Sleep Pattern Disturbance

Sleep Pattern Disturbance

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Impaired oxygen transport
(_) Impaired elimination
(_) Impaired metabolism
(_) Immobility
(_) Medication
(_) Hospitalization
(_) Lack of exercise
(_) Anxiety response
(_) Life-style disruptions
(_) Other:_____________________________
____________________________________
____________________________________

 

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Difficulty falling or remaining asleep
Minor:
(
May be present)
(_) Fatigue on awakening or during the day
(_) Dozing during the day (_) Agitation (_) Mood alterations

 

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
  The patient will:

(_) Demonstrate an optimal balance of rest and activity A.E.B. ___ hours of uninterrupted sleep at night.

(_) Remain awake during the day.

(_) Other:

  (_) Explore with patient potential contributing factors.

(_) Maintain bedtime routine per patient preference.

  • Likes to go to bed @ ___ pm.
  • Prefers quiet
  • Darkness
  • Night light
  • Music

(_) Takes sleeping pill as ordered by a physician @ ____ pm.

(_) Provide comfort measures to induce sleep:

  • Back rub
  • Herbal tea-warm milk
  • Pillows for support
  • Bedtime snack when appropriate.
  • Pain medication if needed.
  • Other:

 

(_) Limit nighttime fluids to:________

(_) Void before retiring.

(_) Coordinate treatment/meds to limit interruptions during sleep period.

(_) Limit the amount and length of daytime sleeping:____________

(_) Increase daytime activity:______
________________________
________________________
________________________

(_) Other:________________
________________________
________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature