CASE STUDY ADPIE (Assessment, Diagnosis, Planning, Intervention, Evaluation) ASSESSMENT A 45-year-old woman comes to the clinic and asks for medication to help her sleep. She states she is worrying too much and states it takes me about an hour to get to sleep, and it is very hard to fall asleep. I feel like I can’t do anything because I am so tired. My husband passed away recently. NURSING INTERVENTIONS Nursing interventions are like road maps directing the best ways to provide nursing care. The more clearly a nurse writes an intervention, the easier it will be to complete the journey and arrive at the destination of successful client outcomes. Nursing Interventions and Rationales Rationale: Ref: Rationale: Ref: EVALUATION? (Ctrl)
The Correct Answer and Explanation is:
Assessment:
The patient is a 45-year-old woman who presents to the clinic complaining of difficulty falling asleep, taking approximately an hour to do so. She reports feeling very tired and unable to function properly during the day due to the lack of quality sleep. The patient also shares that she is experiencing increased worry, and additionally, she mentions that her husband recently passed away. This information suggests that the sleep disturbances and fatigue may be linked to grief and emotional distress.
Diagnosis:
Based on the information provided, the patient may be experiencing insomnia (related to emotional distress, grief, and anxiety) as well as potential acute grief reaction due to the loss of her husband. Other possible diagnoses include anxiety disorder or adjustment disorder, considering the emotional impact of her husband’s death.
The specific nursing diagnoses might include:
- Disturbed Sleep Pattern related to grief, anxiety, and excessive worry.
- Ineffective Coping related to the inability to manage stress and emotions due to recent loss.
- Fatigue related to insufficient restorative sleep.
Planning:
The goal is to help the patient restore a more normal sleep pattern, manage anxiety and grief, and provide emotional support for the mourning process. Outcomes should be measurable, such as:
- The patient will report feeling more rested with fewer instances of difficulty falling asleep within one week.
- The patient will develop at least two healthy coping strategies for managing anxiety and grief by the next visit.
- The patient will verbalize a reduction in feelings of fatigue or excessive tiredness after two weeks.
Nursing Interventions and Rationales:
- Encourage the patient to establish a bedtime routine: A relaxing pre-sleep ritual, such as reading, meditating, or listening to calming music, can help signal the body that it’s time to wind down, reducing anxiety and promoting better sleep.
- Rationale: Establishing a consistent sleep routine can improve sleep onset and quality by reducing anxiety and allowing the body to relax before sleep. (American Academy of Sleep Medicine, 2022)
- Educate the patient on the importance of sleep hygiene: Encourage practices such as avoiding caffeine and alcohol close to bedtime, keeping a cool, quiet, and dark sleep environment, and limiting screen time before sleep.
- Rationale: Sleep hygiene strategies can help create an environment that promotes natural sleep onset and improves sleep quality. (National Sleep Foundation, 2021)
- Provide emotional support and refer the patient to grief counseling or support groups: Grief counseling can help her process the emotional impact of her husband’s death.
- Rationale: Grief support will assist in processing the loss and may reduce anxiety and depressive symptoms, which can impact sleep. (American Psychological Association, 2023)
- Monitor for signs of clinical depression or anxiety: Assess for worsening symptoms that may require more intensive interventions or psychiatric referral.
- Rationale: The emotional distress from grief can evolve into more serious mental health concerns, such as depression or anxiety, requiring further intervention. (National Institute of Mental Health, 2022)
Evaluation:
In evaluating the effectiveness of nursing interventions, the nurse will assess whether the patient:
- Demonstrates an improved sleep pattern, i.e., falling asleep within a reasonable amount of time and feeling more rested.
- Verbalizes or shows signs of improved coping with grief, such as expressing acceptance or engaging in social or community activities.
- Reports decreased levels of fatigue and increased daytime functioning.
Follow-up visits should focus on ensuring that the patient is maintaining progress with coping strategies and sleep hygiene, and adjust the plan as necessary based on any ongoing or worsening symptoms.
Conclusion:
This approach emphasizes the importance of a holistic assessment, individualized planning, and appropriate interventions in promoting improved mental health and quality of life for a patient dealing with grief and sleep disturbances.
