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1180 UNIT X / Promoting Physiologic Health

ter administration, but may be less effective for the treatment of

Client with the Sleep Disorder Care Plan Activity

TABLE 45–1 Selected Sedative-Hypnotic sleep maintenance insomnia.

Medications Used for Insomnia
MEDICATION HALF-LIFE Evaluating
Chloral hydrate (Noctec) 7–10 hours
Using data collected during care and the desired outcomes de-
Eszopiclone (Lunesta) 6 hours
veloped during the planning stage as a guide, the nurse judges
Ethchlorvynol (Placidyl) 10–20 hours
whether client goals and outcomes have been achieved. Data
Flurazepam (Dalmane) 47–100 hours
collection may include (a) observations of the duration of the
Glutethimide (Doriden) 1–12 hours
client’s sleep, (b) questions about how the client feels on awak-
Lorazepam (Ativan) 10–20 hours
ening, or (c) observations of the client’s level of alertness dur-
Melatonin 1 hour
ing the day. Examples of client goals and related outcomes are
Temazepam (Restoril) 9–15 hours
shown in Identifying Nursing Diagnoses, Outcomes, and Inter-
Triazolam (Halcion) 1.5–5.5 hours
ventions earlier in this chapter.
Zaleplon (Sonata) 1 hour
If the desired outcomes are not achieved, the nurse and client
Zolpidem (Ambien) 2.6 hours
should explore the reasons, which may include answers to the
following questions:

■ Were etiologic factors correctly identified?

sleep or nonrestorative sleep associated with menopausal symp- ■ Has the client’s physical condition or medication therapy
MediaLink

toms often benefit by the prescription of 10 mg of zolpidem, a low changed?

dose that was documented to be both safe and efficacious in this
population. Hypnotics are not appropriate if clients have any
symptoms suggestive of sleep-related breathing disorders, or de-
creased renal and/or hepatic function.
Table 45–1 presents some of the common medications used
for enhancing sleep and the half-life of these medications. The
half-life represents how long it takes for half of the medication
to be metabolized and eliminated by the body; hence, those with
shorter half-lives are less likely to cause residual drowsiness af-
■ Did the client comply with instructions about establishing a
regular sleep–wake pattern?
■ Did the client avoid ingesting caffeine?
■ Did the client participate in stimulating daytime activities to
avoid excessive daytime naps?
■ Were all possible measures taken to provide a restful envi-
ronment for the client?
■ Were the comfort and relaxation measures effective?

NURSING CARE PLAN Sleep

ASSESSMENT DATA NURSING DIAGNOSIS DESIRED OUTCOMES*
Nursing Assessment Insomnia related to anxiety Sleep [0004] as evidenced by:
Jack Harrison is a 36-year-old police officer assigned to a high- (as evidenced by difficulty
■ Sleeps through the night
crime police precinct. One week ago he received a surface bullet falling and remaining asleep,
consistently
wound to his arm. Today he arrives at the outpatient clinic to have fatigue, and irritability)
■ Feels rejuvenated after sleep
the wound redressed. While speaking with the nurse, Mr. Harrison
■ No dependence on sleep
mentions that he has recently been promoted to the rank of de-
aids
tective and has assumed new responsibilities. He states that since
his promotion, he has experienced increasing difficulty falling
asleep and sometimes staying asleep. He expresses concern over
the danger of his occupation and his desire to do well in his new
position. He complains of waking up feeling tired and irritable.

Physical Examination Diagnostic Data

Height: 185.4 cm (6′2′′) CBC within normal range, x-ray

Weight: 85.7 kg (189 lb) left arm: evidence of superficial
Temperature: 37.0ºC (98.6ºF) soft tissue injury
Pulse: 80 BPM
Respirations: 18/minute
Blood pressure:
144/88 mm Hg
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NURSING CARE PLAN Sleep continued
NURSING INTERVENTIONS*/SELECTED ACTIVITIES
Sleep Enhancement [1850]
Determine the client’s sleep and activity pattern.
Encourage Mr. Harrison to establish a bedtime routine to facilitate
transition from wakefulness to sleep.
Encourage him to eliminate stressful situations before bedtime.
Instruct Mr. Harrison and significant others about factors (e.g.,
physiologic, psychologic, lifestyle, frequent work shift changes, ex-
cessively long work hours, and other environmental factors) that
contribute to sleep pattern disturbances.
Discuss with Mr. Harrison and his family comfort measures, sleep-
promoting techniques, and lifestyle changes that can contribute to
optimal sleep.
Monitor bedtime food and beverage intake for items that facilitate
or interfere with sleep.
Security Enhancement [5380]
Discuss specific situations or individuals that threaten Mr. Harrison
or his family.
Assist him to use coping responses that have been successful in
the past.
Anxiety Reduction [5820]
Create an atmosphere to facilitate trust.
Seek to understand Mr. Harrison’s perspective of a stressful
situation.
Encourage verbalization of feelings, perceptions, and fears.
Determine the client’s decision-making ability.
EVALUATION
Outcome met. Mr. Harrison acknowledges his insomnia is a somatic expression of his anxiety regarding job promotion and fear of failing.
He states that talking with the police department counselor has been helpful. He is practicing relaxation techniques each night and sleeps
an average of 7 hours a night. Mr. Harrison expresses a feeling of being rested upon awakening.
APPLYING CRITICAL THINKING
1. What further information would be helpful to obtain from
Mr. Harrison about his sleep problem?
2. What suggestions can you make that may help him develop
better sleep habits?
*The NOC # for desired outcomes and the NIC # for nursing interventions are listed in brackets following the appropriate outcome or intervention.
Outcomes, interventions, and activities selected are only a sample of those suggested by NOC and NIC and should be further individualized for each
client.
CHAPTER 45 / Sleep 1181
RATIONALE
The amount of sleep an individual needs varies with lifestyle,
health, and age.
Rituals and routines induce comfort, relaxation, and sleep.
Stress interferes with a person’s ability to relax, rest, and sleep.
Knowledge of causative factors can enable the client to begin to
control factors that inhibit sleep.
Knowledge of factors that affect sleep enables the client to im-
plement changes in lifestyle and prebedtime activities.
Milk and protein foods contain tryptophan, a precursor of sero-
tonin, which is thought to induce and maintain sleep. Stimulants
should be avoided because they inhibit sleep.
Fear is reduced when the reality of a situation is confronted in a
safe environment. Awareness of factors that cause intensification
of fears enhances control.
Feelings of safety and security increase when an individual identi-
fies previously successful ways of dealing with anxiety-provoking
or fearful situations.
Trust is an essential first step in the therapeutic relationship.
Anxiety is a feeling aroused by a vague, nonspecific threat. Identify-
ing the client’s perspective will facilitate planning for the best ap-
proach to anxiety reduction.
Open expression of feelings facilitates identification of specific
emotions such as anger or helplessness, distorted perceptions,
and unrealistic fears.
Maladaptive coping mechanisms are characterized by an inability
to make decisions and choices.
3. What are the most common problems that interfere with clients’
ability to sleep?
See Critical Thinking Possibilities in Appendix A.