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.

My scenario has a 57 old female admitted to ER with a fractured leg secondary to MVA. VS -T 98.8 P 95 RR 24 b/P 145/89 she is AAO*3 complained of severe pain (8) right leg was given medication and reported relief (2). It's 1 am and the pt has not slept since admission she communicates she is use to it, feeling tired, falling asleep anywhere". She often had to have cuban coffee to stay alert as she often had to work with heavy machinery at a plant. I need a diagnosis, sub&obj goals and interventions. I have done the following diagnosis sleep deprivation r/t inadequate sleep hygiene aeb feeling tired and falling asleepbeverwhere" obj fracture right leg, sub use to it, feeling tired, falling asleep everywhere" i believe the pt is sleep deprived and she needs sleep for her fracture to heal, her body needs recuperation i have some intervention such as assess for fatigue, anxiety, encouraging restriction of cafeeine and encouraging a light snack and teach relaxation techn such as soft music but i need someones elses opinion. It would be helpful if they have other suggestions on what tbey would do, thank u

I don't have a careplan book handy but maybe you do a dx of "pain related to injury as evidence by patient states pain is 10/10." Interventions could be something like assess pt's pain level Q??hrs, admin pain meds, monitor vitals."

You could maybe do a psychosocial with something like "anxiety related to MVA or hospital stay as evidence by pt states she's anxious/worried about being in hospital?? Interventions could be something like, stay with patient, assess pt's level of anxiety, teach relaxation techniques.

Hope that helps a little.

You might try Alteration in Health Maintenance r/t inadequate health practices such as unhealthy life style (her major lack of proper sleep habits). Sounds as if she may have set up an abnormal sleep pattern for herself. You would assess the contributing factors to sleep pattern and initiate health promoting behaviors such as reducing caffeine intake and sleep promoting techniques. Also, one question that I had was if the MVA was caused by her falling asleep? Good luck.

I haven't done Care Plans for a few years... but for her sleep deprivation can you refer her for a sleep study as an intervention.

I know this won't help but I will never miss having to do another care plan.

To Datetonite

Thank you very much, i thought the same things too but the prof said it had something to do with sleep I love ur suggestion, thank you very much