- Actual
- Risk for (Potential)
Related To: [Check those that apply]
- Pain/discomfort
- Environmental barrier (e.g. noise, temperature)
- Anxiety/fear
- Depression
- Medications
- Excessive or inadequate stimulation
- Abnormal physiological status or symptoms (dyspnea, hypoxia, neurological dysfunction, and others)
- Normal changes associated with aging
- Insufficient privacy
As evidenced by: [Check those that apply]
- Verbal complaints of difficulty falling asleep
- Awakening earlier or later than desired
- Interrupted sleep
- Verbal complaints of not feeling rested
- Restlessness
- Irritability
- Dozing
- Yawning
- Altered mental status
- Difficulty in arousal
- Change in activity level
- Altered facial expression (e.g., blank look, fatigued appearance)
Patient’s Diagnosis: –
Date:-
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- achieves optimal amounts of sleep as evidenced by: rested appearance, verbalization of feeling rested and improvement in sleep pattern.
- Others
Note: you need to indicate time frame/target as objective must be measurable.
| Nursing Interventions | Scientific Rationale |
|---|---|
| Assess past patterns of sleep in normal environment: amount, bedtime rituals, depth, length, positions, aids, and interfering agents. | Sleep patterns are unique to each individual. |
| Assess patient's perception of cause of sleep difficulty and possible relief measures to facilitate treatment. | Knowing the specific etiologic factor will guide appropriate therapy. |
| Document nursing or caregiver observations of sleeping and wakeful behaviors. | Often, the patient's perception of the problem may differ from objective evaluation. |
| Identify factors that may facilitate or interfere with normal patterns | Knowledge of its 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 setting, patients may be following medication schedules that require awakening in the early morning hours. |
| Instruct patient to follow as consistent a daily schedule for retiring and arising as possible. | This promotes regulation of the circadian rhythm, and reduces the energy required for adaptation to changes. |
| Instruct to avoid heavy meals, alcohol, caffeine, or smoking before retiring. | Though hunger can also keep one awake, gastric digestion and stimulation from caffeine and nicotine can disturb sleep. |
| Instruct to avoid large fluid intake before bedtime. | For patients may need to void during the night. |
| Increase daytime physical activities as indicated | To reduce stress and promote sleep. |
| Instruct to avoid strenuous activity before bedtime. | Over-fatigue may cause insomnia. |
| Discourage pattern of daytime naps unless deemed necessary to meet sleep requirements or if part of one's usual pattern. | Napping can disrupt normal sleep patterns. However the elderly do better with frequent naps during the day to counter their shorter night-time sleep schedule. |
| Suggest use of soporifics such as milk. | Which contains L-tryptophan that facilitates sleep. |
| Explain the need to avoid concentrating on the next day's activities or on one's problems at bedtime. | Obviously, this will interfere with inducing a restful state. |
| Suggest using hypnotics or sedatives as ordered; evaluate effectiveness. | Use of hypnotic medications should be thoughtfully considered and avoided if less aggressive means are effective because of their potential for cumulative effects and generally limited period of benefit. |
| Provide nursing aids (e.g., back rub, bedtime care, pain relief, comfortable position, relaxation techniques). | To promote rest. |
| Organize nursing care. | To promote minimal interruption in sleep or rest. |
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