Nursing Care Plan

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Medical Diagnoses: Disturbed Sleep Pattern, inadequate stimulation, poor sleep hygiene, and substance abuse

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders

Evaluation

Goals

Interventions

Disturbed sleep pattern r/t inadequate stimulation, poor sleep hygiene, and substance use as evidenced by client verbalizations of “I sleep during the day because I have nothing to do,” reported use of a 3 servings of alcohol daily, reported use of a pack of cigarettes daily and verbalization of “I like to sit here and watch TV” while describing her bedroom activities.



 

Short term goals:

1.        Client will identify personal habits that disrupt sleep pattern and strategies to improve quality of sleep as measured by verbalization of at least two contributing factors and strategies by 15:00 on [Month] 14, [Year].

2.        Client will express commitment to avoid daytime napping as a method of alleviating boredom for one week as measured by a verbalization of agreement by 15:00 on [Month] 14, [Year].

3.        Client will describe alternate activities to avoid daytime napping  as a result of boredom measured by verbalization of at least three alternate activities by 15:00 on [Month] 14, [Year].

        

Long term goals:

1.        Client will engage in daily activities that she finds interesting and feasible in lieu of daytime napping as measured by observation and self report of daily participation by 15:00, August 1, [Year].

2.        Client will regularly fall asleep without difficulty as measured by client verbalization of ease of falling asleep consistently by 15:00, August 1, [Year].

3.        Client will wake less frequently throughout the night as measured by verbalization of less frequent awakening compared to baseline by15:00, August 1, [Year].

4.        Client will verbalize the effects of alcohol and nicotine on sleep as measured by client statements reflecting understanding by15:00, [Month] 21, [Year].

Obtain a sleep-wake history including history of sleep problems, changes in sleep patterns, and use of medications and stimulants. Assessment of sleep behavior and patterns are an important part of any health status examination (Hilliker, [Year]).

Assess for use of alcohol or cigarettes prior to use of sleep medication or retiring for the evening.  Alcohol and nicotine should be avoided for several hours prior to sleep (Hilliker, [Year]).

Assess for underlying physiological illnesses as a potential cause for nighttime sleep loss and daytime sleepiness (including, but not limited to pulmonary, cardiovascular and gastrointestinal conditions).  Symptomatology of disease states can cause insomnia (Sateia, Doghramji, Hauri, & Morin, 2000).

Initiate nonpharmacologic interventions for improved sleep including:

·         Sleep restriction

·         Increasing sunlight exposure

·         Educational interventions to promote beneficial sleep hygiene (Including the impact of substance use on sleep quality, keeping regular waking and sleeping times, avoiding naps, refraining from caffeine, impact of exercise on sleep and environmental adjustments to promote sleep)

·         Provide diversional activities to provide stimulation (painting projects, scrapbooking/life review activities)

Nonpharmacologic interventions have been found to improve sleep efficiency and  increase satisfaction with sleep pattern while decreasing use of hypnotics (Morin, Mimeault, & Gagne, 1999).

Evaluate learning outcomes using patient verbalizations of following the treatment recommendations and experiencing enhanced sleep.  Evaluation serves as an assessment of the effectiveness of care and allows opportunity for adjustments to the plan of care (Ackley & Ladwig, [Year]).

Short term goals:

1.        Goal met.  Client identified daytime napping, boredom and coffee as possible sources of sleep problems.  She identified elimination of the nap, reduction in coffee and sitting outside on the balcony as strategies to address those sources at 11:45 AM on [Month] 14, [Year].

2.        Goal met.  Client verbalized agreement to avoid daytime napping to alleviate boredom at 11:55 AM on [Month] 14, [Year].

3.        Goal partially met.  Client identified sitting on the porch to watch people and watching TV as alternate activities.  She was unable to provide a third.  Client problem-solving should continue to be encouraged and goal should be reassessed on [Month] 21, [Year] by 15:00.

Long term goals:

1.        Goal not met.  The client has made no progress towards this goal. Evaluation is set for 15:00 on August 1, [Year].

2.        Goal not met.  The client has made no progress towards this goal. Evaluation of ability to regularly fall asleep without difficulty is scheduled for 15:00, August 1, [Year].

3.        Goal not met.  The client has made no progress towards this goal. Evaluation of reduction in frequency of night awakenings is scheduled for 15:00, August 1, [Year].

4.        Goal not met:  The client has made no progress towards this goal. Client is scheduled to verbalize effects of substance use on sleep by15:00, [Month] 21, [Year]

Client provided sleep-wake history, medication list, and a report of current levels of substance use at 12:10 PM on [Month] 14, [Year].

Client reported use of alcohol and cigarettes close to bedtime.

Analysis of client’s medications revealed medical diagnoses of GERD, hypertension, diabetes mellitus II, and obesity.

Initiated nonpharmacologic interventions for improved sleep including providing diversional activity to increase stimulation, increasing sunlight exposure by encouraging we speak outside on the balcony for a period of 15 minutes, and teaching regarding the impact of cigarettes and alcohol close to bedtime and the need to eliminate napping to alleviate boredom.  Continued education is required to disseminate additional information on promotion of sleep hygiene as well as reinforcement of past teaching.  Reevaluation recommended by 15:00, [Month] 21, [Year].

Pursuant to current evaluation, continued evaluation is recommended of current care plan weekly though 15:00, August 1, [Year].

             


Assessment

             

Subjective:

Client report of difficulty falling and staying asleep.

Client verbalizations of “I sleep during the day because I don’t have nothing to do,”  reported use of a three servings of alcohol daily, reported use of a pack of cigarettes daily and  verbalization of “I like to sit here and watch TV” while describing her bedroom activities.

             

Objective:

Client has a prescription for Ativan.

Client was disrupted for weekly meeting from daytime naps on 4 of 8 visits.

        

Subjective Data:

Regarding inadequate stimulation, patient stated, ““I sleep during the day because I don’t nothing to do.  Regarding poor sleep hygiene, patient stated, “I like to sit here and watch TV” while describing her bedroom activities. Regarding substance use, client stated she consumes approximately a three servings of alcohol and smokes a pack of cigarettes daily.

Objective Data:

Interrupted client’s daytime sleep 4 times out of 8 visits. Client takes Ativan to induce night time sleepiness. 




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References

 

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