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Transcript of Stress Insomnia Output
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UNIVERSITY OF SAN CARLOS
SCHOOL OF HEALTH CARE PROFESSIONS
DEPARTMENT OF NURSING
CASE STUDY:
STRESS INSOMNIA
SUBMITTED BY:
BSN 4B Group 7
Batuigas, Sheila Mae C.
Dumago, Charisse
Mondero, Kristine Rose M.
Mondigo, Armond A.
Mones, Patricia Helen A.
Olayvar, Jennifer P.
Ong, Mary Norriel Y.
Orlanda, Jo Angeli D.
Paulo, Keith Jon P.
Pleños, Tutz Genaida N.
Redido, Francis Gerard H.
Reyes, Paul M.
Romarate, John Raymar M.
Sunpongco, Elyza Kristina V.
SUBMITTED TO:
Mr. Ryan Daniel Dablo, RN
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I. Introduction
A Case of C.K.P.C., 16 years old, male student of the University, came to the clinic for
consultation. The client has been experiencing a difficulty in sleeping. He verbalized that thoughts
keep running inside his head. Received Client sitting on a chair, conscious and coherent with the
following vital signs: Blood pressure of 120/80, Respiratory rate of 20 Cycles per minute, Pulse rate
of 86 and a temperature of 36.6C.
Insomnia is the perception or complaint of inadequate or poor-quality sleep because of difficulty
falling asleep, difficulty maintaining sleep, or waking too early in the morning. These result in the
feeling that sleep is not restorative and often are associated with impaired function during the day.
Insomnia is the most common sleep disorder in the United States. About one-third of the adult
population has experienced it at some time and approximately 10% have a persistent problem.
Insomnia can be classified in terms of its duration: transient, short-term, and chronic. Transient and
short-term insomnia are caused by similar factors, but short-term insomnia usually requires a
greater disturbance. Transient insomnia can be described as lasting from one night to a few weeks
and is usually caused by events that alter your normal sleep pattern, such as traveling or sleeping in
unusual environment (e.g., a hotel) .Short-term insomnia lasts about two to three weeks and is
usually attributed to emotional factors such as worry or stress. Chronic insomnia occurs most nightsand lasts a month or more.
Typically, transient or short-term insomnia are caused by similar factors, but the degree of
disturbance is usually greater to experience short-term insomnia. These include: Stress-related
factors significant personal events, such as losing a job, marital problems, stress and generally
worrying. Uncomfortable sleeping environment (too much light or noise, uncomfortable
temperature).Unusual sleeping environment (e.g., a hotel room).Changes in the daily rhythm hm,
such as a change in work shift or jet lag. Acute medical illness or their treatments.
Chronic insomnia may be caused by one of the following: Chronic medical illnesses - Certain
medical illness can interfere with sleep, especially disorders of the heart (congestive heart failure)
and lungs (chronic obstructive pulmonary disease). Other important physical causes include
heartburn, prostatism, menopause, diabetes, arthritis, hyperthyroidism and hypoglycemia.
Sleep disordered breathing - Disorders of sleep that cause one to stop breathing while asleep may
fragment sleep and cause frequent awakenings during the night. This can be seen rarely with
obstructive sleep apnea, but is much more common with central sleep apnea.
Restless leg syndrome (RLS) is an unpleasant tickling, burning, pricking or aching sensations in
the legs that are generally only relieved with movement and tend to occur while relaxing in the
evening hours. A similar and often overlapping disorder is periodic limb movement of sleep, whichare the recurrent movements of the legs during sleep that may cause arousals from sleep.
Psychophysiologic ("learned") insomnia - Many people go to bed worrying about insomnia
because of previous episodes. This creates an anxiety about going to sleep, which usually leads to
greater difficulty sleeping. Biological factors - As we age, sleep becomes lighter and more
fragmented. Older people often struggle with frequent nighttime awakenings and the inability to
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sleep past the very early morning. Also, during our life spans, the internal biological "clock" that
regulates sleep creeps slightly forward, compelling most older people to go to sleep earlier and to
wake earlier. Lifestyle factors - Excessive caffeine consumption, alcohol and drug abuse, smoking,
and poor sleeping habits are often overlooked as cause of chronically disturbed sleep.
