Sleep Pattern Disturbance
Sleep Pattern Disturbance
(_)Actual (_) Potential
| (_)
Impaired oxygen transport (_) Impaired elimination (_) Impaired metabolism (_) Immobility (_) Medication (_) Hospitalization |
(_) Lack
of exercise (_) Anxiety response (_) Life-style disruptions (_) Other:_____________________________ ____________________________________ ____________________________________ |
| 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.
(_) Takes sleeping pill as ordered by a physician @ ____ pm. (_) Provide comfort measures to induce sleep:
(_) 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
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