NURSING SCIENTIFIC NURSING

CUES OBJECTIVES RATIONALE EVALUATION

DIAGNOSIS RATIONALE INTERVENTIONS
Subjective: Anxiety related to Anxiety, is a common After 2-3 hours of nursing INDEPENDENT: After 2-3 hours of
situational crisis as reaction experienced intervention the client will . nursing intervention
““Usahay evidenced by by patients who are be able to: 1. Provide quiet 1. Speaking in a calm, the client was able
nahadlok ak verbal reports of admitted to a hospital for • Acknowledge environment and age- reassuring voice, to:
tungod hine na concern due to surgery. It can be feelings and identify appropriate comfort allowing presence of • Acknowledge
akon sakit…” As change in life described as an healthy ways to deal measures. family member or feelings and
verbalized by the events unpleasant state of with them having parent hold identify healthy
client. tension or uneasiness that • Demonstrate relaxed child, etc., enhances ways to deal
results from a patient's body posture and level of comfort, with them
Objective: doubts or fears. Anxiety ability to rest and helping to reduce • Demonstrate
can cause physiological sleep appropriately anxiety relaxed body
• Noted client to responses such as • Show behavior of posture and
be apprehensive, tachycardia, decreased anxiety 2. Identify and 2. Coping with the pain ability to rest
uncertain, and hypertension, elevated such as decrease acknowledge client’s and emotional and sleep
fearful. temperature, sweating, apprehensiveness, perception of threat or trauma of an MI is appropriately
nausea, and a heightened uncertainty and fear situation. Encourage difficult. Client may • Show behavior
sense of touch, smell, or • Identify causes and expressions of, and fear death or be of decreased
hearing. A patient may contributing factors. avoid denying feelings anxious about anxiety such as
also experience of, anger grief, sadness, immediate decrease
peripheral and fear. Monitor environment. apprehensivene
vasoconstriction, which temperature, as Ongoing anxiety ss, uncertainty
makes it difficult for the indicated. related to concerns and fear
hospital staff to obtain about impact of • Identify causes
blood. Anxiety may cause heart attack on and
behavioural and cognitive future lifestyle, contributing
changes that result in matters left
factors.
increased tension, unattended or
apprehension, unresolved, and
nervousness, and effects of illness on
aggression. Some family may be
patients may become so present in varying
apprehensive that they degrees for some
cannot understand or time and may be
follow simple instructions. manifested by
Some may be so symptoms of
aggressive and depression.
demanding that they
require constant attention 3. Maintain confident 3. Client and SO may
of the nursing staff manner, without false be affected by the
reassurance.
Reference: anxiety or
Pritchard Michael John uneasiness
(2009). "Identifying and
assessing anxiety in 4. Orient client and SO to 4. Predictability and
medical patients". Nursing routine procedures and information can
Standard. 23 (51): 35–40. expected activities. decrease anxiety for
Doi :10. 7748/ .08.23 Promote participation client
.51.35. c7222. PM ID 1 when possible.
9753776
5. Observe for verbal and 5. Client may not
nonverbal signs of express concern
anxiety, and stay with directly, but words
client. Intervene if client or actions may
displays destructive convey sense of
behavior. agitation,
aggression, and
hostility.
Intervention can
help client regain
control of own
behavior.

6. Accept but do not 6. Denial can be

reinforce use of denial. beneficial in
Avoid confrontations. decreasing anxiety
but can postpone
dealing with the
reality of the current
situation.
Confrontation can
promote anger and
increase use of
denial, reducing
cooperation, and
possibly impeding
recovery.

7. Answer all questions 7. Accurate

factually. Provide information about
consistent information; the situation
repeat as indicated. reduces fear,
strengthens nurse-
 client relationship,
and assists client
and SO to deal
realistically with
situation. Attention
span may be short,
and repetition of
information helps
with retention.

8. Encourage client and 8. Sharing information

SO to communicate with elicits support and
one another, sharing comfort and can
questions and concerns relieve tension of
unexpressed
worries.

9. Provide privacy for client 9. Allows needed time

and SO. for personal
expression of
feelings; may
enhance mutual
support and
promote more
adaptive behaviors.

10. Provide rest periods and 10. Conserves energy

uninterrupted sleep time and enhances
and quiet surroundings, coping abilities
with client controlling
type and number of
external stimuli.

11. Support normality of 11. Can provide

grieving process, reassurance that
including time necessary feelings are normal
for resolution. response to
situation and
perceived changes.
Helps client and SO
identify realistic
goals, thereby
 reducing risk of
discouragement in
face of the reality of
limitations of
condition and pace
of recuperation

12. Encourage in 12. Increased

dependence, self- care, independence from
and decision making staff promotes self-
within accepted confidence and
treatment plan. reduces feelings of
abandonment that
can accompany
transfer from
coronary unit and
discharge from
hospital

Source:
Doenges, M. E.,
Moorhouse, M. F., &
Murr, A. C. (2014).
Nursing Care Plans (9th
ed.). Philadelphia, PA
19103: F. A. Davis
Company.