Insomnia Statistics: 20-40% of all adults have insomnia in the course of any year, 1 out of 3 peoplehave insomnia at some point in their lives. Over 70 million Americans suffer from disorders of sleep
and wakefulness. Of those, 60% have a chronic disorder.
Children & Sleep Statistics: Over 2 million children suffer from sleep disorders. Estimated that 30 to
40% of children to not sleep enough. Children require an average of 9 to 10 hours of sleep each
night.
Women & Sleep Statistics: Women are twice as likely as men to have difficulty falling and staying
asleep. Pregnancy can worsen sleep patterns. Menopause and hormone changes cause changes in
sleep
Older Adult Statistics: Over half of those over the age of 65 experience disturbed sleep. Those over
65 make up about 13% of the US population, but consume over 30% of prescription drug and 40% of
sleeping pills
General Statistics: Adults require an average of 8 to 8.5 hours of sleep each night. Sleep problems
add an estimated $15.9 billion to national health care costs. 84 classifications of sleep disorders
exist. (http://www.sleepmed.md/page/1896 )
As a student nurse, we could help our patients by being equipped with deep understanding of
the disease and the appropriate interventions suited for them. In this way, we could ensure our
patients that quality care is rendered to them. With us having a wide understanding of the disease,it would then be easy for us to impart teachings on prevention of the occurrence of Stress Insomnia.
Aside from rendering our patients with the appropriate interventions they needed, it is also our
responsibility as a student nurse to provide them information and impart health teachings in order
to improve their condition to the best of our abilities. This study will help the nursing profession by
providing information about the proper management and care for patient with Stress Insomnia. It
will also educate the people, especially those with this disease and vulnerable individuals to seek
medical care to prevent Stress Related Insomnia.
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II. Objectives
General:
The objective for this case study presentation is to enhance students’ knowledge, skills
and attitude that will aid them in rendering holistic care to future patients suffering in Stress
Insomnia. This study also aims to develop the skills that are applied for the care of patients
with this condition. At the same time, it allows the students to utilize the different attitude
instilled on them, like being respectful, empathetic and patient.
Specific:
After 1-2 hours of case study presentation, the students of University of San Carlos –
School of Health Care Professions – Department of Nursing will be able to:
a.) Define what Stress Insomnia is according to their understanding.
b.) Explain thoroughly the disease process of Stress Insomnia.
c.) Discuss the pathophysiology of Stress Insomnia.
d.) Identify at least 5 clinical manifestations of Stress Insomnia.
e.) Formulate appropriate nursing care plan for patients with Stress Insomnia.
f.) Enumerate at least 2 complications Stress Insomnia.
g.) Discuss the different drugs: indications, mechanism of action, therapeutic effects,adverse effects and contraindications.
h.) Identify and provide the interventions and health teachings needed for the continuum
of care after hospital admission.
i.) Use the NCP as the framework of patient’s care.
j.) Verbalize the importance of rendering appropriate care for patients with Stress
Insomnia.
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III. Nursing Assessment
University of San Carlos
College of Nursing
Cebu City
I. PATIENT DEMOGRAPHIC PROFILE:
Name: C.K.P.C. Age / Gender: 16 y.o / Male Status: Single__
Home Address______________________________ ______________________
Religion: Roman Catholic Nationality: Filipino Occupation: None_______
II. HEALTH HISTORY PROFILE:A. Past Medical History
1. Pediatric and Adult Illness
Date Illness Medication Remarks
The patient cannot
recall
The patient cannot
recall
The patient cannotrecall
The patient cannot
recall
Mumps
Cough and colds
Tonsillitis
Measles
The patient cannot
recall any medication
The patient did not take
any medication.
The patient did not takeany medication.
The patient cannot
recall any medication.
Cured
Cured
Cured
Cured
2. Immunizations
Immunizations Doses Dates Remarks
BCG
DPT
OPV
MMR
2
3
3
1
The
patient
cannot
recall
Complete
Complete
Complete
Complete
3. Hospitalization
Date & Year Hospital Institution Diagnosis Duration (No. of Days)
The patient didn’t
hospitalized
The patient didn’t
hospitalized
The patient didn’t
hospitalized
The patient didn’t
hospitalized
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4. Injuries and Accidents
The patient didn’t experience any injuries and accidents.
5. Transfusions
The patient has not undergone blood transfusion.
6. Allergies
The patient does not have any allergies.
