Kristine Rielly L.

Bancure BSN3A

Nursing Care Plan

Assessment Nursing Analysis Goals Interventions Rationale Evaluation

Diagnosis
Subjective: Sleep Prolonged periods Short Term Independent Short Term :
“di ako Deprivation of time without After 3 hours of • Identify • To identify After 3 hours of
makatulog kasi related to pain sleep. nursing intervention, presence of causative/ nursing
puro na lang and discomfort the client will: related factors contributing intervention, the
sakit sa on perineum (NANDA, 11th edition • report decreased that can factors. short term goal was
katawan yung secondary to , pp. 630) feeling of discomfort contribute to met as evidenced
nararamdaman labor and as manifested by sleep deprivation. by:
ko” delivery verbalizing feeling of • Reported pain
comfort (5 out of 10) • Position client • To alleviate relief (5 out of
Objective: • Achieve at least 5-6 in a discomfort 10)
• 1hr of sleep hours of continuous comfortable • Pt was able to
per day PTA sleep per day position achieve 6
• 30 mins of • Show signs of • To distract hours of
sleep per decreased yawning at • Provide attention on continuous
day upon daytime comfort pain, reduce sleep that
admission • Report decreased measures tension and to day
• frequent body malaise (touch, quiet promote non • decreased
yawning at environment, pharmacologic yawning at
daytime Long Term dim light, light al pain daytime
during After 3 days of nursing music) management • reported
assessment intervention the client decreased
• overall body will: • To provide overall body
malaise • Be able to comparative malaise
• pain(8 out reestablish and baseline
of 10) maintain normal • Assess sleep
• dark circles sleep pattern pattern • To help in
around the • achieve 7-8 providing better Long Term
 Kristine Rielly L. Bancure BSN3A

eyes hours of continuous • Provide a sleep/rest After 3 days of

sleep per day quiet and nursing intervention
• report absence peaceful the short term goal
of body malaise environment has been fully met
T: 37.4 • report further during sleep • Verbalizing as evidenced by:
P: 86 beats/min. alleviation of pain (3 periods concerns may • reported
R: 20 cycles per out of 10) promote increased
BP: 110/70 mmHg • absence of • Encourage the relaxation periods of sleep
frequent yawning client to of 8 continuous
express hours per day
concerns when • Vasodilation of
unable to sleep the veins provide • absence of
a sleepy, lazy frequent
• Provide a effect, causing yawning
warm bath the client to fall
before the right to sleep • established
client goes to sleep pattern
sleep • To provide
comfort • reported pain
scale of 3 out of
• Expose 10
perineum on
perilight bid for • reported
15 mins absence of body
malaise
• To induce sleep

Dependent
• Prescribe
sedatives
(Valium) as
ordered
Kristine Rielly L. Bancure BSN3A