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