B. Family History
Family History was not taken due to short interaction with the client. Stress
Insomnia is not heredity, but is greatly affected by the kind of lifestyle a person has.
C. Social and Personal History
1. Occupation
The patient has no job and he is in school.
2. Number of Children
The patient does not have any children.
3. Military experience; foreign travel
The patient has neither experience in military nor any foreign travel.
4. Habits (tobacco, alcohol, non-prescription drugs, others)
The patient drinks alcohol occasionally. He consumes 2-3 glasses of hard drinks every time He
drinks.
5. Diet
The patient eats siomai and pork most of the time. He eats fish sometimes. He seldom eats
vegetables in his meal.
6. Type of Family
The patient has a nuclear type of family.
7. Cultural and Religious BeliefsHe believes in superstitions like “barang.” He is a catholic and he goes to church 2-3 times a
month.
Brief description of average day
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6:00 am Wakes up
7:00 am go to school
11:00 am Eats lunch
12:00-2:00 pm Siesta (rests and watches tv)
3:00-6:00 pm class time
6:00-7pm going home
7:00 pm Eats dinner
10:00-12:00 am Watches TV
12:00 are Goes to sleep
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A. Review of System (for the past 6 months). Physical Assessment
General Weight loss fatigue anorexia night sweats chills fever
weakness
>Fever related to inflammation of tonsils(tonsillitis)
>Fatigue related to inadequate sleep and rest
Skin Itch rash lesions bruising bleeding color change
>no significant Manifestation.
Eyes Pain discharge itch vision loss excessive tearing diplopia
glasses/contact lens Date of last exam:
>no significant Manifestation.
Ears Earaches discharges tinnitus hearing loss
>no significant Manifestation.
Nose
Obstruction discharge Epistaxis
>mucous discharges: greenish in color related to colds.
Throat & mouth Sore throat bleeding gums toothache dentures
>Sore throat related to inflammation of tonsils(Tonsilitis)
Neck & Head Swelling dysphagia hoarseness
>no significant Manifestation.
Chest Cough sputum: amount & character hemoptysis wheeze pain on
respiration dyspnea
>Cough related to sudden change in weather. Sputum: Colored Green and
sticky
Cardiovascular Precordial pain palpitation dyspnea on exertion paroxysmal nocturnal
dyspnea orthopnea edema heart murmur thrombophlebitisclaudication
>no significant Manifestation.
Gastrointestinal Heartburn nausea vomiting bloating diarrhea food intolerance
excessive gas or indication constipation change in bowel movement
jaundice melena hemmorhoids hernia
>no significant Manifestation.
Genitourinary Frequency of urination dysuria hematuria urgency hesistency
incontinence urinary infection stools
>no significant Manifestation.
Extremities Joint pains varicose veins claudication back pain edema stiffness
deformities
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>no significant Manifestation.
Endocrine Hot flashes hair loss temperature intolerance polydipsia goiter
>no significant Manifestation.
Neurology Numbness tingling tremor fainting headaches muscle weakness
ataxia unconsciousness paralysis/paresis memory loss dizziness seizure
>no significant Manifestation.
Psych Anxiety depression sexual problems insomnia nightmares
>Insomnia related to stress, according to the client the difficulty in sleeping,
stress is often initiating it.
Others >Difficulty with memory and Poor concentration as verbalized by client.
I. CURRENT HEALTH PROFILE:
A. Presenting complaints and medical diagnosis to include interventions done prior to hospitalization.
Three weeks prior to check-up, the client has been experiencing a difficulty in sleeping. He
verbalized that thoughts keep running inside his head. Received Client sitting on a chair, conscious and
coherent with the following vital signs: Blood pressure of 120/80, Respiratory rate of 20 Cycles per
minute, Pulse rate of 86 and a temperature of 36.6C.
B. PHYSICAL ASSESMENT (head-to-toe)
General
The patient appears pale. He claims to have difficulty in sleeping for three weeks
already. Patient verbalized weakness and easily gets tired due to lack of sleep. The patient
mentioned that he tries to put his self into sleep until 4am but can only take a sleep about anhour since he still needs to wake up early for his 7:30 am class. Vital signs: temperature- 37 ‘C,
RR- 18 cpm, HR-89 bpm, BP- 120-80mmHg
Head and neck
Patient has a black hair, evenly distributed and tidy. No dandruff found, no swelling and
or lesions on the scalp.
