NURSING CARE PLANS Interpersonal Stressor: Physical Classification Systems Deprivation Nursing Diagnosis: Disturbed sleep pattern related

to excessive environmental stimulation. Scientific Basis: Sleep is required to provide energy for physical and mental abilities. Disruption in the individuals usual diurnal pattern of sleep and wakefulness may be temporary or chronic. Such disruption may result in both subjective distress and apparent impairment in functional activities and abilities. (Nursing Care Plans, 2010) Stressors Nursing Goals Nursing Actions Nursing Outcomes

Stressor as Perceived by the Client: -the other patient and their significant others disturbs his sleep at night and even at daytime -client verbalized Pakatuloga na ko ninyo, maluoy mo. Hatagi nalang ko ug pangkatulog para makapahuway na ko. Stressor as Perceived by the Caregiver: -the client has difficulty sleeping because of noise from other patients and significant others coming in and out of the room. -the patient has difficulty sleeping because he feels ngilo all over his body. Line of Defense Used: -circadian Rhythm

After series of nursing Actions, client will achieve improvement or optimal amounts of sleep as evidenced by rested appearance, verbalization of feeling rested and improvement in sleep pattern.

Primary Intervention: -assess past patterns of sleep in normal environment; amount, bedtime rituals, depth, length, positions, aids and interfering agents. R: Sleep pattern are unique to each individual. -assess patients perception of cause of sleep difficulty and possible relief measures to facilitate treatment. R: Knowing the specific etiological factor will guide appropriate therapy. -Document nursing or caregiver observations of sleeping and wakeful behaviors. Note physical (e.g., noise, pain or discomfort, urinary frequency) and/or psychological (e.g., Fear, anxiety) circumstances that interrupts sleep. Often the clients perception of the problem may differ from objective evaluation. -Identify factors that may facilitate or interfere with normal patterns. R: considerable confusion and myths about sleep exist. Knowledge of this role in health/wellness and the wide variation among individuals may allay anxiety, thereby promoting rest and sleep. -Evaluate timing or effects of medications that can disrupt sleep, in both the hospital and home care settings, patient may be following medication schedule that require awakening in the early morning hours. R: Attention to changes in the schedule or changes to once a day medication may solve the problem.

The patient was able to sleep, and he tried to use the different interventions given like engaging to warm bath, relaxation activities and listening to music.

Secondary Prevention: -Instruct client to follow a consistent daily schedule for retiring and arising as possible. R: this promotes regulation of the circadian rhythm, and reduces the energy required for adaptation to changes. -Instruct to avoid strenuous activity before bedtime. R: Over fatigue may cause insomnia. -Discourage pattern of daytime naps unless deemed necessary to meet sleep requirements or if part of ones usual pattern. R: napping can disrupt normal sleep pattern -suggest use of soporifics such as milk. R: milk contains-tryphtophan which facilitates sleep. -Recommend an environment conducive to sleep and rest (e.g., quite, comfortable temperature, ventilation, darkness, closed door, suggest use of ear plugs or eye shades as appropriate. -Suggest engaging in relaxing activity before retiring (e.g., warm bath, calm music, reading and relaxation exercises) -explain the need to avoid concentration to next days activities or ones problems at bedtime. R: obviously this will interfere with inducing restful state. Planning a designated time during the next day to address these concerns may provide permission to let go of the worries at bedtime. -If unable to fall asleep about 30-45 minutes, suggest engaging in relaxing activity. R: the bed should not be associated with wakefulness. -attempt to allow sleep cycles at least 90 minutes. R: experimental studies have indicated that 60-90 minutes are needed to complete one

cycle, and the completion of an entire cycle is necessary to benefit from sleep. Tertiary Prevention: -teach about possible causes of sleeping difficulties and optimal ways to treat them. -instruct non-pharmacological sleep enhancement techniques, such as deep breathing exercises, music and relaxation exercises.

Classification Systems Deprivation Nursing Diagnosis: Activity intolerance related to possible anemia

Stressors

Nursing Goals

Nursing Actions

Nursing Outcomes

Stressor as Perceived by the Client: -client verbalized dali ra kayo ko kapuyon maam.

