Nursing Student's SOAPIE - Sleep disturbance, noise, 2 days post delivery

S> "Dili ko katulog ug tarong sa gabii, saba man gud ( can't sleep well at night because of the
noise)," as verbalized by the patient.
O> Patient seen lying on bed awake, coherent, responsive
> Temp 37C, PR 80bpm, RR 24cpm, BP 100/70mmHg
> Puffy eyelids
> listless
> Dark circles under eyes
> Yawns frequently
> Lochia Rubra - mild
> Uterine fundus - 2 finger's breath above the umbilicus
A> Sleep pattern disturbance related to noisy environment.
P> After 3 to 4 hrs of nursing intervention, the patient will be able to improve sleep pattern.
I> Established rapport.
> Listened to patient's concerns.
> Identified contributing factors to insomnia.
> Noted environmental factors affecting sleep.
> Recommended limiting intake of chocolate and caffeine before bedtime.
> Provided calm environment.
E> Patient seen taking a nap.