Student Nurse: Jeyser T.

Gamutia BN4B Patient: JM Age: 30 y/o Diagnosis: Retropharyngeal Abscess June 20, 2018

ASSESSMENT NURSING INFERENCE DESIRED INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS OUTCOMES
Short Term Independent
Objective: Disturbed Sleep Precipitating Factors: After 8 hrs of nursing 1) To alleviate
 Client appears Pattern r/t  Round the clock intervention, the client 1) Position client in a discomfort
to be fatigued hyperthermia. health care will be able to: comfortable position
and worn- interventions
looking with DEFINITION:  Noisy ward 1)Report decreased
noted Time-limited feeling of discomfort
drowsiness. disruption of as manifested by
 Client tends to sleep (natural verbalizing feeling of 2) Provide comfort 2) To distract attent
sleep most of periodic SYMPHATETIC comfort. measures (touch, qui ion onpain, redu
the time suspension of NERVOUS SYSTEM: et environment, dim ce tension andto
during the consciousness).  Decreased REM light, light music) promotenonphar
day. macological pai
 V/S REFERENCES:  Increased nmanagement
T= 39.1 North American Norepinephrrine
P= Nursing
R= 20 Diagnosis  Decreased
BP= 110/60 Association serotonin 3) Provide a quiet and 3) To help in provi
peaceful ding
Subjective: https://nurseslab  Impaired environment better sleep/rest
 Client s.com/10- processing of during sleep periods
verbalized: ileostomy- information in the
“Wala ko colostomy- brain. 2)Achieve optimal
mayo katulog, nursing-care- amount of sleep
ma’am. Gina plans/ as evidenced by rested
 Decreased
tugnawan ko.” appearance,
oscillations of the
verbalization 4) Encourage the client 4) Verbalizing con
brain.
of feeling rested, and to express concerns cerns may
Strengths: improvement in sleep when unable to sleep promote
 Strong family pattern. relaxation
support  Disturbed Sleep
Student Nurse: Jeyser T. Gamutia BN4B Patient: JM Age: 30 y/o Diagnosis: Retropharyngeal Abscess June 20, 2018

 Compliant to Pattern
medications.
5) Provide a warm bath 5) Vasodilation of
before the client the veins
Weaknesses: goes to sleep. provide a sleepy
 Low financial lazy
means effect, causing
the client to
fall right to sleep