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ANXIETY Nursing Care Plan


The anxiety or the fear of something unknown has 4 types namely: mild anxiety, moderate anxiety, severe anxiety, and panic state. A person experiencing mild anxiety is alert and more aware of the environment. His/her attention is focus on environment and immediate events. But they are restless, irritable, and sometimes reported insomniac. Moderate anxiety is a person that had a narrow perception in which he/she is able to ignore distractions in dealing with problems. In this state, concentration increased, pulse and respiration is also increased. The client is trembling and his/her voice quivers or changes pitch.

Severe anxiety is when a person is preoccupied with feelings of discomfort and sense of impending doom. Impending doom is an unaccountable fear or being terrified. His/her range of perception is reduced and anxiety interferes with effective functioning. The person is experiencing headache, tingling sensation, and increased pulse and respiration with reports of dizziness. In panic state, the ability to concentrate is disrupted and person's behavior is disintegrated. The person distorts situation and does not have realistic perceptions of what is happening. The person in panic state may be experiencing terror or confusion or unable to move or speak.

ASSESSMENT
Subjective:
"I'm afraid, I don't know what will happen after my operation," as verbalized by the patient.
 

Objectives:
The patient is pale in appearance and cold clammy skin. The patient is poor eye contact. Vital signs are taken and noted as follows: Body temperature is 36.5 degrees Celcius, blood pressure is 130/90 mmHg, respiratory rate is 18 cycles per minute, and pulse rate is 88 beats per minute. The patient's body temperature, pulse rate, and respiratory rate are all normal while his/her blood pressure is above normal and consider as hypertension.

DIAGNOSIS
Anxiety related to fear of unknown secondary to cold clammy skin and pale in appearance. (Cold clammy skin is due to cold sweat).

PLANNING
After 4 hours of nursing intervention, the patient's anxiety level will gradually decreased to manageable level. (Why not totally gone? Because only if the operation was finished, the patient's anxiety will be gone.)

INTERVENTION
You must monitor the patient's vital signs because increase anxiety may affect physiologic changes. Determine prescribed medications or OTC medications, some medications can heighten sense of anxiety such as steroids, weight-loss pills, and caffeine. Observe the client's behaviors to determine the level of patient's anxiety: mild, moderate, severe or panic.
 

Encourage therapeutic relationship and be available to client for listening and talking. Provide accurate information to the situation and do not give false reassurance, helps the client what is reality based. Provide diversional activities such as watching TV or listening to music, before and after the operation. Gradually increase the client's activities and involvement with others as anxiety is decreased. Use cognitive therapy to focus on correct faulty catastrophic interpretations of symptoms.

Assist the patient to identify precipitating factors and new methods of coping with disability anxiety. Assist also in developing skills like awareness of negative thoughts,saying stop and substituting a positive thought to eliminate negative self-talk. Mild phobias tend to respond well to behavioral therapy.

Review strategies such as role playing and use of visualizations to practice anticipated events, prayer, and medication. Also review medication regimen and possible interactions, especially with over-the-counter drug substitution and changes in dosage.

During Panic State:


You may stay with the client, maintaining a calm, confident manner. Speak in brief statements using simple words. Provide for non threatening, consistent environment and atmosphere. You must also minimize stimuli. Monitor visitors and interaction to lessen effect of transmission of feelings. Set limits on inappropriate behavior and help client to develop acceptable ways of dealing with anxiety. 

Review strategies, such as role playing, use of visualizations to practice anticipated events, prayer and medication. Also review medication regimen and possible interactions, especially with over-the-counter drug substitutions, changes in dosage, or time of side to minimize side effects.

EVALUATION
After 4 hours of nursing intervention, the patient's anxiety level was gradually decreased to manageable level. (If the nursing intervention did not work, try to reassess the patient and make another nursing care plan).

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INEFFECTIVE AIRWAY CLEARANCE Nursing Care Plan

Ineffective airway clearance is a state when an individual is cannot clear secretions or obstructions in the respiratory tract. Below is an example of nursing care plan for patients with ineffective airway clearance.

ASSESSMENT
Subjective:
" I can't breath that much, something's obstructing inside my throat." as verbalized by the patient.

Objectives:
The patient is pale in appearance, and having difficulty in vocalizing. The patient experience restlessness, difficult of breathing and positive in productive cough. Restlessness is a state when you can not find comfort, irritable, and cannot stay still. Vital signs are taken and noted as follows: Body temperature is 36.8 degrees Celcius, blood pressure is 120/80 mmHg, respiratory rate is 32 cycles per minute, pulse rate is 96 beats per minute. Only pulse rate is at normal range, body temperature and respiratory rate are above normal while client's blood pressure is considered pre-hypertension.

DIAGNOSIS
Ineffective airway clearance related to difficulty in breathing as evidenced by restlessness and difficulty of vocalizing. (Difficulty in breathing or also known as dyspnea and difficulty in vocalizing here were caused by obstruction in the respiratory tract.

PLANNING
After 2 hours of nursing intervention, airway patency will be maintained and signs of dyspnea will disappear. (Why 2 hours? We need to manage the breathing problem as soon as possible because it can cause serious harm or damage to the patient.)

INTERVENTIONS
Evaluate client's cough, gag reflex and swallowing ability to determine ability to protect his/her own airway. Gag reflex is the natural contraction at the back of the throat and naturally urges vomiting when a too large object is touching the inner roof of the mouth. Assist with appropriate testing such as pulmonary function of sleep studies to identify causative of precipitating factors. Monitor breath sounds to check for the accumulation of secretions or respiratory blisters. By using the process of auscultation, you can monitor the patient's breath sounds.

Insert oral airway using correct size for adult or child when needed, this is to maintain anatomic position of tongue and natural airway especially when tongue or laryngeal edema or thick secretions may block airway. Suction the nose or mouth as necessary to clear airway when excessive or vicious secretions are blocking the airway of the client is unable to swallow. Elevate the head of the bed to decrease pressure on the diaphragm and to enhance the drainage secretions.
Encourage deep breathing and coughing exercises, splint chest to maximize effort. Administer analgesics to improve cough when pain is inhibiting effort but be cautious because over medication can depress respiration and cough effort. Give expectorants or bronchodilators as ordered. Increased fluids intake to at least 2000 mL/day within cardiac tolerance may require IV in acutely ill, hospitalized client. Encourage warm versus cold liquids as appropriate. Provide supplemental humidification, if needed. Hydration can help liquefy viscous secretions and improve secretion clearance. Monitor for signs and symptoms of congestive heart failure like crackles, edema, weight gain when client is at risk. Perform client with postural drainage and percussion as indicated if not contraindicated by condition, such as asthma.

EVALUATION
After 2 hours of nursing intervention the patient's airway patency is clear and maintained, and signs of dyspnea was disappeared.

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!