CASE SCENARIO:

At the hospital, Mrs. Javier, a 33-year-old woman who is working as a call center agent, was
presented with a chief complaint of fatigue, worry, and eye problem. The patient verbalized, "Sa
sobrang pagod ko, hindi na ako makapag focus sa aking mga ginagawa". As a result, she is
having a panic attack—an indescribable feeling of worry. The nurse describes the patient's
situation objectively as a lack of energy to focus on daily living and shows an irritable and
worried behavior rather than fear which indicates anxiety. According to the initial assessment,
the temperature is 38.5 degrees Celsius, the respiratory rate is at 11 breath, the pulse rate is 90,
and the blood pressure is 80/65 millimeters of mercury. The patient also mentioned that as a call
center agent, she feels pain and discomfort when blinking her eyes. The nurse observes the
patient's eye redness, and stringy mucus near the eye.
 PHINMA UNIVERSITY OF PANGASINAN
COLLEGE OF ALLIED HEALTH SCIENCES - DEPARTMENT OF NURSING
NURSING CARE PLAN

DIAGN INFERE PLANNI INTERVEN RATION EVALUAT

ASSESSM OSIS NCE NG TION ALE ION
ENT

Subjective: Dry eyes Dry eye, a Short- Assess the Assessing The patients
related to susceptibl Term client’s client’s showed less
“Ang sakit discomfo e to eye Goal: medication medicatio discomfort.
ng mata ko, rt to eye discomfor noting the use ns known
pag evidence t or After 3 of certain to The patient

pinipikit ko by damage to hours of drugs. decrease was able to

at sobrang reduced the nursing tear verbalize

hapdi.” ability to cornea interventi production the

on: Instruct high increased of
blink. and .
risk client in ability to
conjunctiv
Objective: The self Prevent or blink and
a due to
Eye redness patients management limit was able to
reduced
Stringy will interventions. symptoms increased
quantity
mucus near show less of dry eye. tear
or quality
the eye discomfo production.
of
Wear
rt. To protect
tears to
eyeglasses or
eyes and The patient
moisten
safety shield
reduce verbalized
the eye,
glasses.
effects. “My eyes
which Long-
are now
may Term Teach the
When the feeling
compromi Goal: patient to take
patient is better.”
se health. lubricating
unable to
After 7 eye drops or
blink or
days the ointments as
otherwise
patient prescribed.
protect
will
eyes while
increased
in health
ability to
care
blink and
facility.
increased
 tear
productio
n.

PHINMA UNIVERSITY OF PANGASINAN

COLLEGE OF ALLIED HEALTH SCIENCES - DEPARTMENT OF NURSING
NURSING CARE PLAN

ASSESSM DIAGNO INFERE PLANN INTERVENTIO RATION EVALUA

ENT SIS NCE ING N ALE TION

Subjective Anxiety Anxiety Short- Monitor vital To identify The patient

: related to is a vague Term signs (e.g., rapid physical was able to

physiologi uneasy Goal: or irregular pulse, responses verbalize
“ilang cal factors feeling of In 5 rapid associated awareness
araw na of central discomfor hours of breathing/hyperve with both of feelings
akong nag nervous t or dread nursing ntilation, changes medical of anxiety.
aalala nang system accompan intervent in blood pressure, and
hindi ko simulation ied by an ion the diaphoresis, emotional The patient

alam ang - autonomi patient tremors, or conditions. was able to

dahilan” as hypermeta c will restlessness) identify

verbalized bolic state response verbalize healthy

by the and (the awarene ways to

Assist the client in Becoming deal with
patient. pseudo source is ss of
developing self- aware and express
catechola often feelings
awareness of helps client
Objective: mine nonspecif of anxiety.
verbal and to control
V/S taken effect of ic or anxiety.
nonverbal these
as follows: thyroid unknown
behaviors. behaviors
hormones to the Long-
Temp: 37° and begin
as individual Term:
Celsius to deal
evidenced ); a In 10
Provide comfort with issues
RR: 16 days of
by feeling of
measures (e.g., that are
bpm
increased apprehens nursing
calm or quiet causing
PR: 90 intervent
feeling of ion
environment, soft anxiety.
bpm
apprehens caused by ions the
music, warm bath,
BP: 120/80 patient
ion. anticipati
back rub,
on of will be
Therapeutic Aids in
danger. It able to meeting
Touch).
 is an identify basic
alerting healthy human
Be available to the
sign that ways to need,
client for listening
warns of deal with decreasing
and talking
impendin and sense of
g danger express isolation,
and anxiety and
enables assisting
the client to
individual feel less
to take anxious.
measures
to deal Establishes

with that rapport,

threat. promotes
expression
of feelings,
and helps
client/signi
ficant other
look at
realities of
the illness
or
treatment
without
confrontin
g issues
they are
not ready
to deal
with.

PHINMA UNIVERSITY OF PANGASINAN

COLLEGE OF ALLIED HEALTH SCIENCES - DEPARTMENT OF NURSING
NURSING CARE PLAN
ASSESSM DIAGNO INFERE PLANNI INTERVEN RATIONA EVALUAT
ENT SIS NCE NG TION LE ION

Subjective: Fatigue Fatigue is Short Asses the To evaluate The patient

related to an term: vital signs fluid status was able to
“Nahihirapa irritability overwhel After 5 and verbalized
n akong of central ming hours of cardiopulmo understandi
Establish
mag pokus nervous sustained nursing nary ng of
realistic goals
sa aking system as sense of interventi response to factors
with the client
mga evidenced exhaustion on the activity. contributing
and encourage
ginagawa” by and patient to current
forward
as impaired decreased will be situation.
movement. This
verbalized ability to capacity able to
enhances The patient
by the concentrat for verbalize
the was able to
patient. e. physical understan
Assess
commitment perform
and ding of
psychological
in activities of
mental factors
and
Objective: promoting daily living
work at contributi
Personality
optimal and
usual ng to
Lack of Factors that
outcomes. participate
level. current
energy may affect
situation. in desired
Irritable reports of
activities at
Worried fatigue. Client can
Long level of
Behavior potentially
Term: ability.
have issues
After 10 Note desire
V/S taken that affect
days of and level of
as follows: desire to be
nursing ability to meet
active (or
interventi health
Temp: 37° work),
on the maintenance
Celsius resulting in
patient needs, as well
RR: 16 bpm over or
will be as self-care
PR: 90 bpm under
able to activities of
BP: 120/80 activity or
perform daily living.
concerns of
activities
secondary
of daily
gain from
living and
exaggerated
participat
fatigue
e in
 desired reports.
activities
at level of Care may

ability. begin with

helping
client make
a decision to
improve
situation, as
well as
identifying
factors that
are
currently
interfering
with
meeting
needs.
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