Sleep

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DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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1. Purpose and clinical relevance

Sleep affects healing, mood, cognition, pain perception, and safety, and disrupted sleep is both a symptom and a driver of decline. The skilled value is not recording that sleep is poor but analyzing why — untreated pain, nocturnal dyspnea, nocturia, anxiety, restless legs, an offending medication, or sleep-disordered breathing — because most contributors are reversible, and because a sedative-hypnotic prescribed for insomnia can itself cause falls. That analysis requires nursing judgment.

The purpose of this module is to give clinicians the skilled framework and chartable language that demonstrate sleep assessment, contributing-factor analysis, sleep-aid safety management, and sleep-disordered-breathing screening were reasonable and necessary and required the skills of a licensed nurse. It is the primary home for sleep assessment; the disease-specific contributors are cross-linked, not duplicated, into Pain, Psychiatric / Mental Health, Cardiovascular, and Respiratory.

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