Head has an appropriate size for his body. Eyes are chinky, eyelashes evenly distributed,
eyebags seen on both eyes, pupils dilate when directed with penlight, no swelling and no
tenderness noted. Nose has no discharges, symmetrical in form, no swelling and no lesions
noted. Lips are pale, and moist and no swelling noted. Oral mucosa is moist and pinkish, no
lesions noted. Ears are symmetrical in size and shape and are parallel to each other; no
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discharges noted. Face’s skin temperature is normal. No lesions and swelling on the neck. Gag
reflex is okay.
Cardiovascular
Patient can breathe normally. No obstructions noted. No abnormal breath sounds
heard.
Gastrointestinal
Bowel sounds heard in all four quadrants. Patient verbalize that he urinates 3 to 5 times
a day. No pain in urinating, urine color is yellowish and has a funky urine odor. Can defecate one
to two times a day without any complain of pain.
Upper extremities
Skin temperature is normal, no lesions, no scars noted, and no wounds seen. Fair in
color and is evenly distributed, can grab pen, reflexes are normal, fingers are complete. Nail
fingers are clean. Can bend elbows voluntarily, can shrug shoulder with absence of pain. CFT is
more than 3 seconds.
Lower extremities
Patient can walk properly, legs are symmetrical in shape and length, no lesions noted,
no pain in joints claimed.
Neurology
Patient can recognized time, place and the people around. He has a good mind
condition. He verbalizes of difficulty in sleeping for three weeks already and is worried for his
condition.
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IV. Anatomy and Physiology
Anatomy
Sleep and wakefulness is a tightly regulated process. Reciprocal connections in the brain produce
consolidated periods of wakefulness and sleep that are entrained by environmental light to occur at
specific times of the 24-hour cycle.
Promotion of wakefulness
Brain areas critical for wakefulness include the tuberomammillary nucleus (TMN) in the posterior
hypothalamus. The TMN contains histamine neurons, which project stimulatory inputs to brainstem
arousal centers such as the locus coeruleus (LC) (norepinephrine), the dorsal raphe nuclei (DRN)
(serotonin), the ventral tegmental area (VTA) (dopamine), and the basal forebrain (acetylcholine). These
brainstem arousal centers (see the image below) project diffusely to cortical areas to promote arousal.
The TMN also inhibits sleep-promoting areas, such as the anterior hypothalamus. Similarly, the
brainstem arousal regions inhibit sleep-promoting regions in the anterior hypothalamus. Adenosine, a
neurotransmitter, accumulates in the brain during prolonged wakefulness and inhibits wake-promoting
regions in the posterior hypothalamus and the basal forebrain. Acetylcholine in the basal forebrain also
projects diffusely to cortical areas and the TMN to promote wakefulness.
The ascending arousal system. Adapted from Saper et al. Hypothalamic Regulation of Sleep and
Circadian Rhythms. Nature 2005;437:1257-1263.
Promotion of sleep
The anterior hypothalamus includes the ventrolateral preoptic nucleus (VLPO), containing gamma-
aminobutyric acid (GABA) and the peptide galanin, which are inhibitory and promote sleep (see theimage below). They project to the TMN and the brainstem arousal regions to inhibit wakefulness. GABA
is the predominant inhibitory neurotransmitter in the central nervous system (CNS).
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Ventrolateral pre-optic nucleus inhibitory projections to main components of the arousal system to
promote sleep.
The homeostatic and circadian processes
Both animal and human studies support a model of 2 processes that regulate sleep and wakefulness:homeostatic and circadian. The homeostatic process is the drive to sleep that is influenced by the
duration of wakefulness. The circadian process transmits stimulatory signals to arousal networks to
promote wakefulness in opposition to the homeostatic drive to sleep. (See the image below.)
Sleep-wake cycle.
Melatonin and the circadian process
The suprachiasmatic nucleus (SCN) is entrained to the external environment by the cycle of light and
darkness. The retinal ganglion cells transmit light signals via the retinohypothalamic tract to stimulate
the SCN. A multisynaptic pathway from the SCN projects to the pineal gland, which produces melatonin.
Melatonin synthesis is inhibited by light and stimulated by darkness. The nocturnal rise in melatonin
increases between 8 and 10 am and peaks between 2 and 4 am, then declines gradually over the
morning.[13] Melatonin acts via 2 specific melatonin receptors: MT1 attenuates the alerting signal and
MT2 phase shifts the SCN clock. The novel sleep-promoting drug ramelteon acts specifically at the MT1
and MT2 receptors to promote sleep.
