Student Nurses Community

NURSING CARE Insomnia

ASSESSMENT

SUBJECTIVE:
Patient verbalizes I
cant sleep at night.
I dont feel wellrested.

OBJECTIVE:
Dark shadows
under the eyes
Appears tired in
the morning
Lack of energy
in the morning

DIAGNOSIS

Insomnia related to
metabolic disease
as evidenced by
look of tiredness
and lack of energy
in the morning

INFERENCE

biological,
physical,
psychological,
and
environmental
factors

prolonged period
of stress

Development of
conditioned
arousal to stimuli
that would
normally be
associated with
sleep

repeated
difficulty with
sleep initiation,
maintenance,
consolidation
(insomnia)

PLANNING

INTERVENTIONS

After 1 week of
nursing
interventions,
patient will be able
to:

Independent

develop an
uninterrupted
sleep pattern 5 to
8 hours per night

Limit fluid intake in

the evening

report feelings of
being
rejuvenated after
sleep
establish an
effective sleep
routine

Identify
circumstances that
interrupt sleep

Encourage
participation in
regular exercise
program during
daytime
Develop behavioral
program for insomnia
(not napping in
bedtime, establishing
routine bedtime and
arising, and not
reading or watching
TV in bed)
Develop a sleep
relaxation program
with client (e.g., selfhypnosis, progressive
muscle relaxation,

RATIONALE

To prevent sleep
disturbance
because of
interruptions
To reduce need for
night time
elimination/ sleep
disruption
To release energy.
However, exercise
in bedtime may
stimulate rather
than relax the body
For effective sleep
promotion
Employing both
physical and mental
relaxation can help
minimize anxiety
and promote sleep.
To relieve
discomfort and take
maximum
advantage of

EVALUATION

After 1 week of
nursing
interventions,
goal met.
Patient was able
to practice
relaxation
techniques
before bedtime
to promote
sleep and is
involved in daily
activities thus
inducing sleep
during night
time. He/she
also verbalizes
feeling
rejuvenated
after a good
nights sleep
and establish an
effective sleep
routine.

Student Nurses Community

imagery)
look of tiredness
and lack of
energy in the
morning

Dependent:
Administer
medications as
ordered 1 hour before
sleep ( such as Iterax
10mg)

sedative effect