Sleep Pattern Disturbance

 

Instructions: Fill out this form, print it, and hand it in with your assessment to your instructor. When you click on Next at the bottom of the page, you see the data you submitted. Please follow the instructions on how to save the data on the next page.

AOL users: Read this instruction.

Definition: state in which an individual experiences a change in the quantity or quality of his rest pattern that causes discomfort or interferes with desired life style

1. Your initials (required): 


2. Defining Characteristics- check those that apply to your client:

None- high risk diagnosis  difficulty falling asleep, taking more than 30 minutes to fall asleep 
difficulty remaining asleep, awakens more than 3 times/night  states does not feel rested
awakes earlier than usual complains of fatigue dozes during the day

3. Related Factors- check those that apply to your client:

aging related sleep changes stress, anxiety pain, discomfort environmental changes- noise, light etc
dyspnea nausea urinary frequency treatment related- immobility, traction, restraints awakenings for nursing care
medications awakening to care of family members (infants, children, aging parents)



4. Goal (ultimate, long term) 

5. Outcome Criteria (short term) 


6. Evaluation: Was the outcome criteria met? 

Yes- Give Evidence: 

No- Explain how you would change the plan: 


7A. Interventions 

1. 

2.

3. 

4. 

5.

6. 

7B. Rationale for each intervention
1. 

2. 

3. 

4. 

5. 

6. 
 
 

 
 
Back to top
Return to Care Plan Homepage