COLLEGE OF NURSING
Silliman University
CUES/EVIDENCES
SUBJECTIVE:
“Murag hapit nako mabuang
ani akong anxiety”
“Sige rakog ka anxious most
of the time”
“Nagsugod akong anxiety
mga 1 month pagsugod sa
online class, feel nako di ko
ka cope tungod pressured
kayko sa acads ug sa family.”
“Feel nako gi control nakos
anxiety”
“Di kayko ka decide ug
tarong kay mabalaka ko if
sakto ba or sayop akong
gihimo”
“Dili napod tarong akong pag
tulog karon, mga 3-4 hours
nalang ako tulog kada gabii”
OBJECTIVE:
- Shaky & sweaty
hands
- Feet constantly
tapping the floor
- Restless
- Diaphoresis
- Dry skin, and patchy
Dumaguete City
NURSING CARE PLAN
NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
INDEPENDENT:
Ineffective coping r/t After 2 weeks of our 1. Establish a trusting A trusting relationship
situational crisis as care, the patient will be relationship with allows the client to
evidenced by disturbed able to: the client. freely express his/her
thought processes feelings and does not
1. Demonstrate see the student nurse
ways and ability as a threat.
to cope
effectively. 2. Maintain the To enhance therapeutic
2. Report a decrease trusting relationship and to
in restlessness. relationship with provide for meeting
3. Verbalize a return the client by being psychological needs.
to normal number available to her;
hours of sleep (6- answer her
8 hours) questions and
4. Verbalize signs queries, and
and symptoms of respecting her
increasing decisions/
anxiety and 3. Discuss with the This is the first step in
intervene to client the teaching the client to
maintain anxiety situations that interrupt the escalation
at manageable trigger anxiety. of anxiety.
level.
5. Maintain eye 4. Provide a quiet Anxiety might be
contact when environment as increased by noisy
talking to student much as possible. surroundings and
nurses and family cause panic to the
members. client.
 lips 5. Teach relaxation Anxiety is minimized
- Unable to maintain exercises such as when the patient is
eye contact deep breathing relaxed and these are
- Easily distracted techniques, music effective non-
- therapy, or guided pharmacological ways
imagery. to decrease anxiety.

6. Encourage To assist client in

verbalization of dealing with anxiety.
fears and anxieties
and expression of
feelings of
depression and
anger. Let the
client know that
these are normal
reactions.
7. Remain with the Safety of the client is a
client when priority. A highly
anxiety attacks are anxious client should
severe. not be left alone.

DEPENDENT:
1. Administer Stimulate serotonin and
anxiolytics as dopamine receptors on
prescribed by the nerves, thereby altering
physician the chemical messages
that nerves receive.

2. Administer SSRIs Increases levels of

as prescribed by serotonin in the brain.
the physician SSRIs block the
reabsorption of
serotonin into neurons.
 CUES/EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE EVALUATION
Subjective data: Disturbed sleep pattern Independent:
At the end of the 2-
related to psychological week nursing care,
Awakens earlier than desired; stress 1. Determine type of Identification of
the client will be able
wakes up in the middle of the sleep pattern individual situation and
to:
night most of the time disturbance present, degree of interference
 Verbalize including usual with functioning
Report of difficulty in falling understanding bedtime, determines need
asleep of relationship rituals/routines, for/appropriate
of anxiety and number of hours of interventions.
Her number of hours of sleep sleep sleep, time of
range from 3-4, which is lesser disturbance. arising,
than her usual (6-7 hrs) 7 months environmental
 Identify
ago needs, and how
appropriate
much of a problem it
interventions
is to client.
to promote
sleep.
Objective data: 2. Provide quiet Promotes relaxation and
Dark circles under eyes  Report environment, cues for falling asleep.
improvement comfort measures Stimulating effects of
Frequent yawning in sleep (e.g., caffeine/alcohol
Restless pattern, back rub, wash interfere with ability to
increased hands/face, bath), fall asleep.
sense of well- and sleep aids, such
being, and as warm milk .
feeling well- Restrict use of
rested. caffeine and alcohol
before bedtime.

Promotes reduction of
3. Discuss use of
anxious feelings,
relaxation
resulting in improved
techniques/thoughts,
sleep/rest.
visualization.

Having a plan can

4. Suggest ways to
reduce anxiety about
handle waking/not
not sleeping.
sleeping (e.g.,do not
 lie in bed and think,
but get up and
remain inactive, or
do something
boring).

Increases fatigue,
5. Involve client in
promotes sleep but
exercise program,
avoids excessive
avoiding exercise
stimulation from
within 2 hours of
activity before bedtime.
going to bed.
Sedative drugs interfere
with REM sleep and
6. Avoid use of
affect quality of rest. A
sedatives, when
rebound effect may lead
possible.
to intense dreaming,
nightmares, and more
disturbed sleep.

Collaborative Although drug is

recommended for short-
1. Administer term use  only, it may
medications as be beneficial until other
indicated, e.g., therapeutic
zolpidem (Ambien) interventions are
successful.