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Nursing Diagnosis: Disturbed Sleep pattern Application of NANDA, NOC, NIC

Nursing Diagnosis: Disturbed Sleep pattern
Betty J. Ackley

NANDA Definition: Time-limited disruption of sleep (natural periodic suspension of consciousness)

Defining Characteristics: Prolonged awakenings; sleep maintenance insomnia; self-induced impairment of normal pattern; sleep onset >30 minutes; early morning insomnia; awakening earlier or later than desired; verbal complaints of difficulty falling asleep; verbal complaints of not feeling well-rested; increased proportion of Stage 1 sleep; dissatisfaction with sleep; less than age-normed total sleep time; three or more nighttime awakenings; decreased proportion of Stages 3 and 4 sleep (e.g., hyporesponsiveness, excess sleepiness, decreased motivation); decreased proportion of REM sleep (e.g., REM rebound, hyperactivity, emotional lability, agitation and impulsivity, atypical polysomnographic features); decreased ability to function

Related Factors: Ruminative presleep thoughts; daytime activity pattern; thinking about home; body temperature; temperament; dietary; childhood onset; inadequate sleep hygiene; sustained use of antisleep agents; circadian asynchrony; frequently changing sleep-wake schedule; depression; loneliness; frequent travel across time zones; daylight/darkness exposure; grief; anticipation; shift work; delayed or advanced sleep phase syndrome; loss of sleep partner, life change; preoccupation with trying to sleep; periodic gender-related hormonal shifts; biochemical agents; fear; separation from significant others; social schedule inconsistent with chronotype; aging-related sleep shifts; anxiety; medications; fear of insomnia; maladaptive conditioned wakefulness; fatigue; boredom
Noise; unfamiliar sleep furnishings; ambient temperature, humidity; lighting; other-generated awakening; excessive stimulation; physical restraint; lack of sleep privacy/control; interruptions for therapeutics, monitoring, lab tests; sleep partner; noxious odors
Mother's sleep-wake pattern; parent-infant interaction; mother's emotional support
Urinary urgency, incontinence; fever; nausea; stasis of secretions; shortness of breath; position; gastroesophageal reflux

