Makic: Ackley and Ladwig’s Nursing Diagnosis Handbook, 
13th Edition
Case Study Answers

Lecture Notes

Problem-Based Learning/Critical Thinking

Case Study—Restless Leg Syndrome

Case Scenario

Abdul Malek is a 21-year-old college student. He attends the local state university and is a junior studying graphic design. Three weeks into his fall semester, Abdul’s professors notice that he is falling asleep in class and often looks restless. Abdul taps his foot and squirms around in his seat. Abdul, who is usually an excellent student, has failed his first test in his Graphic Design II course. His professor asks him to see his advisor because the fear is that Abdul has become chemically impaired. His advisor sends Abdul to the student health services and his case is reviewed by the nurse.

Nursing Assessment

Abdul is a well-developed 22-year-old male with a BMI of 20. His vital signs are blood pressure 104/78; temperature 98.4°F; heart rate—64 beats per minute; respiratory rate—16 breaths per minute. A nutritional history confirms a well-balanced diet with the exclusion of pork products. Abdul had been working out every day at the University gym but reports that he is currently “too tired” to do so. Abdul denies drug or alcohol use and this is confirmed by serum analysis. Abdul complains about sleeping poorly and feeling as if, “I am moving all night.” He states that he often wakes up his dorm mate and feels bad about that. The nurse reclines Abdul on the examination table and checks his deep tendon reflexes (DTRs) which are all 2+. The nurse asks Abdul to relax and dims the lights while she consults with the primary care practitioner. While the nurse is out of the examination room Abdul dozes, and when the nurse returns, the nurse observes Abdul’s right leg jerking several times before she arouses him.

A.	ASSESS

1.	Identify significant symptoms by underlining them in the assessment.

2.	List those symptoms that indicate the client has a health problem (those you have underlined).
•	falling asleep in class
•	often looks restless
•	taps his foot
•	squirms around in his seat
•	failed his first test
•	“too tired”
•	complains about sleeping poorly
•	“I am moving all night”
•	often wakes up
•	dozes
•	right leg jerking several times

3.	Group the symptoms that are similar.
•	falling asleep in class
•	often looks restless
•	taps his foot
•	squirms around in his seat
•	failed his first test
•	complains about sleeping poorly
•	dozes
•	“too tired”
•	“I am moving all night”
•	often wakes up
•	right leg jerking several times

B.	DIAGNOSE

1.	Select possible nursing diagnoses for this client.

Do this by looking at the list of nursing diagnoses in the book, Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care.

Possible nursing diagnoses:
•	Sleep deprivation
•	Disturbed sleep pattern
•	Fatigue
•	Ineffective coping
•	Stress overload

2.	Validate the possible nursing diagnoses.

Compare the signs and symptoms (defining characteristics) that you have identified from your client assessment with the defining characteristics for the nursing diagnosis that you have selected. Also read the definition and determine if this diagnosis fits this client.

Validated nursing diagnoses include:
•	Sleep deprivation

3.	Write/select a nursing diagnostic statement for one of the nursing diagnoses by combining the nursing diagnosis label with the related to (r/t) factors.

a.	The label is the title of the nursing diagnosis as defined by NANDA-I. Include the Domain and Class.
b.	A related to (r/t) statement describes factors that may be contributing to or causing the problem that resulted in the nursing diagnosis.

NANDA-I label: Sleep deprivation; Domain 4: Activity/rest, Class 1: Sleep/rest

Definition
Prolonged periods of time without sustained natural, periodic suspension of relative consciousness that provides rest.

Defining Characteristics
Altered attention; anxiety; apathy; combativeness; confusion; decreased functional ability; drowsiness; expresses distress; fatigue; fleeting nystagmus; hallucinations; heightened sensitivity to pain; irritable mood; lethargy; prolonged reaction time; psychomotor agitation; transient paranoia; tremors

Related Factors (r/t)
Age-related sleep stage shifts; average daily physical activity is less than recommended for age and gender; discomfort; environmental disturbances; environmental overstimulation; late day confusion; nonrestorative sleep-wake cycle; sleep terror; sleep walking; sustained circadian asynchrony; sustained inadequate sleep hygiene

At-Risk Population
Individuals with familial sleep paralysis

Associated Conditions
Conditions with periodic limb movement; idiopathic central nervous system hypersomnolence; narcolepsy; neurocognitive disorders; nightmares; sleep apnea; sleep-related enuresis; sleep-related painful erections; treatment regimen

The complete nursing diagnostic statement is:
Sleep deprivation r/t conditions with periodic limb movement

C.	PLAN

1.	Select appropriate NOC outcome from the Ackley/Ladwig text.

NOC outcome: Sleep

Fill out the grid with NOC indicators and the appropriate Likert scale.
Select the appropriate point on the Likert scale to measure the client’s current status.