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THE STRESS RESPONSE
Stress can be physical, such as a loud noise, cold temperature, and strenuous activities. It can also be
psychological, such as anxiety, guilt, or joy. Each person’s threshold to stress is different, but is a fact of
everyday life to everyone.
The hypothalamus receives information from almost all parts of the brain including the limbic system,
the emotional brain. The hypothalamus responds to signals of stress by recruiting the sympathetic
division of the autonomic nervous system, also called the flight or fight response.
The body prepares for the flight and fight response by:
1) Shunting blood from the skin and digestive organs to the muscles.
2) Providing more fuel through an increase in glucagon action, in other words, releasing glucose
from stored glycogen. The hypothalamus stimulates a release of ACTH from the anterior
pituitary gland to increase cortisol levels from the adrenal glands.
Cortisol helps to supply cells with amino acids and fatty acids for energy supply while diverting glucose
from muscles for use by the brain. Cortisol and related compounds are sometimes used to reduce
inflammation, but the concentration necessary for inflammation reduction is toxic to the body. These
drugs must be carefully monitored.
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V. Pathophysiology
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VIII. DISCHARGE PLAN
University of San Carlos
Department of Nursing
Discharge Plan and Instruction
Name: C.K.P.C____Age:_16___Sex: ____Male__Religion:_____Roman catholic_____Diagnosis: _______________Stress Insomnia_________________________________
Surgery Undergone, if Any: _____________ Hospital: __________________________
Rm/Ward-Bed No.: _____________ Physician: _______________________________
A. Objectives (SMART/KSAV)
After Mr. C.K.P.A. will be discharge, he will be able to:
a) Adhere to prescribed medications and treatment.
b) Appreciate the given diet and exercise in promotion of health and wellness.
c) Perform diet recommended and followed restriction given
d) Identify different ways to minimize or prevent complications.
e) Verbalize understanding on disease process and therapeutic regimen.
B.
1. MEDICATIONS
Name of drug DosageFrequency
Route Curative Effects Side Effects
Hydroxyzine diHCl 10g By mouth
short-term
treatment of
nervousness and
tension
Drowsiness, dizziness,
blurred vision, dry
mouth, or headache
2. EXERCISE/ACTIVITY
Type of Activity allowed/to be continued:
Walking exercise at least 15-20 minutes a day.
Deep Breathing Exercises – Perform this when you wake up in the morning, do this for a set 0f 10
cycles while awake to promote lung expansion allowing oxygen to be delivered to the tissues
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Use of equipment (if any): None.
Restrictions: No vigorous exercise prior to sleeping.
3. TREATMENT (prescribed treatment to be continued at home or to a referred health institution.)
Adhere to prescribed diet to promote strength, energy and good nutrition.
Adequate bed rest to prevent fatigue and stress.
Drink water about 8 glasses a day to promote good hydration to the body.
Changing the habits that are reinforcing sleeplessness.
4. HEALTH TEACHINGS (Provide a separate sheet on specified health teachings)
(/) clinic appointment schedules ( ) use of alternative medicines
( ) follow-up laboratory examinations ( ) relapse prevention measures
( ) understanding and knowing what to do with side effects of medications(/) Others: Self-help techniques to cure insomnia
5. a.) OBSERVED SIGNS AND SYMPTOMS THAT NEEDS REPORTING:
SEVERE ANXIETY
DEPRESSION
b.) INTERVENTIONS / HOME REMEDIES that may be done immediately prior to seeking
consultation:
Bed rest Do relaxation activities, like deep breathing exercises.
Instruct the client to sleep/rest in a quiet environment and perform comfort
measures in preparation for sleep such as fixing the bed sheets, back rub and
washing of face
Limiting intake of chocolate and caffeine/alcoholic beverages, especially prior to
bedtime.
Explore other sleep aids such as warm bath and protein intake before bedtime.
6. DIET
Food to eat: Chlorophyll-rich foods, such as leafy green, vegetables, steamed or boiled
Oyster shell can purchased in health food stores and taken as a nutritional supplement
Whole grains: Whole wheat, brown rice, and oats have a calming and soothing effect on the
nervous system and the mind. Carbohydrates also boost serotonin, which promotes better
sleep.
