF., & Murr, A. (2019). Nurses Pocket Guide : biofeedback.
Diagnosis, Prioritized Interventions, and Rationales (15th edition). F. A. Davis
Company

FATMA AIZAH M. KANDA

BBN/DTS/2020 NAME OF STUDENT