INDICATOR	1 = Severely compromised	2 = Substantially compromised	3 = Moderately compromised	4 = Mildly compromised	5 = Not compromised	
Hours of sleep	1*	2	3	4	5	
Sleep pattern	1*	2	3	4	5	
Sleep quality	1*	2	3	4	5	
Sleep efficiency	1*	2	3	4	5	
Feels rejuvenated after sleep	1*	2	3	4	5	
Sleeps through the night consistently	1*	2	3	4	5	

2.	Or write outcomes to help resolve the symptoms (defining characteristics). Refer to Section III of the Ackley/Ladwig text for the nursing diagnosis care plan.

Outcomes:
Client will within a week:
•	Verbalize a plan that provides adequate time for sleep.
•	Identify actions that can be taken to ensure adequate sleep time.
•	Awaken refreshed once adequate time is spent sleeping.
•	Be less sleepy during the day once adequate time is spent sleeping.

3.	Select appropriate NIC interventions from the Ackley/Ladwig text.

NIC intervention: Sleep enhancement

4.	Select appropriate NIC activities.
a.	Monitor/record the client’s sleep pattern and number of sleep hours.
b.	Encourage the client to establish a schedule that allows age-appropriate hours of sleep with minimal environmental and personal disruptions.

Note: The Ackley/Ladwig text gives sample NIC activities.

5.	Select interventions from Section III care plan that will enable the client to attain acceptable outcomes.

Nursing Interventions and Rationales

• Minimize care-environmental factors that may lead to sleep deprivation if they persist. See Nursing Interventions and Rationales for Disturbed Sleep Pattern.
• Address personal client factors that may lead to sleep deprivation if they persist. See Nursing Interventions and Rationales for Insomnia.
• Assess for hypersensitivity to pain in sleep-deprived clients. EB: In a laboratory experiment using 14 healthy adults, sleep restriction protocols altered processes of pain habituation and sensitization, which may help explain why chronic pain conditions often accompany insufficient sleep (Simpson et al, 2018). EB: In an observational study of postoperative orthopedic surgery subjects (n = 50), a significant correlation was found between increased self-reported pain scores and decreased total sleep time (Miller et al, 2015).
• Assess the amount of sleep obtained each night compared with the amount of sleep needed given the client’s age, medical diagnoses, and personal preferences. EBN: In an observational study (n = 141), subjects reported a large variation in how many hours of sleep they obtained in hospital as compared to home; however, the average reduction in hospital sleep duration, compared to home, was 1.8 hours (an average of 5.3 hours of sleep in hospital vs. 7.1 hours at home) (Delaney et al, 2018).
• Assess the extent to which clients can be provided 3 to 4 consecutive hours of sleep time that is free from disturbance. CEB: In a meta-analysis using data from 159 studies, a nurse scientist found that the deepest stages of sleep occurred during the first 3 to 4 hours of the sleep period followed by several 90- to 110-minute sleep cycles that consisted of increasingly lower percentages of deep sleep (Floyd, 2002).
• If sleep-disrupting environmental factors that are inherent in hospitalization cannot be reduced adequately to prevent sleep deprivation, schedule specific times for rest and sleep during the day. EB: Purposefully scheduled daytime naps may compensate in part for less sleep at night, as well as promote recovery from acute illness (Tan et al, 2019).
• If personal sleep-disrupting factors that are inherent in insomnia cannot be reduced adequately to prevent the client’s sleep deprivation, consider scheduling a specific time for rest and sleep during the day. EB: Although the number and duration of daytime naps may need to be limited if the client has difficulty initiating and maintaining nighttime sleep despite use of sleep-promoting interventions for insomnia, a purposefully scheduled nap may compensate in part for less sleep at night (Tan et al, 2019). CEB: Nurse scientists who conducted observational studies were the first to question the prohibition against all daytime napping by showing that carefully scheduled short naps appeared to supplement, rather than displace, nighttime sleep (Hayter, 1985; Floyd, 1995).
• If caffeine is used by the client to alleviate daytime drowsiness, monitor amounts and time of use. CEB: An experimental study of 12 participants found that caffeine (400 mg), even when consumed 6 hours before bedtime, had a disruptive effect on both objective and subjective sleep measures (Drake et al, 2013).
• If naps are inadequate for preventing excessive daytime sleepiness due to sleep deprivation, consider and carefully evaluate use of unstudied, but commonly used, countermeasures for fighting drowsiness. CEB: A descriptive study of 77 middle-aged adults identified the following unstudied strategies as possibly effective interrupters of drowsiness: (1) change physical position, (2) improve ventilation (e.g., get fresh air, turn on fan, open window), (3) reduce air temperature (e.g., turn on air conditioning, turn on fan), (4) increase auditory stimulation (e.g., play music, sing, engage in conversation, listen to debate), and (5) engage in interesting visual activity (e.g., board games, watching TV sports events, watching serial TV dramas) (Davidsson, 2012).
▴ If daytime drowsiness occurs despite adequate periods of undisturbed nighttime sleep and supplemental daytime naps, consider undiagnosed sleep apnea as a possible cause. EB: Sleep-disordered breathing affects 17% of men and 9% of women in the general population, of whom the majority are undiagnosed and untreated (Tan et al, 2019).