Scientific Basis: Stressor as Perceived by the Caregiver: -restless, easy fatigability observed, irritable, weakness noted, lack of interest and activity observed. Line of Defense Used: -

After series of nursing Actions, client will be able to demonstrate strategies on how to increase activity tolerance.

Primary Intervention: -assess patients ability to perform normal tasks/ADLS, noting reports of weakness, fatigue, and difficulty accomplishing tasks. R: Influence choice of interventions/ needed assistance. -Noted changes in balance/gait disturbance. R: May indicate neurological changes associated with Vit. B12 deficiency affecting patients safety/ risk of injury. -suggested patient to change position slowly: monitor dizziness. R: Postural hypotension/ cerebral hypoxia may cause dizziness, fainting and increase risk for injury. -instructed patient to stop activity if palpitations, chest pain, SOB, weakness, or dizziness occur. R: cellular ischemia potentiates risk for infarction and excessive cardiopulmonary stain/ stress may lead to failure. -recommended quiet atmosphere, bed rest if indicated, and stress needs to monitor and limit visitors, phone calls, and repeated unplanned interruptions. R: enhances rest to lower bodys oxygen, and reduces strain on the heart and lungs. Secondary Prevention: -monitor vital signs before, during, and after activity. Note adverse response to increased levels of activity. R: Cardiopulmonary manifestations result from attempt by the heart and lungs to supply adequate amount of oxygen to the tissues. -elevated head of bed as tolerated. R: Enhances lung expansion to maximize oxygenation. -Assisted patient to prioritize ADLS. Alternate rest periods with activity periods. R: promotes adequate rest, maintains energy level, and alleviates strain on the cardiac

The patient was able to

and respiratory. -provided/recommended assistance with activities as necessary, allowing patients to do as much as possible. R: Although help may be necessary, selfesteem is enhanced, when patient does something for self. -monitor laboratory studies as indicated. R: indications of nutritional needs, restrictions, and necessity. -provided the primary care whenever necessary. R: for health promotion and maintenance of wellness. Tertiary Prevention: -planned activity progression, including activities that patient views as essential. Increase activity levels as tolerated. R: promotes gradual return to normal activity level and improve muscle tone without under fatigue. It also increases self-esteem and sense3 of control. -implemented energy saving techniques such as seating to perform task. R: encourages patients to do as much as possible while conserving limited energy and preventing fatigue. -discuss importance of maintaining environmental temperature and body warmth as indicated. R: vasoconstriction decreases peripheral circulation, impairing tissue perfusion. Patients comfort/need for warmth must be balance with need to avoid excessive heat and resultant vasodilation. -provided the primary and secondary measures to the client whenever necessary. R: to strengthen the essential core and inhibits further damage.

Classification Systems Deprivation Nursing Diagnosis: Ineffective coping related to situational crisis. Scientific Basis:

Stressors

Nursing Goals

Nursing Actions

Nursing Outcomes

Stressor as Perceived by the Client: -client verbalized di na nako makaya.Kapoy na kayo ko. Stressor as Perceived by the Caregiver: -poor concentration observed, restless, irritable, rarely communicates with other family members. Line of Defense Used: -

After series of nursing Actions, client will be able to express positive appraisal and demonstrate behaviors to restore positive coping.

Primary Intervention: -Reviewed pathophysiology affecting the patient and extend of feelings of hopelessness, helplessness, loss of control over life, level of anxiety, and perception of situation. R: indicator of degree of disequlibrium and need for intervention to prevent or resolve the crisis. -established therapeutic nurse-patient relationship. R: Patient may feel free in the context of this relationship to verbalize feelings of helplessness/powerlessness and to discuss changes that may be necessary in patients life. -noted expressions of indecision, dependence, on other, and inability to manage own ADLs. R: may indicate to lean on others for a time. Early recognition and intervention can help patient regain equilibrium. -Assess presence of positive coping skills/inner strengths such as use of relaxation technique, willingness to express feelings, use of support systems. R: when the individual has a coping skills that have been successful in the past, they may be used in the current situation to relieve tension and preserve the individual sense of control. -noted expressions of inability to find meaning life/reason for living, feelings of futility or alienation from God. R: crisis situation may evoke questioning of spiritual beliefs affecting ability to cope with current situation and plan for the future. Secondary Prevention: -Encourage patient to talk about what is happening at this time and what has occurred to precipitate feelings of helplessness and anxiety. R: provides clues to assist patient to develop coping and regain equilibrium. -evaluated ability to understand events. Correct misperceptions, provide factual

