CUES EXPLANATION OF OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

THE PROBLEM
Subj: STG: Maintain a calm, non- STG: Goal fully met
Anxiety is contagious
Anxiety is a vague threatening manner while
and may be
“I have been feeling of dread or After 4 hours of working with the client. After 4 hours of
transferred from
feeling apprehension comprehensive comprehensive nursing
health care provider to
depressed, (uneasiness); it is nursing intervention, the
client or vice versa.
anxious, and the activation of intervention, patient was able to
Client develops feeling
under the autonomic the patient will Discuss feelings of
of security in presence
stress”. nervous system in be able to dread, anxiety, and so
of calm staff person.
response to an Discuss feelings forth as manifested by
external or internal of dread, absence of Feelings of
Obj: stimuli that can anxiety, and so discomfort,
have behavioral, forth as apprehension or
Therapeutic skills need
The patient emotional, manifested by Establish and maintain a helplessness
to be directed toward
appears cognitive, and absence of trusting relationship by
putting the client at
older than physical symptoms. Feelings of listening to the client;
ease, because the
stated age, In contrast, fear is discomfort, displaying warmth,
nurse who is a stranger
had good eye the feeling of apprehension answering questions
may pose a threat to
contact and apprehension over or helplessness directly, offering
the highly anxious
reports a specific threat or unconditional acceptance;
client.
reduced danger to the being available and
socialization. person. respecting the client’s use LTG: Goal partially met
of personal space. After 3 days
Feelings of Client will be free from
discomfort, anxiety attacks as
apprehensio Remain with the client at manifested by absence
The client’s safety is
n or LTG: all times when levels of of irritable and
utmost priority. A
helplessness After 3 days anxiety are high (severe or restlessness
highly anxious client
Client will be panic); reassure client of
should not be left
Her mood at free from his or her safety and
alone as his anxiety will
the time of anxiety attacks security.
escalate.
interview as manifested
was by absence of
depressed, irritable and
Anxious behavior
and anxiety restlessness Move the client to a quiet
escalates by external
level is area with minimal stimuli
stimuli. A smaller or
moderate. such as a small room or
secluded area
With seclusion area (dim
enhances a sense of
consistent lighting, few people, and
security as compared
with mood so on.)
to a large area which
can make the client
feel lost and panicked.
Nsg.dx
Anxiety
The client will feel
related to Maintain calmness in your
more secure if you are
situational approach to the client.
calm and inf the client
and
feels you are in control
maturational
of the situation.
crises as
manifested
by Irritable Provide reassurance and
Helps relieve anxiety.
secondary to comfort measures.
Major
Depression
Pharmacological
Educate the patient
therapy is an effective
and/or SO that anxiety
treatment for anxiety
disorders are treatable.
disorders; treatment
regimen may include
antidepressants and
anxiolytics.
Support the client’s
The client uses
defenses initially.
defenses in an attempt
to deal with an
unconscious conflict,
and giving up these
defenses prematurely
 may cause increased
anxiety.

Maintain awareness of Anxiety is

your own feelings and communicated
level of discomfort. interpersonally. Being
with an anxious client
can raise your own
anxiety level.
Discussion of these
feelings can provide a
role model for the
client and show a
different way of
dealing with them.

Stay with the patient During a panic attack,

during panic attacks. Use the patient needs
short, simple directions. reassurance that he is
not dying and the
symptoms will resolve
spontaneously. In
anxiety, the client’s
ability to deal with
abstractions or
complexity is impaired.

Avoid asking or forcing the

client to make choices. The client may not
make sound and
appropriate decisions
or may unable to make
decisions at all.
Observe for increasing
anxiety. Assume a calm Early detection and
manner, decrease intervention facilitate
environmental modifying client’s
stimulation, and provide behavior by changing
temporary isolation as the environment and
indicated. the client’s interaction
with it, to minimize the
spread of anxiety.

PRN medications may be

indicated for high levels of Medication may be
anxiety. Watch out for necessary to decrease
adverse side effects. anxiety to a level at
which the client can
feel safe.

Encourage the client’s

participation in relaxation Relaxation exercises
exercises such as deep are effective
breathing, progressive nonchemical ways to
muscle relaxation, guided reduce anxiety.
imagery, meditation and
so forth.

Teach signs and symptoms

of escalating anxiety, and So the client can start
ways to interrupt its using relaxation
progression (e.g., techniques; gives the
relaxation techniques, client confidence in
deep- breathing exercises, having control over his
physical exercises, brisk anxiety.
walks, jogging,
 meditation).

Administer SSRIs as
ordered. Panic attacks are
caused by
neuropsychiatric
disorder that responds
to SSRI
antidepressants.

Help the client see that

mild anxiety can be a The client may feel
positive catalyst for that all anxiety is bad
change and does not need and not useful.
to be avoided.

Encourage client to talk

about traumatic Verbalization of
experience under feelings in a
nonthreatening nonthreatening
conditions. Help client environment may help
work through feelings of client come to terms
guilt related to the with unresolved issues.
traumatic event. Help
client understand that this
was an event to which
most people would have
responded in like manner.
Support client during
flashbacks of the
experience.

KRISTIAN KARL B. KIW-IS

F> Anxiety related to situational and maturational crises as manifested by Irritable

D> Received sitting on bed Dressed appropriately for the season. Grooming is good. The patient
appears older than stated age, had good eye contact and reports reduced socialization. Her mood at
the time of interview was depressed, and anxiety level is moderate. With consistent with mood. Able
to explain what she will do if when she gets to a stop sign while driving, she responded: “I will stop”.
She states that she needs help with her mental health. “I have been feeling depressed, anxious, and
under stress”

A>
 Maintained a calm, non-threatening manner while working with the client.
 Established and maintain a trusting relationship by listening to the client; displaying warmth,
answering questions directly, offering unconditional acceptance; being available and respecting
the client’s use of personal space.
 Remained with the client at all times when levels of anxiety are high (severe or panic); reassure
client of his or her safety and security.
 Moved the client to a quiet area with minimal stimuli such as a small room or seclusion area
(dim lighting, few people, and so on.)
 Maintained calmness in your approach to the client.
 Provided reassurance and comfort measures.
 Educated the patient and/or SO that anxiety disorders are treatable.
 Supported the client’s defenses initially.
 Maintained awareness of your own feelings and level of discomfort.
 Stayed with the patient during panic attacks. Use short, simple directions.
  Avoided asking or forcing the client to make choices.
 Observed for increasing anxiety. Assume a calm manner, decrease environmental stimulation,
and provide temporary isolation as indicated.
 Encouraged the client’s participation in relaxation exercises such as deep breathing, progressive
muscle relaxation, guided imagery, meditation and so forth.
 Taught signs and symptoms of escalating anxiety, and ways to interrupt its progression (e.g.,
relaxation techniques, deep- breathing exercises, physical exercises, brisk walks, jogging, and
meditation).
 Administered SSRIs as ordered.
R> Responded to relaxation techniques with a decreased anxiety level.