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Nursing Diagnosis Disturbed Sleep pattern

Posted by d.nurisna at Thursday, June 24, 2010 . Thursday, June 24, 2010 Labels: NURSING DIAGNOSIS Nursing care Plans Disturbed Sleep pattern. NANDA Nursing Diagnosis Definition Disturbed Sleep pattern Time-limited disruption of sleep Disturbed Sleep pattern Characteristics: Prolonged awakenings, sleep maintenance insomnia, self-induced impairment of normal pattern, sleep onset more than 30 minutes, early morning insomnia, awakening earlier or later than desired, verbal complaints of difficulty falling asleep, verbal complaints of not feeling well-rested, increased proportion of Stage 1 sleep, dissatisfaction with sleep, less than age-normed total sleep time, three or more nighttime awakenings, decreased proportion of Stages 3 and 4 sleep, decreased ability to function Related Factors: Daytime activity pattern, Thinking about home, Body temperature, Temperament, Dietary, Childhood onset, Inadequate sleep hygiene, Sustained use of antisleep agents, Circadian asynchrony, Frequently changing sleep-wake schedule, Depression, Loneliness, Frequent travel across time zones, daylight/darkness exposure, grief, anticipation, shift work, delayed or advanced sleep phase syndrome, loss of sleep partner, life change, preoccupation with trying to sleep, periodic gender-related hormonal shifts, biochemical agents, fear, separation from significant others; social schedule inconsistent with chronotype, aging-related sleep shifts, anxiety, medications, fear of insomnia, maladaptive conditioned wakefulness, fatigue, boredom Nursing Outcomes Nursing care Plans Disturbed Sleep pattern

y y y y y y y

Sleep Rest Well-Being Psychosocial Adjustment: Life Change Quality of Life Pain Level Comfort Level

Client Outcomes

y y

Wakes up less frequently during night Awakens refreshed and is not fatigued during day

y y

Falls asleep without difficulty Verbalizes plan to implement bedtime routines

NIC Interventions (Nursing Interventions Classification)

Sleep Enhancement

Nursing Interventions nursing care Plans Disturbed Sleep pattern

y y y y y y y y y y y y y y y y y

Assess client's sleep patterns and usual bedtime rituals and incorporate these into the plan of care. Determine current level of anxiety, if client is anxious. Assess for signs of new onset of depression: depressed mood state, statements of hopelessness, poor appetite. Observe client's medication, diet, and caffeine intake. Look for hidden sources of caffeine, such as over-the-counter medications. Provide measures to take before bedtime to assist with sleep. Provide pain relief shortly before bedtime and position client comfortably for sleep. Keep environment quiet. Do a careful history of all medications including over-the-counter medications and alcohol intake. If client is waking frequently during the night, consider the presence of sleep apnea problems and refer to a sleep clinic for evaluation. Evaluate client for presence of depression or anxiety. Encourage social activities. Suggest light reading or TV viewing that does not excite as an evening activity. Increase daytime physical activity. Encourage walking as client is able. Avoid use of hypnotics and alcohol to sleep. Reduce daytime napping in the late afternoon; limit naps to short intervals as early in the day as possible. Use soothing sound generators with sounds of the ocean, rainfall, or waterfall to induce sleep, or use "white noise" such as a fan to block out other sounds. Determine if client has a physiological problem that could result in insomnia such as pain, cardiovascular disease, pulmonary disease, neurological problems such as dementia, or urinary problems.

Observe elimination patterns. Have client decrease fluid intake in the evening, and ensure that diuretics are taken early in the morning.

If client continues to have insomnia despite developing good sleep hygiene habits, refer to a sleep clinic for further evaluation.

Client/Family Teaching for Disturbed Sleep pattern y Teach the following guidelines for good sleep hygiene to improve sleep habits: Go to bed only when sleepy, When awake in the middle of the night, go to another room, do quiet activities, and go back to bed only when sleepy, Use the bed only for sleeping not for reading or snoozing in front of the television, Avoid afternoon and evening naps, Get up at the same time every morning, Recognize that not everyone needs 8 hours of sleep, Move the alarm clock away from the bed if it is a source of distraction. y y y y y y Encourage client to avoid coffee and other caffeinated foods and liquids and also to avoid eating large high-protein or high-fat meals before bedtime. Advise client to avoid use of alcohol or hypnotics to induce sleep. Ask client to keep a sleep diary for several weeks. Teach relaxation techniques, pain relief measures, or the use of imagery before sleep. Teach client need for increased exercise. Encourage client to develop a bedtime ritual that includes quiet activities such as reading, television, or crafts.

4 Disturbed Sleeping Pattern


Sleep is disrupted when a person experiences unpleasant sensation arising from difficulty of breathing and ineffective expectoration of mucus secretions in the airways.

