Abby experienced trauma,
both physical and emotional in her past life when she and her husband live
together. She escapes and left her husband and went to other city 1300 miles
away from their house to change her life for she thought the better. Unfortunately,
she still gathers her fear from the past and it kept haunting her day and
night. She has been always lack of sleep, she felt fear when someone touches
her or even calls her. She screams most of the time, she preoccupied most of
the time. She feels that someone is stalking her and wants to abduct her. It's
been 6 months since she left but she still experiencing this anxiety which is
considered severe and she also were experiencing panic state. Below is a sample
of anxiety nursing care plan of Abby.
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 Celsius, 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 decrease 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 Abby,
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 Abby's behaviors to determine the level of patient's anxiety:
mild, moderate, severe or panic.
- Encourage therapeutic relationship and be available to Abby for her listening
and talking. Provide accurate information to the situation and do not give
false reassurance, it helps the patient what is reality based. Provide her
diversional activities such as watching TV or listening to her music, before
and after the operation. Gradually increase the Abby's activities and her
involvement with others as anxiety is decreased. Use cognitive therapy to focus
on her correct faulty catastrophic interpretations of symptoms.
- Assist Abby, the patient, to identify precipitating factors and new methods
of coping with disability anxiety. Assist her 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 her medication regimen
and possible interactions, especially with over-the-counter drug substitution
and changes in dosage.
During Panic State:
- You may stay with Abby, maintaining her a calm, confident manner. Speak in
brief statements using simple words. Provide her for non-threatening,
consistent environment and atmosphere. You must also minimize her stimuli.
Monitor visitors and interaction to lessen effect of transmission of feelings.
Set limits on inappropriate behavior and help her 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).
For more samples of nursing care plan you are free to check it out in our NCP LIST page.
weight-loss pills, and caffeine. Observe the client's behaviors to determine the level of patient's anxiety: mild, treatment
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