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
·         Sleep
·         Rest
·         Well-Being
·         Psychosocial Adjustment: Life Change
·         Quality of Life
·         Pain Level
·         Comfort Level
Client Outcomes
·         Wakes up less frequently during night
·         Awakens refreshed and is not fatigued during day
·         Falls asleep without difficulty
·         Verbalizes plan to implement bedtime routines
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
·         Sleep Enhancement
Nursing Interventions and Rationales
·         Assess client's sleep patterns and usual bedtime rituals and incorporate these into the plan of care. Usual sleep patterns are individual; data collected through a comprehensive and holistic assessment are needed to determine the etiology of the disturbance (Spenceley, 1993). Staff nurses' evaluation of client's sleep states are usually valid (Edwards, Schuring, 1993).
·         Determine current level of anxiety, if client is anxious, see Nursing Interventions and Rationales for Anxiety. Anxiety interferes with sleep. Interventions such as relaxation training can help clients reduce anxiety (Pagel, Zafralotfi, Zammit, 1998). Many clients with insomnia display hyperarousal during the day in addition to the nighttime (Sateia et al, 2000).
·         Assess for signs of new onset of depression: depressed mood state, statements of hopelessness, poor appetite. Refer for counseling as appropriate. Sleep deprivation in normal subjects did not result in the usual complaints of people with insomnia. Many symptoms associated with sleep deprivation probably arise from central nervous system hyperarousal (Bonnett, Arand, 1998).
·         Observe client's medication, diet, and caffeine intake. Look for hidden sources of caffeine, such as over-the-counter medications. Difficulty sleeping can be a side effect of medications such as bronchodilators; caffeine can also interfere with sleep.
·         Provide measures to take before bedtime to assist with sleep (e.g., quiet time to allow the mind to slow down, carbohydrates such as crackers, or a back massage). Simple measures can increase quality of sleep. Carbohydrates cause release of the neurotransmitter serotonin, which helps induce and maintain sleep (Somer, 1999). Research has shown back massage to effectively promote sleep (Richards, 1994).
·         Provide pain relief shortly before bedtime and position client comfortably for sleep. Clients have reported that uncomfortable positions and pain are common factors of sleep disturbance (Sateia et al, 2000).
·         Keep environment quiet (e.g., avoid use of intercoms, lower volume on radio and television, keep beepers on nonaudio mode, anticipate alarms on IV pumps, talk quietly on unit). Excessive noise causes sleep deprivation that can result in ICU psychosis (Barr, 1993). Health volunteers exposed to recorded critical care noise levels experienced poor sleep (Topf, 1992). More than half of the noises in ICUs were caused by human behavior such as talking and TV watching (Kahn, Cook, 1998).
·         Use soothing sound generators with sounds of the ocean, rainfall, or waterfall to induce sleep, or use "white noise" such as a fan to block out other sounds. Ocean sounds promoted sleep for a group of postoperative open-heart surgery clients (Williamson, 1992).
·         For hospitalized stable clients, consider instituting the following sleep protocol to foster sleep:
o Night shift: Give client the opportunity for uninterrupted sleep from 1 AM to 5 AM. Keep environmental noise to a minimum.
o Evening shift: Limit napping between 4 PM and 9 PM. At 10 PM turn lights off, provide sleep medication according to individual assessment, and keep noise and conversation on the unit to a minimum.
o Day shift: Encourage short naps before 11 AM. Enforce a physical activity regimen as appropriate. Schedule newly ordered medications to avoid waking client between 1 AM and 5 AM.
Critical care nurses can take effective actions to promote sleep (Edwards, Schuring, 1993).
·         Determine if client has a physiological problem that could result in insomnia such as pain, cardiovascular disease, pulmonary disease, neurological problems such as dementia, or urinary problems. Sleep disturbances in the elderly may represent a complex interaction of age-related changes and pathological causes (Sateia et al, 2000).
·         Observe elimination patterns. Have client decrease fluid intake in the evening, and ensure that diuretics are taken early in the morning. Many elderly people void during the night. Increasing water intake at night or taking diuretics late in the day increases nocturia, which results in disrupted sleep.
·         Do a careful history of all medications including over-the-counter medications and alcohol intake. Alcohol intake and medication effects are common causes of insomnia in the elderly. Rebound insomnia associated with the use of shorter-acting hypnotics may perpetuate a cycle of sleep disturbance and chronic hypnotic use (Sateia et al, 2000).
·         If client is waking frequently during the night, consider the presence of sleep apnea problems and refer to a sleep clinic for evaluation. Sleep apnea in the elderly may be caused by changes in the respiratory drive of the central nervous system or may be obstructive and associated with obesity (Foyt, 1992).
·         Evaluate client for presence of depression or anxiety, which can result in insomnia. Refer for treatment as appropriate. Anxiety and depression are common in the elderly and can result in insomnia (Sateia et al, 2000).
·         Encourage social activities. Help elderly get outside for increased light exposure and to enjoy nature. Exposure to light and social interactions influence the circadian rhythms that control sleep (Elmore, Betrus, Burr, 1994; Sateia et al, 2000).
·         Suggest light reading or TV viewing that does not excite as an evening activity. Soothing activities decrease stimulation of the reticular activating system and help sleep come naturally.
·         Increase daytime physical activity. Encourage walking as client is able.
·         Avoid use of hypnotics and alcohol to sleep. Long-term use of hypnotics can induce a drug-related insomnia. Alcohol also disrupts sleep and can exacerbate sleep apnea (Evans, Rogers, 1994).
·         Reduce daytime napping in the late afternoon; limit naps to short intervals as early in the day as possible. The majority of elderly nap during the day (Evans, Rogers, 1994). Avoiding naps in the late afternoon makes it easier to fall asleep at night.
·         Help client recognize that there are changes in length of sleep. Client may not be able to sleep for 8 hours as when younger, and more frequent awakening is part of the aging process (Floyd et al, 2000).
·         If client continues to have insomnia despite developing good sleep hygiene habits, refer to a sleep clinic for further evaluation (Pagel, Zafralotfi, Zammit, 1997).
Nursing Interventions and Rationales
·         Provide support to the family of client with chronic sleep pattern disturbance. Ongoing sleep pattern disturbances can disrupt family patterns and cause sleep deprivation in the client or family members, which creates increased stress on the family.
Client/Family Teaching
·         Encourage client to avoid coffee and other caffeinated foods and liquids and also to avoid eating large high-protein or high-fat meals close to bedtime. Caffeine intake increases the time it takes to fall asleep and increases awake time during the night (Evans, Rogers, 1994). A full stomach interferes with sleep.
·         Advise the client that research on use of melatonin is still equivocal. While it may help the client to fall asleep faster, it does not improve the quality or length of time in the sleep interval, and long-term results are unknown (Hughes, Sack, Lewy, 1998; Defrance, Quera-Salva, 1998; Walsh et al, 1999).
·         Advise client to avoid use of alcohol or hypnotics to induce sleep. Sleep induced by alcohol is often disrupted later in the night (Walsh et al, 1999). Use of benzodiazapines, while they are effective in inducing and maintaining sleep, have major side effects including daytime drowsiness, dizziness or light-headedness, and memory loss (Holbrook et al, 2000).
·         Ask client to keep a sleep diary for several weeks. Often the client can find the cause of the sleep deprivation when the pattern of sleeping is examined (Pagel, Zafralotfi, Zammit, 1998).
·         Teach relaxation techniques, pain relief measures, or the use of imagery before sleep.
·         Teach client need for increased exercise. Encourage to take a daily walk 5 to 6 hours before retiring. Moderate activity such as walking can increase the quality of sleep (King et al, 1997).
·         Encourage client to develop a bedtime ritual that includes quiet activities such as reading, television, or crafts.
·         Teach the following guidelines for good sleep hygiene to improve sleep habits:
o Go to bed only when sleepy.
o When awake in the middle of the night, go to another room, do quiet activities, and go back to bed only when sleepy.
o Use the bed only for sleeping—not for reading or snoozing in front of the television.
o Avoid afternoon and evening naps.
o Get up at the same time every morning.
o Recognize that not everyone needs 8 hours of sleep.
o Move the alarm clock away from the bed if it is a source of distraction.
o Do not associate lulls in performance with sleeplessness; sleeplessness should not be blamed for everything that goes wrong during the day.
These guidelines on sleep hygiene have been shown to effectively improve quality of sleep (Morin, 1993; Pagel 1997; Walsh et al, 1999).

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