Re: Help on care plan
My first thought was Acute Pain for diagnosis. I know you stated she had relief from pain med, but I am assuming the pain will return. Regardless, you said her pain is still a 2, so you could implement other interventions, such as positioning, relaxation techniques.
The other diagnosis that goes along with sleep deprivation is Readiness for Enhanced Sleep. The diagnosis would depend on whether she has a readiness to learn. If so, then it would be educating the pt. regarding relaxation, reducing caffeine, and the other interventions that you mentioned. I think your diagnosis of Sleep Deprivation is fine. You could also use the Fatigue diagnosis.
Lastly, you may want to consider the Anxiety diagnosis. Afterall, she did just go through a traumatic event (MVA) and may be anxious. Hope this helps.
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