CHINESE GENERAL HOSPITAL COLLEGE OF NURSING
NURSING CARE PLAN
Assessment                    Diagnosis                                  Planning                        Intervention                    Rationale                        Evaluation
Subjective data:              Sleep deprivation related to pain and      Short term goal:                Independent:                                                     Short term goal: FULLY
 -“Mga apat na oras lng ata   discomfort secondary to trans-urethral     After 3 hours of nursing        -Position client in a           -to alleviate discomfort and     MET
ako nakakatulog sa gabi       resection of the prostate                  intervention, the client will   comfortable position            promote sleep
tapos paputol-putol pa,                                                  be able to identify
kumikirot parin kasi yung     Inference:                                 appropriate interventions       -provide comfort measures       To distract attention on
sa loob eh” as verbalized     Trans-urethral resection of the prostate   to promote sleep as             such as quiet environment       pain, reduce tension and to      Long term goal: PARTIALLY
                              involves a surgical removal of the inner   manifested by:                  and dim light                   promote non                      MET. Because of time
-“sa umaga paidlip-idlip      portion of the prostate through an           -Explaining atleast two                                       pharmacological                  restriction, some of the
naman ako, binabawi ko        endoscope inserted through the urethra     management in promoting                                         management                       outcomes wasn’t able to
yung tulog sa gabi” as        which can cause post-operative pain to     sleep.                                                                                           be observe. The client was
verbalized                    the patient. Pain can lead to anxiety,       -Verbalize understanding                                                                       only able to show absence
                              sleep deprivation                          of sleep disorder               -assess sleep pattern           -to provide comparative          of being irritable and also
Objective data:                                                            -shows decrease in being                                      baseline                         show’s decreased in
-appears restless                                                        irritable                                                                                        yawning.
-pain scale of 7/10                                                                                      -encourage the client to        -verbalizing concerns may
-irritability                 Reference:                                 Long term goal:                 express concerns when           promote relaxation
-frequent yawning during      http://www.jjs.me.uk/teaching/acutepain    After 2 days of nursing         unable to sleep
assessment                    Smetltzer, S., Bare, B., Hinkle, J. and    intervention, the client will
                              Cheever, K. 12th ed. Medical-Surgical      be able to establish a          -provide a warm bath            -Vasodilation of the veins
                              Nursing.                                   normal sleeping pattern as      before the client goes to       provide a sleepy, lazy
                                                                         evidenced by:                   sleep                           effect, causing client to fall
                                                                           -reports decrease feeling                                     to sleep
                                                                         of discomfort
                                                                           -decrease of yawning          -Suggest abstaining from        -because they impair ability
                                                                         during daytime                  daytime naps                    to sleep at night
                                                                           -absence of being irritable
                                                                           -reports prolonged and        -investigate anxious            -to help determine basis
                                                                         continues sleeping hours        feelings                        and appropriate anxiety-
                                                                         during night.                                                   reduction techniques
                                                                           -being active during
                                                                         daytime                         -limiting fluid intake before   -to reduce need for
                                                                                                         sleeping                        nighttime elimination
CHINESE GENERAL HOSPITAL COLLEGE OF NURSING
             NURSING CARE PLAN
                          -Discuss effective age-       -To enhance client’s ability
                          appropriate bedtime rituals   to fall asleep
                          Dependent:
                          -Prescribe sedatives as       -to induce sleep
                          ordered