Multicultural
• Be aware of racial and ethnic disparities in sleep deprivation. EB: A national survey of 444,306 American adults found that non-Hispanic black, American Indian/Alaska Native, Native Hawaiian/Pacific Islander, and multiracial populations reported a higher prevalence of sleeping less than 7 hours compared with the rest of the U.S. adult population (Liu et al, 2016).

Home Care
• Assessments and interventions discussed previously can all be adapted for use in home care.
▴ If daytime drowsiness occurs despite adequate periods of undisturbed nighttime sleep and supplemental daytime naps, consider sleep apnea as a possible cause. CEB: In a household survey of more than 7000 adults, unexplained excessive daytime sleepiness was identified as a predictor of undiagnosed sleep apnea (Dosman et al, 2014).
• Teach family members about the prevalence and long-term consequences of inadequate amounts of sleep for both clients and family caregivers. EB: A national survey of 444,306 American adults found that more than one-third (34.8%) were likely sleep deprived (i.e., slept less than 7 hours per night), an amount at which physiological and neurobehavioral deficits may manifest and become progressively worse under chronic conditions (Liu et al, 2016). CEB: In an integrative review of 10 studies, insufficient sleep was associated with poor attention, decreased performance, increased mortality and morbidity, and cardiovascular risk factors, including hypertension, insulin resistance, hormonal deregulation, and inflammation (Mullington et al, 2009).
▴ If sleep is deprived due to insomnia, refer client to a nurse practitioner or other sleep specialist trained in cognitive behavioral therapies for insomnia (CBT-I). EB: A meta-analysis of 37 comparative effectiveness studies found that chronic insomnia subjects with comorbid medical and psychiatric conditions improved their ability to initiate and maintain sleep after completion of multicomponent CBT-I programs (Wu et al, 2015).
• Teach client/family caregivers about the need for those with medical conditions to avoid schedules and commitments that interfere with obtaining adequate amounts of sleep. EB: Critical appraisal of 22 studies provided evidence that sleep disturbance was common in critically ill subjects up to 12 months after hospital discharge (Altman et al, 2017).
• Promote adoption of behaviors that ensure adequate amounts of sleep for all family members.
• Teach family members ways to avoid chronic sleep loss.
• Advise against chronic use of caffeinated drinks to overcome daytime fatigue and drowsiness while focusing on elimination of factors that lead to chronic sleep loss. CEB: In an integrative review of 26 controlled laboratory studies of adult subjects, caffeine was found helpful in the temporary management of sleepiness, but overuse and late-day use contributed to subsequent sleep disruption and caffeine habituation (Roehrs & Roth, 2008).

D.	IMPLEMENT

The next step in the nursing process is to give the nursing care utilizing the nursing interventions.

E.	EVALUATE

After putting into effect the nursing interventions, the results of the care should be evaluated by determining if the outcomes were met. If the outcomes are acceptable, the care plan is resolved. If the outcomes are not acceptable, further assessment should be done to answer the following questions:

NOC Indicator	Rating at admission	Rating 4 days later	Rating 1 week later	
Hours of sleep	1	2	4	
Sleep pattern	1	2	3	
Sleep quality	1	2	3	
Sleep efficiency	1	2	4	
Feels rejuvenated after sleep	1	3	4	
Sleeps through the night consistently	1	2	3	

•	Was the correct nursing diagnosis chosen?
Yes, Abdul is suffering from sleep deprivation and his learning was being affected.
•	Was the outcome appropriate?
Yes, the outcome is to promote better sleep quality and pattern.
•	Were the interventions appropriate in this situation?
Yes, along with medication for his restless leg syndrome, the sleep deprivation interventions effectively reversed his poor sleeping habits.
•	What other interventions might have been helpful?
Referral to a relaxation class such as yoga or meditation.

Changes in the nursing diagnosis, outcomes, and interventions should be made as needed. This is continued use of critical thinking to ensure appropriate nursing care.