Nursing Care Plan Example for: Disturbed Sleep Pattern

Disturbed Sleep Pattern

Scenario:

A 36 year old male has been admitted to your medical surgical floor for 23 hour observation due to exhaustion. The patient reports difficultly falling asleep and then staying asleep for the past 5 months. He states that ever since he started his new job 5 months ago working the night shift he is getting less and less sleep. In addition, he states that since his 5th child was born it is loud in his house and he can’t sleep when he gets home from work. He states he is sometimes pulling 16 hours shifts straight and may be gets 3 hours of sleep before he has to go back in. Pt admits to dozing off frequently especially on the job which is why he is came to the hospital because he states he think he has “narcolepsy or something”. He also report being very agitated at the slightest things and that him and his wife have been fighting a lot. Pt states his wife says it is like his is a different person. You note the patient looks very tired with dark circles underneath his eyes.

Nursing Diagnosis:

Disturbed Sleep Pattern related to lifestyle disruptions as evidence by reports of difficulty falling and remaining asleep, agitation, dozing during the day, and mood alterations.

 

Subjective Data:

The patient reports difficultly falling asleep and then staying asleep for the past 5 months. He states that ever since he started his new job 5 months ago working the night shift he is getting less and less sleep. In addition, he states that since his 5th child was born it is loud in his house and he can’t sleep when he gets home from work. He states he is sometimes pulling 16 hours shifts straight and may be gets 3 hours of sleep before he has to go back  in. Pt admits to dozing off frequently especially on the job which is why he is came to the hospital because he states he think he has “narcolepsy or something”. He also report being very agitated at the slightest things and that him and his wife have been fighting a lot. Pt states his wife says it is like his is a different person.

 

Objective Data:

A 36 year old male has been admitted to your medical surgical floor for 23 hour observation due to exhaustion. You note the patient looks very tired with dark circles underneath his eyes.

 

Nursing Outcomes:

-The patient will report optimal balance of sleep.

-The patient will report less dozing off during the day.

-The patient will report less agitation.

-The patient will verbalize 4 techniques on how to fall asleep and stay asleep.

-The patient will verbalize 3 side effects of taking a sleep aid.

-The patient will verbalize how and when to take a sleep aid and how they are not to be used on an everyday basis.

 

Nursing Interventions:

-The nurse will assess the patients sleeping pattern and help him develop a sleeping plan.

-The nurse will provide a dark, quiet, and comfortable atmosphere for the patient to sleep in.

-The nurse will discourage caffeine or large meal intake 2 hours before the patient goes to sleep.

-The nurse will educate the patient on 4 techniques on how to fall sleep and stay asleep.

-The nurse will educated the patient on 3 side effects of taking a sleep aid.

-The nurse will educate the patient on when to take a sleep aid and how they are not to be used on an every day basis.

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