Mushrooms (all types)
Fruit, especially mulberries and lemons, which calm the mind
Seeds: jujube seeds are used to calm the spirit and support the heart. Chia seeds also have a
sedative effect.
Basil
Foods such as bread, bagels, and crackers that are high in complex carbohydrates have a mildsleep-enhancing effect because they increase serotonin, a brain neurotransmitter that promotes
sleep
A glass of warm milk with honey is one of the oldest and best remedies for insomnia. Milk
contains tryptophan which, when converted to seratonin in the body, induces sleep and
prevents waking
Lettuce has a long-standing reputation for promoting healthy sleep. This is due to an opium-
related substance combined with traces of the anticramping agent hyoscyarnin present in
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lettuce. Lettuce should be an integral part of your evening diet if you are suffering from sleep
disorders. The meal should also include legumes, peanuts, nutritional yeast, fish or poultry.
These foods contain vitamin B3 (niacin). Niacin is involved in seratonin synthesis and promotes
healthy sleep. Mixed with a little lemon juice for flavor, lettuce juice is an effective sleep-
inducing drink highly preferable to the synthetic chemical agents in sleeping pills
b.) Restrictions:
ALCOHOL, CAFFEINATED DRINKS, coffee, cola and tea can also reinforce sleeplessness,
spicy foods, stimulant drugs, additives, preservatives, Sugar and foods high in sugar and refined
carbohydrates. These raise blood-sugar levels and can cause a burst of energy that disturbs
sleep, Foods that are likely to cause gas, heartburn, or indigestion, such as fatty or spicy foods,
garlic-flavored foods, beans, cucumbers, and peanuts, Monosodium glutamate (MSG), often
found in Chinese food. This causes a stimulant reaction in some people, Foods such as meat that
are high in protein can inhibit sleep by blocking the synthesis of serotonin, making us feel more
alert, Avoid cigarettes and tobacco. While smoking may seem to have a calming effect, nicotine
is actually a neurostimulant and can cause sleep problem
7. SPIRITUAL AND PSYCHOLOGICAL NEEDS
( ) spiritual counseling ( ) confession( X) supportive counseling
( ) grief work ( ) family therapy ( ) join organizations/church activities
( ) anger management ( ) reconciliation of conflicted relationships
A. DISCHARGE DETAILS
a.)
Date and time of discharge:b.) Accompanied by:
c.) Mode of transportation:
d.) General condition upon discharge:
THESE DISCHARGE INSTRUCTIONS WERE EXPLAINED TO THE PATIENT AND / OR RELATIVE
Read and understood: (translated according to patient’s convenience)
: If all measures fail, an interpreter is asked.
PATIENT / RELATIVE
(Signature over printed name)
Validated:
STUDENT NURSE
(Signature over printed name)
CLINICAL INSTRUCTOR
(Signature over printed name
CONTENT:
Self-help techniques to cure insomnia
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Another technique for getting insomnia and some other sleep disorders under control is by keeping a
sleep diary.
Practicing this involves keeping a record of the times that you go to bed, wake up as well as when you
experience times of restlessness. You write down your sleeping patterns, but you also keep track of your
daytime habits.
This may help you understand some of the triggers of insomnia.
For example, some issues that often exacerbate insomnia include late-night caffeine, Internet surfing or
watching TV late into the night.
So any natural sleep aids may target these issues through proper sleep hygiene.
Similarly you can use natural sleep remedies such as herbal supplements like valerian or lavender that
may be useful to get a better nights sleep.
Though insomnia is a serious problem that must be treated, you can practice many self-help techniques
to improve the condition.
You can practice a regular routine of yoga, meditation or even deep breathing, all exercises that have
been shown to relieve stress and improve your health.
You can also adopt new habits to help you sleep and prevent nights of sleeplessness. These may include
anything from sticking to a regular sleep schedule to avoiding stressful situations before bedtime or
throughout the day.
All of these techniques, in addition to professional help, can help you combat insomnia effectively.
Treatments for sleep disorders can include a complement of strategies. Some common remedies
include:
Sleep hygiene or behavioral and lifestyle changes
Pharmacological interventions
Non-pharmacologic medications: over-the-counter aids, devices and equipment, natural
remedies, dietary supplements
Alternative therapies: acupuncture, hypnosis, relaxation, massage.