The patient was able to

information. R: assists in identification and correction of perception of reality and enables problem solving to begin. -provided quiet non-stimulating environment, and determine what patient needs. R: decreases anxiety and provides control for patient during crisis situation. -Accepted verbal expressions of anger setting limits on maladaptive behaviour. R: Verbalizing angry feelings is an important process for resolution of grief and loss however preventing destructive actions preserves patient self-esteem. -discussed feelings of self-blame/ projection of blame on others. R: although these mechanisms may be protective at the movement of crisis, they eventually are counterproductive and intensify feelings of helplessness and hopelessness. -promoted safe and hopeful environment as needed. Identify positive aspects of this experience and assist patient to view it as a learning opportunity. R: may helpful while patient regains inner control. The ability to learn from the current situation can provide skills for moving forward. -Provided the primary care whenever necessary. R: For health promotion and maintenance of wellness. Tertiary Prevention: -Provided support for patient to problemsolve solutions for current condition. Provide information and reinforce reality as patient begins to ask questions. R: helping patient/SO to brainstorm possible solution(giving consideration to the pros and cons of each promotes feelings of selfcontrol/esteem). -referred to other resources as necessary such as religious officers. R: additional assistance may be needed to help patient resolve problems and make decisions. -provided the primary and secondary measures to the client whenever necessary. R: to strengthen the central core and inhibits further damage.

Classification Systems Deprivation Nursing Diagnosis: Hopelessness related to deteriorating physiological condition. Scientific Basis:

Stressors

Nursing Goals

Nursing Actions

Nursing Outcomes

Stressor as Perceived by the Client: -client verbalized Para asa pa man mag dialysis ko nga muras ra man japon mamatay rako. Its like prolonging the agony wa na gyud koy pag-asa mabuhi. Stressor as Perceived by the Caregiver: -sleep pattern disturbance, decreased verbalization, decreased affect,turning away from speaker,closing eyes, crying noted. Line of Defense Used: -

After series of nursing Actions, client will be able to identify and use of coping mechanism to counteract feelings of hopelessness.

Primary Intervention: -Review familial/social history and physiological history for problems such as history of poor coping abilities, disorder of familial relating patterns, emotional problems, recent or long term illness of client or family member, multiple social and physiological trauma to individual/ family members. R: to identify causative factors. -Note current familial/social/physical situation of client like newly diagnosed with chronic/terminal disease, and lack of support system. R: to identify contributing factors. -Identify cultural/spiritual values and note language barriers. R: that can impact beliefs in own ability to change situation. -determine coping behaviors and defense mechanisms. R: to identify patients ability to cope. -note behaviors indicative of hopelessness. R: To assess level of hopelessness. -Determine coping behaviors previously used and clients perception of effectiveness then and now. R: to assess level of hopelessness. -Establish a therapeutic/ facilitative relationship showing positive regard for the client. R: client may feel safe to disclose feelings and feel understood and listened to. Secondary Prevention: - Encourage client to verbalize and explore feelings and perceptions. R: to support client in identifying feelings and to begin to cope with the problems as the client perceives. - Express hope to client and encourage S.O

The patient was able to

and other health team members to do so. R: Client may not identify positives in own situation. -Assist client/family to become aware of factors or situations leadin to feeling of hopelessness. R: provides opportunity to avoid/modify situation. Tertiary Prevention: -Discuss initial signs of hopelessness. R: to assist client identify feelings and to begin to cope with problems as perceived by the client. - Help client begin to develop coping mechanism that can be learned and use effectively. R: to counteract hopelessness.