Assessment

Nursing Diagnosis

Planning

Nursing Interventions

Rationale

Expected Outcome

S > The mother Disturbed Short Term: -monitor vital signs -to have a Short Term: verbalized that Sleep comparable After 3 hours of-encourage SO to baseline data After 3 hours her child often Pattern r/t nursing increase intake of of nursing wakes up difficulty of interventions warm milk for the -to promote interventions during breathing the SO will be child drowsiness the SO shall midnight. able to verbalize have

O>

patient

understanding - provide a quiet verbalized -to promote of sleep environment for understanding comfort and

manifested: >changes in behavior (irritability) >restless >DOB >nasal flaring The patient may manifest: >lack interest food >weight loss >DOB >tachypnea of in

disturbance and the child relaxation of sleep identify /sleep periods disturbance interventions to -instruct SO to for the child and identified promote sleep provide a dim interventions for the child. promote environment for -to promote to the child comfort for sleep for the child. Long Term: the child >advise SO to After 3 days of provide blanket >to avoid Long Term: nursing for the child chills and to interventions, After 3 days promote SO will be able >instruct SO to comfort of nursing interventions, to report elevate HOB improvement in > to the SO shall have reported sleep pattern of maximize the child. improvement lung sleep expansion of in the child and pattern for the to decrease child DOB

Nursing Care Plan: Sleep Pattern Disturbance

Nursing Care Plan for Sleep Pattern Disturbance. Nanda defines the nursing diagnosis of sleep pattern disturbance as time limited disruption of sleep (natural,periodic suspension of consciousness), amount, and quality

Sleep Pattern Disturbance Related To (Etiology)


y y y y y y y y y y y y

Depression Fear Anxiety Fear of insomnia Fatigue Inadequate sleep hygiene Biochemical agents Nightmares Obsession thoughts Fears (e.g., dark, intrusion,death) Adrenaline rush related to high levels of anxiety Panic attacks

As Evidenced By (Assessment Finding/Diagnostic Cues)


y y y y y y

Early morning awakenings Arising earlier or later than desired Verbal complaints of difficulty falling asleep Verbal complaints of not feeling well-rested Three or more nighttime awakenings Decreased ability to function

Sleep Pattern Disturbance Nursing Care Plan Outcome Criteria


y y y

Develops an uninterrupted sleep pattern 5 to 8 hours per night Reports feelings of being rejuvenated after sleep Establishes an effective sleep routine

Long-Term Goals Client will:


y y y

State he/she begins to see improvement in quality of sleep and pattern of sleep after 2 weeks State that the relaxation exercises (tapes) are useful sleep aids by (date) Work with nurse to review and revise plan if sleep pattern has not improved after 2 weeks

Short-Term Goals Client will:


y y y

Identify personal habits that disrupt sleep pattern and those things that could augment quality of sleep after first interview Form a sleep plan with nurse that the client is willing to try within 2 days Identify any other issues that might need attention that are contributing to sleep pattern disturbance, and be open for referrals

Sleep Pattern Disturbance Interventions and Rationales


1. Assess client and family usual sleep pattern, any changes that have occurred, and what was happening at the time. Identify if there was a precipitating event around onset of sleep problem or if it is chronic. R: Information from both client and family clarifies specific sleep disturbance. 2. Identify the client s usual sleep patterns including the following:
y y y y

Bedtime rituals Time of rising, time of retiring Use of alcohol and/or caffeine before sleep Use of sleep aids (prescribed or over-the-counter medications)

R: Establish a baseline and help identify problems:


y y

Sleeping medications and alcohol interfere with rapid eye movement (REM) sleep. Caffeine and exercise before retiring can interfere with sleep.

3. Review sleep hygiene measures with the client. Determine if the client does any of the following: refrains from naps, alcohol and caffeine at night; follow a regular retiring and arising schedule; exercise pattern. R: Identifying baseline helps target needed interventions. 4. Develop a sleep relaxation program with client (e.g., self-hypnosis, progressive muscle relaxation,imagery). R: Employing both physical and mental relaxation can help minimize anxiety and promote sleep. 5. Demonstrate and rehearse these techniques with client until client feels relaxed and is able to practice them at bedtime. R: Have client practice chosen relaxation method with nurse. Allow time for client to begin to feel results of relaxation. 6. Suggest use of relaxation tapes. R: If client has racing thoughts or is troubled by a problem, tapes can help the client focus on relaxation. 7. Encourage client to:
y y y y y

Use decaffeinated beverages until sleep pattern improves. Limit fluid intake 3 to 5 hours before retiring. Increase physical activity during the day, even if fatigued. Avoid daytime naps. Establish regular times of retiring and waking.

R: These are known sleep aids.

8. Establish with client a sleep program that incorporates the elements of good sleep hygiene and relaxation tools. R: Client is more likely to follow plan if he/she is involved with the incorporation of known effective techniques. 9. Suggest to client that if he/she does not feel drowsy after 20 minutes, get up and engage in a quiet activity that is boring not stimulating. R:Waiting for sleep that will not come can increase anxiety and frustration. Doing something monotonous at bedtime might help the client become drowsy. 10.Encourage client to practice the agreed-upon bedtime routine for 2 weeks even if there does not seem to be a benefit. R:It might take 2 weeks or longer for habits to settle in. 11.Encourage client to simultaneously work on any issues that might be adversely affecting sleep (e.g., anxiety disorders, social or personal problems, job related issues, interpersonal difficulties). Offer referrals when appropriate. R: Disturbances in sleep are often secondary to other issues, either emotional or physical. If such issues are present, they need to be addressed. For more Nursing Care Plans click here.

You can use this Nursing Care Plan for Sleep Pattern Disturbance for patients suffering from depression and anxiety.

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