Turingan. Marie Abigail A.

1-Nur 8
NURSING CARE PLAN- SLEEPLESS NIGHTS
Cues/Clues
Subjective:
Verbalized that he
has been
experiencing
sleepless nights.
Objective:
Teary eyes
Flushed face

Nursing Diagnosis
Actual:
Persistent
insomniac
episodes
Changes in sleep
patterns

Scientific Rationale
According to
mayoclinic.com, Insomnia
is a persistent disorder that
can make it hard to fall
asleep, hard to stay asleep
or both, despite the
opportunity for adequate
sleep. With insomnia, you
usually awaken feeling
unrefreshed, which takes a
toll on your ability to
function during the day.
Insomnia can sap not only
your energy level and mood
but also your health, work
performance and quality of
life.

Objective/ Goal of Care

Long Term:
After 3 days,
patient will be free
from signs of sleep
deprivation.
Short Term:
Achieve at least 8
hours of sleep
without
interruption.

Interventions
Independent:
1. Tepid sponge bath
2. Administer
medications that
will allow
maximum rest.
3. Provide patient
with food and
drinks such as milk
or high-protein
snacks.

Rationale
Reduces stress,
and promoting
rest.

Evaluation
Not Met
Patient expressed
body malaise and
desire to sleep.

NURSING CARE PLAN- COUGH

Cues/Clues
Subjective:
Verbalized that he
has been
experiencing
productive cough
with whitish
mucoid secretions,
moderate in
amount.
Objective:
VS: T-39 C; PR108/min; RR-20;
BP- 120/80
Rales
Wheezes

Nursing Diagnosis
Actual:
Cough
Disposal of
mucous secretions

Scientific Rationale
According to
mayoclinic.com, A chronic
cough can ruin your sleep
and leave you feeling
exhausted. Severe cases of
chronic cough can result in
vomiting, lightheadedness,
depression, even rib
fractures. While it can
sometimes be difficult to
pinpoint the problem that's
triggering a chronic cough,
the most common causes
are tobacco use, postnasal
drip, asthma and acid reflux
the backflow of stomach
acid that can irritate your
throat. Chronic cough
typically disappears once
the underlying problem is
treated.

Objective/ Goal of Care

Long Term:
After 3 days,
patient will be free
from productive
coughing.
Short Term:
After 3 hours,
cough with
mucous secretions
will lessen.

Interventions
Independent:
1. Increase fluid
intake
2. Promote small
frequent feedings
Dependent:
1. Paracetamol tab
500 mg was given
2. IVF of D5 NSS
was started
3. Bisolvon syrup
was started
Interdependent:
1. Brought to the Xray department for
chest x-ray
2. Specimen CBC
was taken
3. Specimen for
Urinalysis was
taken.

Rationale
Facilitates healing
process and
enhances natural
resistance.

Evaluation
Partially Met
VS: T-37.8 C; RR22; PR-90; BP120/80
Total fluid intake
was 300 cc