NURSING CARE PLAN

Cues Nursing Diagnosis Rationale to Nursing Goals and Objectives Nursing Interventions Rationale to Nursing Evaluation
Diagnosis Interventions
Subjective Cues: Ineffective coping Inability to form a valid
At the end of 3 weeks Independent After 3 weeks of
“Di ak maaram kun related to appraisal of the
nursing interventions,  Review pathophysiology Indicators of degree of nursing
mag-aano ako kay situational crisis as stressors, inadequate
the client will be able to affecting the client and extent of disequilibrium and need for interventions,
waray ko na trabaho evidenced by choices of practiced verbalize awareness of feelings of hopelessness/ intervention to prevent or resolve the patient
ngan gutiay la an verbalization of responses, and/ or
own coping/ problem- helplessness/ loss of control the crisis. Studies suggest that up verbalized
sweldo ha ak asawa, inability to cope/ inability to use available
solving abilities and over life, level of anxiety, to 85% of all physically ill people awareness of
ngan may-ada pa ask for help resources. meet psychologic needs perception of situation. are depressed to some degree. own coping/
gud kami apo na as evidenced by problem-solving
kami an nag-aalaga appropriate expression  Establish therapeutic nurse- Client may feel freer in the context abilities and met
kay ginbiyaan hiya of feelings and use of client relationship. of this relationship to verbalize psychologic
han iya nanay. Reference: resources. feelings of helplessness/ needs as
Naghuhulat la gihap Doenges, Moorhouse & powerlessness and to discuss evidenced by
kami kun magpadara Murr’s Nurse’s Pocket changes that may be necessary in appropriate
an am anak para Guide edition 12 the client’s life. expression of
may-ada pandugang feelings and use
ha gastuson.” as  Note expression of indecision, May indicate need to lean on of resources.
verbalized by the dependence on others, and others for a time. Early
client. inability to manage own recognition and intervention can
activities of daily living help client regain equilibrium.
(ADLs).

 Assess presence of positive When the individual has coping

coping skills/ inner strengths; skills that have been successful in
e.g., use of relaxation the past, they may be used in the
techniques, willingness to current situation to relieve tension
Objective Cues: express feelings, use of support and preserve the individual’s
- Displayed feelings systems. sense of control. However,
of inadequacy limitations of condition may
- Expressed concerns impact choices available to client.
about changes in
life events  Encourage client to talk about Provide clues to assist client to
- Appeared fatigue what is happening at this time develop coping and regain
- Restlessness and what has occurred to equilibrium.
 NURSING CARE PLAN
Cues Nursing Diagnosis Rationale to Nursing Goals and Objectives Nursing Interventions Rationale to Nursing Evaluation
Diagnosis Interventions
Subjective Cues: precipitate feelings of
helplessness and anxiety.

 Evaluate ability to understand Assist in identification and

events. Correct misperceptions, correction of perception of reality
provide factual information. and enables problem- solving to
begin.

 Provide quiet, nonstimulating Decreases anxiety and provides

environment. Determine what control for the client during crisis
client needs, and provide if situation.
possible. Give simple, factual
Objective Cues: information about what client
can expect and repeat as
necessary.

 Allow client to be dependent in Promotes feelings of security

the beginning, with gradual (client will know nurse will
resumption of independence in provide safety). As control is
ADLs, self-care, and other regained, client has the
activities. Make opportunities opportunity to develop adaptive
for client to make simple coping/ problem- solving skills.
decisions about care/ other
activities when possible,
accepting choice not to do so.

 Discuss feelings of self- blame/ Although these mechanisms may

projection of blame on others. be protective at the moment of
crisis, they eventually are
counterproductive and intensify
feelings of helplessness and
hopelessness.
 NURSING CARE PLAN
Cues Nursing Diagnosis Rationale to Nursing Goals and Objectives Nursing Interventions Rationale to Nursing Evaluation
Diagnosis Interventions
Subjective Cues:
 Promote safe and hopeful May be helpful while client
environment, as needed. regains inner control. The ability
Identify positive aspects of this to learn from the current situation
experience and assist client to can provide skills for moving
view it as a learning forward.
opportunity.

 Provide support for client to Helping client/ SO to brainstorm

problem- solve solutions for possible solutions (giving
current situation. Provide consideration to the pros and cons
information and reinforce of each) promotes feelings of self-
Objective Cues: reality as client begins to ask control/ esteem.
questions; look at what is
happening.

 Provide for gradual Reduces anxiety of sudden change

implementation and and allows for developing new
continuation of necessary and creative solutions.
behavior/ lifestyle changes.
Reinforce positive adaptation/
new coping behaviors.

