NURSING CARE PLAN 1

Date identified: July 17, 2021

Date evaluated: July 19, 2021

CUES NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective cue: Anxiety related to fear of Short Term Goal: Independent: Short Term Goal:
unspecified
“Parati nalang ako takot consequences Within 2 hours of Assess patient’s level of Different levels of Goal met. After 2 hours of
ewan ko kung bakit. nursing interventions, anxiety. anxiety will affect the nursing interventions,
Takot ako kung mag-isa the patient will appear coping mechanism of the patient was able to
baka mapano ako. Di ko relaxed and will be able client. verbalized, “nakaka tulong
alam. ” to know some tong mga divertional
techniques on how to Determine how patient This assessment helps activities tulad nang deep
Objective cues: lessen the anxiety such copes with anxiety. determine the breathing exercise kasi
as deep breathing effectiveness of coping dinidistract nito ang anxiety
- getting nervous with no exercise. strategies currently used ko at mas na rerelax ang
reason (feeling of by patient. pakiramdam ko kumpara sa
numbness, getting Long Term Goal: kung hinahayaan ko lang
pale/nanlalamig) Monitor vital signs. To identify physical yung anxiety na lamunin
Within 3 days of nursing responses associated ako.”
- difficulty of swallowing interventions, the with both medical and
if getting anxious patient will be able to emotional conditions. Long Term Goal:
observed verbalize level of anxiety
is reduced to Acknowledge awareness Acknowledgment of the Goal met. After 3 days of
- dizziness and manageable level and of patient’s anxiety. patient’s feelings nursing interventions,
headaches observed will demonstrate validates the feelings and patient was able to
effective coping. communicates demonstrate understanding
- difficulty in sleeping acceptance of those through use of effective
noted feelings. coping behaviors as
evidenced by active
Instruct to do deep This may help the participation in treatment
breathing exercise. patient to relax. regimen. “Mas na rereduce
yung anxiety ko at mas na
Provide accurate Helps the client to cocontrol ko na. Di tulad ng
information about the identify what is reality dati na talagang halos
situation. based. nangangamba talaga ako sa
takot,” as verbalized by the
Establish a therapeutic To avoid a contagious patient………………………………
relationship, conveying effect/ transmission of K.P.Josol,FSUU/SN(7/17/21)
empathy and anxiety.
unconditional positive
reward.

Maintain a calm manner The health care provider

while interacting with can transmit his or her
patient. own anxiety to the
hypersensitive patient.

Encourage client to Verbalization of feelings

explore underlying in a nonthreatening
feelings that may be environment may help
contributing to irrational patient come to terms
fears. Help patient to with unresolved issues.
understand how facing
these feelings, rather
than suppressing them,
can result in more
adaptive coping abilities.

Assist the patient in Using anxiety-reduction

developing anxiety- strategies enhances
reducing skills patient's sense of
(relaxation, deep personal mastery and
breathing, positive confidence. Also,
visualization, reassuring provides the client with a
self-statements, and sense of control over the
others). fear. Distracts the client
so that fear is not totally
focused on and allowed
to escalate.

Suggest that the patient Emotion connected to

substitute positive thought, and changing to
thoughts for negative a more positive thought
ones. can decrease the level of
anxiety experienced. This
also gives the client an
alternative way of
Dependent: looking at the problem.

Administer antianxiety Biological factors may be

medications involved in phobic/panic
(Benzodiazepines: reactions, and these
Alprazolam (Xanax), medications (particularly
Clonazepam (Klonopin), Alprazolam (Xanax))
diazepam (Valium), produce a rapid calming
lorazepam (Ativan) effect and may help
chlordiazepoxide client change behavior
(Librium), by keeping anxiety low
oxazepam (Serax)) as during learning and
indicated; watch out for desensitization sessions.
any adverse side effects Addictive tendencies of
CNS depressants need to
be weighed against
benefit from the
Collaborative: medication.

Encourage patient to The presence of support

seek assistance from an group reinforces feelings
understanding significant of security for the
other or from the health patient.
care provider or support
group when anxious
feelings become difficult.