NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data: Fear related to phobic After 3 hours of nursing INDEPENDENT After 3 hours of nursing
stimulus as manifested interventions the patient will interventions the patient
“Kapag by diminished activity, be able to:  Establish rapport.  It reduced anxiety was able to:
nakakakita ako ng avoidance, narrowed a) Discuss phobic and to get the trust a) Discuss phobic
maraming tao focus on the source of object or situation and authority of the object or situation
kahit kakilala ko fear, tachycardia, pallor with the nurse. patient. with the nurse.
sila and increase b) Function in b) Function in
nakakaramdam perspiration. presence of phobic presence of
ako ng takot at object or situation  Ensured safety.  To prevent and phobic object or
hindi ako without experiencing reduce risks, situation without
mapakali” as panic anxiety by errors, and harm experiencing
verbalized by the time of discharge that occur to panic anxiety by
patient. from treatment. patients during time of discharge
c) Display appropriate provision of health from treatment.
Objective Data: range of feelings care c) Display
and less fear upon appropriate range
 Diminished seeing people.  Monitor Vital Signs.  For baseline data. of feelings and
activity Use coping techniques to less fear upon
 Avoidance manage fear. seeing people.
 Narrowed  Encourage the Use coping techniques to
focus on verbalizations of  To understand the manage fear
the source feelings and personal
of fear concerns. experience of the
Vital Signs: patient so that we
 BP: can respond
130/80 appropriately to the
 RR: 23 situation.
 PR: 113 Verbalizations of
 Temp: concerns also
36.5 helps the provider
 SO2: 98% to give better and
more appropriate
care.
 Provide open
environment in  Help patient feel
which patient feel accepted in
safe to discuss present condition
feelings. and promotes
sense of dignity
and control.

 Promote calm, and

quiet environment.  Facilitates rest
conserves energy
and may enhance
coping abilities.
 Encourage to do
deep breathing
exercise as needed.  Helps promotes
relaxation.

 Present and discuss

reality of the
situation with client
in order to recognize  Client must accept
aspects that can be the reality of the
changed and those situation before the
that cannot. work of reducing
the fear can
progress.
 Suggest that the
client substitute
positive thoughts for
negative ones.
 Emotion connected
to thoughts, and
changing to a more
positive thought
can decrease the
 level of anxiety
experienced. This
also gives the
client an alternative
way of looking at
the problem.

 Include client in
making decisions  Allowing the client
related to selection choices provides a
of alternative coping measure of control
strategies. and serves to
increase feelings of
self-worth.

 Encourage client to
explore underlying  Verbalization of
feelings that may be feelings in a
contributing to nonthreatening
irrational fears. Help environment may
client to understand help client come to
how facing these terms with
feelings, rather than unresolved issues.
suppressing them,
can result in more
adaptive coping
abilities.