Collaborative
 Refer to other resources as Additional assistance may be
necessary (e.g., clergy, needed to help client resolve
psychiatry clinical nurse problems/ make decisions.
specialist/ psychiatrist, family/
marital therapist)
 NURSING CARE PLAN
Cues Nursing Diagnosis Rationale to Nursing Goals and Objectives Nursing Interventions Rationale to Nursing Evaluation
Diagnosis Interventions
Subjective Cues: Anxiety related to Mood and anxiety At the end of 3 weeks Independent After 3 weeks
“Hagi kay maka- changes in role disorders are nursing interventions,  Assess patient’s level of - Different levels of anxiety of nursing
aringit an nanay ha function as characterized by a the patient will be able anxiety. affects the coping mechanism interventions,
ak apo kay evidenced by variety of to recognize signs of of the client. the patient
ginbiyaan la niya an expressions of neuroendocrine, anxiety, demonstrate recognized
ak anak pati an ila
helplessness neurotransmitter, and positive coping  Acknowledge awareness of - Acknowledgements of signs of
anak. Syempre, kay patient’s anxiety.
waray na iba na ag- neuroanatomical mechanisms and patient’s anxiety validates the anxiety,
aalaga ha bata, kami disruptions. describe a reduction in feelings and communicates demonstrated
na liwat an gintagan Identifying the most the level of anxiety acceptance of those feelings. positive coping
responsibilidad hito, functionally relevant experienced. mechanisms
imbis mga dagko na differences is -This can be done by and described a
 Determine how the patient
an ak anak, ha ak complicated by the interviewing the patient. This reduction in the
apo naliwat ak
copes with anxiety.
high degree of will determine the effectiveness level of anxiety
mabantay nga waray interconnectivity of coping strategies currently experienced.
ko na lugod trabaho, between used by the patient.
ambot kun aanhon neurotransmitter- and
ini.” as verbalized
neuropeptide-
by the client
containing circuits in
limbic, brain stem, and  Maintain a calm manner -The health care provider can
higher cortical brain while interacting with transmits his or her own
areas. Elements in the patient. anxiety to the hypersensitive
environment around patient. The patient’s feeling of
Objective Cues: an individual can stability increases in a calm
- Displayed feelings increase anxiety. and nonthreatening
of inadequacy atmosphere.
- Expressed concerns Source:
about changes in  Encourage patient to talk
US National Library -Recognition and exploration of
life events about anxious feelings and
of Medicine National factors leading to or reducing
- Appeared fatigue examine anxiety-provoking
Institutes of Health anxious feelings are important
- Restlessness situations if able to identify
  steps in developing alternative
them and assist patient in
assessing the situation responses. Patient may be
realistically and recognizing unaware of relationship
 NURSING CARE PLAN
Cues Nursing Diagnosis Rationale to Nursing Goals and Objectives Nursing Interventions Rationale to Nursing Evaluation
Diagnosis Interventions
Subjective Cues: factors leading to those between emotional concerns
feelings. and anxiety.

 Instruct the patient to do deep - This helps the patient to relax.

breathing exercises.

 Encourage the patient to join - May serve to reduce level of

or participate in exercise or anxiety by relieving tension.
activity program in the
community.

Objective Cues:  Assist in developing skill - These techniques conjure up

(substituting a positive soothing scenes, places or
thought) such as diverting experiences in the mind that
attention such as drawing, helps the patient relax and
guided imagery, mindfulness focus.
meditation and repetitive
prayer.
 NURSING CARE PLAN
Cues Nursing Diagnosis Rationale to Nursing Goals and Objectives Nursing Interventions Rationale to Nursing Evaluation
Diagnosis Interventions
Subjective Cues: Anxiety related to Mood and anxiety At the end of 3 weeks Independent After 3 weeks
“ Makuri gad an ak situational crisis disorders are nursing interventions,  Assess patient’s level of - Different levels of anxiety of nursing
kabutang kay waray as evidenced by characterized by a the patient will be able anxiety. affects the coping mechanism interventions,
ko anak ngan asawa, feelings of variety of to recognize signs of of the client. the patient
ako la na usa ha
discomfort and neuroendocrine, anxiety, demonstrate recognized
balay. Gintatagan la
ak danay ha ak mga
helplessness neurotransmitter, and positive coping  Acknowledge awareness of - Acknowledgements of signs of
kag-anak para neuroanatomical mechanisms and patient’s anxiety. patient’s anxiety validates the anxiety,
pankaon ngan disruptions. describe a reduction in feelings and communicates demonstrated
panggasto. Bisan Identifying the most the level of anxiety acceptance of those feelings. positive coping
may-ada ko malain functionally relevant experienced. mechanisms
 Determine how the patient
na gin-aabat, na diri differences is -This can be done by and described a
copes with anxiety.
ako magpa-admit complicated by the interviewing the patient. This reduction in the
ngan check-up kay high degree of will determine the effectiveness level of anxiety
waray ko interconnectivity of coping strategies currently experienced.
pangbayad.” as between used by the patient.
verbalized by the
neurotransmitter- and
patient
neuropeptide-  Maintain a calm manner -The health care provider can
containing circuits in while interacting with transmits his or her own
limbic, brain stem, and patient. anxiety to the hypersensitive
higher cortical brain patient. The patient’s feeling of
areas. Elements in the stability increases in a calm
Objective Cues: environment around and nonthreatening
- Displayed feelings an individual can atmosphere.
of inadequacy & increase anxiety.
helplessness  Encourage patient to talk
-Recognition and exploration of
- Expressed concerns Source: about anxious feelings and factors leading to or reducing
about changes in US National Library examine anxiety-provoking anxious feelings are important
life events of Medicine National situations if able to identify steps in developing alternative
- Appeared fatigue them and assist patient in
Institutes of Health responses. Patient may be
- Restlessness assessing the situation
  unaware of relationship
realistically and recognizing
 NURSING CARE PLAN
Cues Nursing Diagnosis Rationale to Nursing Goals and Objectives Nursing Interventions Rationale to Nursing Evaluation
Diagnosis Interventions
Subjective Cues: factors leading to those between emotional concerns
feelings. and anxiety.

 Instruct the patient to do deep - This helps the patient to relax.

breathing exercises.

 Encourage the patient to join - May serve to reduce level of

or participate in exercise or anxiety by relieving tension.
activity program in the
community.

Objective Cues:  Assist in developing skill - These techniques conjure up

(substituting a positive soothing scenes, places or
thought) such as diverting experiences in the mind that
attention such as drawing, helps the patient relax and
guided imagery, mindfulness focus.
meditation and repetitive
prayer.