12.4 Putting It All Together

Client Scenario

Mrs. Salvo is a 65-year-old woman admitted to the hospital for a gastrointestinal (GI) bleed. She has been hospitalized for three days on the medical-surgical floor. During this time, she has received four units of PRBCs, has undergone a colonoscopy and an upper GI series, and had hemoglobin levels drawn every four hours. The nurse reports to the client’s room to conduct an assessment prior to beginning the 11 p.m.-7 a.m. shift.

Although Mrs. Salvo’s hemoglobin has stabilized for the last 24 hours, Mrs. Salvo appears fatigued with bags under her eyes. In conversation with her, she yawns frequently and wanders off in her train of thought. She reports, “You can’t get any rest in here. I am poked and prodded at least once an hour.”

Applying the Nursing Process

Assessment: The nurse notes that Mrs. Salvo has bags under her eyes, is yawning frequently, reports difficulty achieving rest, and seems to have difficulty following the conversation.

Based on the assessment information that has been gathered, the following nursing care plan is created for Mrs. Salvo:

Nursing Diagnosis: Disturbed Sleep Pattern related to interruptions for therapeutic monitoring as evidenced by reports of difficulty achieving rest, bags under eyes, frequent yawning, and difficulty following conversation.

Overall Goal: The client will demonstrate improvement in sleeping pattern.

SMART Expected Outcome: Mrs. Salvo will report feeling more rested on awakening within 24 hours.

Planning and Implementing Nursing Interventions:

The nurse will assess the client’s sleep pattern and therapeutic monitoring disturbances. The nurse will group lab draws, vital signs, assessments, and other care tasks to decrease sleep disruption. The nurse will ensure the client’s door is closed and lighting is turned down to create a restful environment. The nurse will complete as many tasks as possible when Mrs. Salvo is awake and advocate with the interprofessional team for uninterrupted periods of rest during the night.

Sample Documentation:

Mrs. Salvo has a disturbed sleep pattern due to frequent therapeutic monitoring. Mrs. Salvo reports difficulty achieving rest, and despite stabilization in hemoglobin level, continues to demonstrate signs of fatigue. Interventions have been implemented to group therapeutic care to minimize disruption to the client’s sleep.

Evaluation:

The following morning, Mrs. Salvo reports improved sleep and feeling more rested with fewer awakenings throughout the night. SMART outcome “met.”