Nursing Care Plan

Problem Identified: Anxiety Nursing Diagnosis: Anxiety related to scheduled surgery as evidenced by excessive sweating. Cause Analysis: A vague uneasy feeling of discomfort or dread accompanied by an automatic response; the source then often nonspecific or unknown to the individual; a feeling of apprehension caused by anticipation of danger. It is an altering signal that warns of impending danger and enables the individual to take measures to deal with threat. (Nurses Pocket Guide, Page 91) Cues Subjective: I have fears, as stated by the patient regarding the surgery. Objective: LTO: Excessive sweating Shaky hands Difficulty of sleep After 1 hour of nursing intervention, the patient will be able to appear relaxed and report anxiety is STO: After 30 minutes of nursing intervention, the patient verbalizes awareness of feelings of anxiety. Expected Outcome Nursing Interventions Independent actions: 1. Establish rapport, introduce name. 2. Monitor vital signs. 3. Note reports of difficulty of sleeping. 4. Provide accurate information of the surgery. 5. Monitor visitors and interactions. Rationale Independent actions: 1. Establishment of rapport creates a trusting relationship between patient and nurse. 2. To identify physical response to medical and emotional conditions. 3. Behavioral indicators of use of withdrawal to deal with anxiety. 4. Helps patient identify what is reality based. Goal met, the patient appeared relaxed and LTO: Evaluation STO: Goal met, the patient verbalized awareness of feelings of anxiety.

reduced to a manageable level.

5. To lessen the effect of transmission of feelings.

reported anxiety is reduced to a manageable level.

References: Nurses Pocket Guide, Pages 91-98