RLE 002

Cebu Normal University

College of Nursing Cebu City
Mission-Vision: Care Using Knowledge and Compassion Theory-based (Betty Neuman)

NURSING CARE PLAN

Assessment Diagnosis 3 points 3 points Goals Theoretical Basis 2 points 2 points Interventions Evaluation 4 points 1 point Bibliography 15 points

Name of Student:__Requina, Deanne Miles M. Clients Initials:_____ _J.L.A _______ Stressor Classification: (Please check) Age:28 y/o Gender: F Civil Status: married Religion:_RC ___ _ Physiological (body structure and functions) Allergies: ___no known food and drug allergies _ _ _ Psychological (mental processes and emotion) Diet:_____Diet as tolerated ________________ ______ Socio-cultural (relationships, social expectations) Date of Admission:___January 3, 2013- 1:06pm ______ ______ Spiritual (influence of spiritual beliefs) Diagnosis/Impression: G3P2 (2002) H. mole ______ Developmental (developmental processes over the lifespan)

NURSING DIAGNOSIS
Assessment Subjective: Wa pa man naschedule ako raspa day, wa paman mi kakuhag dugo. Gikulbaan pud ko day oi kay basin magdugo nya ko, as verbalized. Objective: >received on bed, awake and coherent; without IVF; with patent heplocl on right arm; frequent asking of questions noted; with baseline vital signs of Diagnosis

NURSING GOALS
(Goal attainable within the shift)

NURSING OUTCOME
(with Rationale & Source)

Mutual Planning

Interventions

Actual Evaluation

Mild Anxiety related to threat to change in health status, and upcoming surgery.

After an hour of nursing intervention, the client will be able to: verbalize awareness of feelings of anxiety. identify ways to deal with and express anxiety. After 8 hours of nursing interventions, the client will be able to: appear relaxed and report anxiety is reduced to a manageable level.

PRIMARY INTERVENTIONS Promotive: I- Encourage client to acknowledge and to express feelings. R- to assist client identify feelings
S- Doenges, 2010 I- Provide comfort measures. R- to promote comfort. S- Doenges, 2010 I- Provide accurate information about the situation. R- helps client identify what is reality based. S- Doenges, 2010

Preventive: I- Establish a therapeutic relationship. R- Nurse needs to be aware of own feelings of anxiety or uneasiness to avoid the contagious effect or

T=36.2C, P=102bpm, R=19cpm, BP=110/80mmHg.

Theoretical basis: Anxiety is the vague uneasy feeling of discomfort or dread accompanied by an autonomic response ( the source 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. Mild anxiety does not usually require medication, but patients can benefit from therapy. In therapy, the person can learn to cope with their anxiety by using relaxation techniques. - Black and Hawks, 2005

transmission of anxiety. S- Doenges, 2010 I- Acknowledge anxiety or fear. R- Do not deny or reassure client that everything will be alright. S- Doenges, 2010 SECONDARY INTERVENTIONS Curative I- Be available to client for listening and talking. R- to begin to deal with problems. S- Doenges, 2010 I- Identify actions and activities the client has previously used to cope successfully when feeling nervous or anxious. R- to relieve anxiety S- Doenges, 2010 I- Monitor vital signs. R- to identify physical responses associated with both medical and emotional conditions. S- Doenges, 2010 TERTIARY INTERVENTIONS Rehabilitative I- Encourage client to develop an exercise or activity. R- which may serve to reduce level of anxiety by relieving tension. S- Doenges, 2010

Bibliography:
Doenges, M.E., Moorhouse, M.F., and Moore, A.C. (2010). Nurses Pocket Guide (12 th edition) Philadelphia, Pennsylvania: F.A. Davis Company