DIZON, DEXIE

BSN IIIA
DAY 2

F  Disturbed thought process related to inadequate support system as evidenced by inappropriate non-
reality based thinking.

D  Received patient sitting on bed. Awake, alert and oriented; with normal vital signs taken as follows:
Temp: 36.3, BP: 120/90, SPO2:98%, RR: 18, PR: 80; dressed appropriately for season; clothes are clean
but noted poor hygiene; hair is unwashed and uncombed; Slouched shoulders; Pale; Blank expression;
and easily gets agitated.

A  Assessed patient’s vital signs for baseline

 Assessed for signs and symptoms of physical illness
 Observed for increasing anxiety by observing mannerisms and patient’s way of speaking such as
stuttering, voice volume, and speaking pace
 Reoriented patient to person, place and time.
 Established and maintain a trusting relationship by listening to the patient; displaying warmth,
answering questions directly, offering unconditional acceptance; being available and respecting the
personal space
 Provided reassurance and comfort measures
 Maintained awareness of own feelings and level of discomfort.
 Maintained calmness in the patient approach
 Assumed a calm manner, decreased environmental stimulation, and provided temporary isolation as
indicated
 Supported the patient’s defences initially
 Avoided forcing the patient to make choices
 Stayed with the patient during panic attacks using short and simple directions
 Encouraged patient to perform ADL’s like bathing and other personal hygiene
 Encouraged for the patient’s participation in relaxation exercises like deep breathing
 Educated the patient that anxiety disorders are treatable
 Administered medication as indicated.

R  Actively participated in the interventions rendered as evidenced by decrease inappropriate non-

reality based thinking. Endorsed patient comfortably sleeping.