 Expose client to a
predetermined list of
anxiety-provoking
stimuli rated in  Experiencing fear
hierarchy from the in progressively
least frightening to more challenging
the most frightening. but attainable
 steps allows client
to realize that
dangerous
consequences will
not occur. Helps
extinguish
conditioned
 Help client to learn avoidance
how to use these response
techniques when
confronting an
actual anxiety-  Client needs
provoking situation. continued
Provide for practice confrontation to
sessions (e.g.role- gain control over
play), deal with fear. Practice helps
phobic reactions in the body become
real- life situations. accustomed to the
feeling of
relaxation,
enabling the
individual to handle
DEPENDENT feared
object/situation.
Administer antianxiety
medications as indicated;
watch out for any adverse
side effects ( Alprazolam Biological factors may be
(Xanax), Clonazepam involved in phobic/panic
(Klonopin), diazepam reactions, and these
(Valium), lorazepam medications (particularly
(Ativan) chlordiazepoxide Xanax) produce a rapid
(Librium), oxazepam calming effect and may
(Serax) help client change
behavior by keeping
anxiety low during learning
and desensitization
sessions. Addictive
tendencies of CNS
depressants need to be
weighed against benefit
from the medication.
 DRUG STUDY
Classification of Drug Mechanism Contraindications Side effects Nursing Responsibilities
of Action
Generic Name: Risperidone Description: Risperidone is Risperidone should not be More Common: 1) Administer medication
used to treat schizophrenia, given if a known following the 10 Rights of
Brand Name: allergy/hypersensitivity to  Aggressive behavior drug administration.
bipolar disorder, or irritability
associated with autistic risperidone or paliperidone (a  Agitation 2) Maintain seizure
 Risperdal
disorder. This medicine metabolite of risperidone) is  Anxiety precautions, especially
 Perseris present. Hallucinogen when initiating therapy
should not be used to treat  Changes in vision,
Classification: Atypical behavioral problems in older persisting perception disorder including blurred and increasing dosage
or HPPD may be a relative vision 3) Monitor Temperature If
Antipsychotics. adults who have dementia.
contraindication for fever occurs, rule out
 Difficulty concentrating
Route: Oral, IM, risperidone because some underlying infection, and
patients treated with  Difficulty speaking or consult physician for
Subcutaneous Pharmacokinetics
risperidone for their HPPD swallowing appropriate comfort
Dosage: Pharmacodynamics: reported that panic and visual  Inability to move the measures.
symptoms intensified. eyes 4) Relieves both positive and
Schizophrenia is 25 mg IM The primary action of negative symptoms of
 Increase in amount of
every 2 week. risperidone is to decrease schizophrenia
urine
dopaminergic and  Loss of balance 5) Observe client which
Bipolar I Disorder is 25 mg IM
serotonergic pathway activity administering to ensure
every 2 weeks control
in the brain, therefore medication is swallowed
 Mask-like face and not cheeked
decreasing symptoms of
 Memory problems 6) Monitor for onset EPS and
schizophrenia and mood
 Muscle spasms of the weight gain
disorders. Risperidone has a
face, neck, and back 7) Report tardive dyskinesia
high binding affinity for
 Problems with (TD) immediately.
serotonergic 5-HT2A
urination 8) Change position slowly
receptors when compared to
 Restlessness or need 9) Monitor for EPS
dopaminergic D2 receptors in 10) Stress importance of
the brain. Risperidone binds to keep moving
medication compliance
to D2 receptors with a lower (severe)
11) Stress importance of
affinity than first-generation  Shuffling walk laboratory monitoring
antipsychotic drugs, which  Skin rash or itching
bind with very high affinity. A  Stiffness or weakness
reduction in extrapyramidal of the arms or legs
symptoms with risperidone,  Tic-like or twitching
when compared to its movements
predecessors, is likely a result  Trembling and
of its moderate affinity for shaking of the fingers
dopaminergic D2 receptors. and hands
 Trouble sleeping
Absorption:   Twisting body
movements.
Well absorbed. The absolute
oral bioavailability of Less Common:
risperidone is 70% The  Back pain
relative oral bioavailability of  Chest pain
risperidone from a tablet is
 Speech or vision
94% when compared to a
problems
solution
 Sudden weakness or
Distribution: Widely numbness in the face,
distributed throughout the arms, or legs
body and can be found in
Rare:
ascitic, pleural, and joint
fluids. Penetrates the CSF  Rare
with inflamed meninges.  Confusion
Plasma protein binding: 15-  Dizziness
18%.  Drowsiness
 Extreme thirst
Metabolism: Extensively  Fast, shallow
metabolized by hepatic breathing
cytochrome P450 2D6  Fast, weak heartbeat
isozyme to 9-  Headache
hydroxyrisperidone (i.e.  Increased thirst
paliperidone), which has  Lip smacking or
approximately the same puckering
receptor binding affinity as
risperidone.6,9 Hydroxylation
is dependent on debrisoquine
4-hydroxylase and
metabolism is sensitive to
genetic polymorphisms in
debrisoquine 4-
hydroxylase.7,9 Risperidone
also undergoes N-
dealkylation to a lesser
extend.
Excretion: Risperidone is
extensively metabolized in the
liver. In healthy elderly
subjects, renal clearance of
both risperidone and 9-
hydroxyrisperidone was
decreased, and elimination
half-lives are prolonged
compared to young healthy
subjects
Unusual facial expressions or
body positions
 Loss of appetite
 Muscle cramps
 Pale, clammy skin
 Poor coordination
 Prolonged, painful,
inappropriate erection
of the penis
 Puffing of the cheeks
 Rapid or worm-like
movements of the
tongue
 Shivering
 Talking, feeling, and
acting with excitement
and activity that
cannot be controlled
 Uncontrolled chewing
movements
 Uncontrolled twisting
movements of neck,
trunk, arms, or legs
 Unusual bleeding or
bruising