ASSESSMENT
Subjective:"I'm afraid of what will be the result of my operation," as verbalized by the patient.
Objectives:
The patient was diminished his/her self-esteem, he/she has loss competence and narrowed focus on the source of fear. Vital signs are taken and noted as follows: Body temperature is 36.5 degrees Celcius, blood pressure is 140/90 mmHg, respiratory rate of 22 cycles per minute, and pulse rate of 108 beats per minute.
DIAGNOSIS
Fear related to possible unwanted result as evidenced by narrowed focus on the source of fear and increase pulse pressure.PLANNING
After 4 hours of nursing intervention, the patient will verbalize accurate knowledge of safety related to current situation.INTERVENTION:
- Identify sensory deficits of Mr. Tepper that may be present such as vision or hearing impairment. Sensory deficits may lead to misinterpretation of his environment. Determine Mr. Tepper's age or his developmental level. This will help in understanding on usual or typical fears. Investigate Mr. Tepper's reports of his subjective experiences, which could be indicative of his delusions or hallucinations. Note degree of his incapacitation. Be alert to signs of denial and depression. Be alert to and evaluate potential for his violence. Measure vital signs and physiological responses to situation.
- Stay with Mr. Tepper more often to have him someone else to be there because it provides him with desired support person that can diminished feelings of fear. Listen to Mr. Tepper's concern, it promotes atmosphere of caring and permits exploration of his misperception. Acknowledge normalcy of fear, pain, despair, and give "permission" to express feelings appropriately. This promotes attitude of caring and opens door for discussion about feelings and addressing reality of situation. If necessary, provide presence or physical contact such as hugging, refocusing attention. These soothe his fears and provide assurance.
- Manage Mr. Tepper's environmental factors such as loud noises, harsh lightning, changing of person's location or stranger in care. These can cause stressto him, especially to adult individuals like him. Speak to Mr. Tepper in simple sentences and concrete terms because it facilitates his understanding and retention of information. Provide opportunity for questions and answer honestly to enhance sense of trust and nurse-client relationship. Avoid arguing about his perceptions of the situation to limit conflicts when his fear response may impair rational thinking. Encourage contact with his peer who has successfully dealt with a similarity fearful situation. This provides a role model and Mr. Tepper is more likely to believe others who had similar experience to him. Enhances sense of control by identifying Mr. Tepper's responsibility for the solutions while reinforcing that the nurse will be available for help if he desired or needed. Check use of Mr. Tepper on anti-anxiety medications and reinforce use as prescribed. Assist in identifying areas in which he control can be exercised and those in which control is not possible, thus enabling Mr. Tepper to handle fearful situations. Instruct in use of relaxation or visualization and guided imagery skills. Explain procedures within Mr. Tepper's ability to understand and handle to prevent his confusion and overload.
EVALUATION
After 4 hours of nursing intervention, the patient verbalized accurate knowledge of safety related to the current situation.
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