Nursing Documentation: Sleep-Rest Pattern

Sleep-Rest Pattern

Subjective data

Sleep Habits:

How would you rate the quality of your sleep?

Special Problems

Do you ever experience difficulty with falling asleep? Remaining asleep? Do you ever feel fatigued after a sleep period?

Sleep Aids

What helps you to fall asleep? medications? reading? relaxation technique? Watching TV? Listening to music?

 

Objective Data

1. Observe appearance

a. Pale b. Puffy eyes with dark circles

2. Observe behavior

a. Yawning

b. Dozing during day

c. Irritability

d. Short attention span

 

Associated nursing Diagnoses

Wellness Diagnosis:

Opportunity to enhance sleep

Risk Diagnosis

Risk for sleep pattern disturbance

Actual Diagnosis:

Sleep Pattern Disturbance.

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