NURSING CARE PLAN

Identified Problem: 

Name: DONNA MAE V. LUCI Section: BSN 4- NIGHTINGALE Date/Time:

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

RATIONALE

Independent:
Severe A vague Short term Goal: Short term Goal:
Subjective: Anxiety uneasy feeling Establish relationship Anything about which the client feels
Related to of discomfort or After 4 hours through use of empathy, anxious will serve to increase the
“Natatakot po akong obsessional dread of nursing warmth, and respect. ritualistic behaviors. Establishing The patient
mahawaan ng ibang thoughts and accompanied by intervention, the Demonstrate interest in trust provides support and should respond to
tao kaya gusto ko impulses as an automatic patient shall client as a person communicates that the nurse accepts relaxation
laging malinis na evidenced by response; the respond to through use of attending the client as a person with the right to techniques with a
malinis ang aking repetitive source often relaxation behaviors. self-determination.
actions and lower anxiety
paligid at ang aking nonspecific or techniques with a
decreased unknown to the decreased anxiety Acknowledge behavior level after 4 hours
katawan, ayokong Lack of attention to ritualistic
nadudumihan kahit social function. individual; a level. without focusing behaviors can diminish them. As of nursing
kaunti lang” as feeling attention on it. Verbalize anxiety is reduced, the need for intervention.
verbalized by the of apprehension empathy toward client’s behaviors is reduced. Reflecting the
patient. caused by experience rather than client’s feelings may reduce the Long term Goal:
anticipation of Long term Goal: disapproval or criticism. intensity of the ritualistic behavior
Objective: danger. It is an Better to say,” I see you The patient
altering signal After 18 undress 3 times every must be able to
-excessive hand that warns hours of nursing morning. That must be cope effectively
washing, showering and of impending intervention that tiring for you,” rather with stressful
tooth brushing danger and patient shall than “Try to dress only 1 situations after 18
enables the demonstrate time today.” hours of nursing
-excessive cleaning and individual to ability to cope intervention
washing of house, take measures to effectively with Use a relaxed manner without resorting
household items, food, deal with threat. stressful situations with the client; keep the Any attempts to decrease stress will to obsessive
car and other areas without resorting environment calm. help the client to feel less anxious, thoughts or
 to obsessive which may reduce the intensity of the compulsive
excessive checking of thoughts or ritualistic behaviors. behaviors.
locks, compulsive Assist client to learn
behaviors. stress management, (e.g., Stress-management techniques can be
-applying rigid rules and thought-stopping, used, instead of ritualistic behaviors,
patterns to the placement relaxation exercises, to break habitual pattern.
of objects, furniture, imagery).
books, clothes
Identify what the client
perceives as relaxing Planned activities allow the client
Vital Signs As (e.g., warm bath, music). less time forward bath, music).
Follows: Engage in constructive Engage in constructive activities such
activities such as quiet as quiet games that require
T: 36.60 C games that require concentration, as well as arts and
concentration, as well as crafts such as needle work,
PR: 99 bpm
arts and crafts such as woodworking, ceramics, and
RR: 20 cppm needlework, painting.
woodworking, ceramics,
BP: 130/90 mmHg and painting.

Encourage participation
in a regular exercise Exercise therapy can help relieve
program. anxiety. Note: Exercise does not need
to be aerobic or intensive to achieve
the desired effect.

Give positive
reinforcement for non- This approach will prevent the client
compulsive behavior. from obtaining secondary gains from
Avoid reinforcing the maladaptive behaviors.
compulsive behavior.
Help significant other(s)
learn the value of not
focusing on the ritualistic
behaviors.

Assist client to find ways

to set limits on own
behaviors. At the same Encourages client to problem-solve
time allow adequate time ways to limit own behaviors while
during the daily routine recognizing that behaviors cannot be
for the ritual(s). stopped by others without increasing
anxiety. If the time required for
performing the ritual(s) is not
considered in planning care, client
will feel rushed and anxious while
performing behaviors. A mistake in
compulsive behavior is more likely to
be made if client feels rushed, and the
whole ritual will have to be started
again, resulting in increased anxiety
— possibly to an unmanageable
level.

Limit the amount of time

allotted for the Provides initial control of
performance of rituals. maladaptive behaviors until client can
Encourage client to enforce own limits and substitute
gradually decrease this more adaptive response(s) to stress.
time.

Encourage client to This exploration provides an

explore the meaning and opportunity to begin to understand
purpose of behaviors; to the process and gain control over the
describe the feelings obsessive-compulsive sequence.
when the behaviors When the opportunity for ritualistic
occur, intensify, or are behavior does not occur, the client
interrelated;and to fears that something bad will happen.
examine the precipitating Recognizing precipitating factors
factors to the allows client to interrupt escalating
performance of the ritual. anxiety.

Dependent:

Administer medications
as These drugs help balance serotonin
indicated,e.g.:Fluvoxami levels, decreasing feelings of anxiety,
ne(Luvox),clomipramine
(Anafranil),fluoxetine reducing need for ritualistic
(Prozac) behavior(s), and allowing client to
learn of other methods of stress
reduction. Note: Luvox is classified
as a selective serotonin reuptake
inhibitor and has fewer side effects
than tricyclics.
Administer medications
as indicated. Clients who are refractory to
antidepressants may require
combination therapy (e.g., buspirone
and fluoxetine or lithium and
clomipramine)

Collaborative:

Discuss home situation,

include family/SO as
appropriate. Involve in Returning to unchanged home
discharge plan. environment Increases risk that client
will resume compulsive behaviors.