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Nursing

Diagnosis
Cues
Anxiety related to
what will happen
after the
chemotherapy
Subjective
Cues:
Objective Cues:
- The client was
observed to be
anxious and
always ask
questions
regarding her
chemotherapy

Analysis

Goal
Objectives

Vague uneasy
feeling of
discomfort or
dread
accompanied by
an autonomic
response; 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.

Goal: After 8
hours of nursing
intervention, the
client will be able
to appear relaxed
and report
anxiety is
reduced to a
manageable
level.

Objectives:
After the nursing
intervention, the
client's level of
anxiety is
assessed.

Nursing
Intervention

Identify clients
perception of the
threat
represented by
the situation.
Monitor vital
signs.

Rationale

These factors can


cause/exacerbate
anxiety.

To identify
physical
responses
associated with
both medical and
emotional
conditions.

Observe
behaviours.

To identify
clients level of
anxiety.

Establish a

To avoid the

Evaluation

After 8 hours of
nursing
intervention, the
client appeared
to be relaxed and
report anxiety is
reduced to a
manageable
level, the goal
was met.
After the nursing
intervention. The
clients level of
anxiety was
assessed, the
objective was
met.

After the nursing

After the nursing


intervention, the
client will be able
to identify
feelings and
begin to deal
with problems.

therapeutic
relationship,
conveying
empathy and
unconditional
positive regard.
Provide accurate
information
about the
situation.
Provide comfort
measures. Modify
procedure as
much as
possible.
Accept client as
is.

Assist client to
use anxiety for
coping with the
situation, if

contagious
effect/transmissio
n of anxiety.

Helps client to
identify what is
reality based.
To limit degree of
stress and avoid
overwhelming
anxious adult.
The client may
need to be where
he or she is at
point in time,
such as in denial
after receiving
the diagnosis of a
terminal illness.
Moderate anxiety
heightens
awareness and
permits the client
to focus on
dealing with
problems.

intervention, the
client were able
to identify
feelings and
begin to deal
with problems,
the objective was
met.

helpful.

Nursing
Diagnosis
Cues
Fear related to
what will be the
results after the
2d echo
Subjective
Cues:

- The client
reported that she is
afraid of what will
be the results of her
2d echo.
Objective Cues:

Analysis

Goal
Objectives

Response to
perceived threat
[real or
imagined] that is
consciously
recognized as a
danger.

Goal:
After 8 hours of
nursing
intervention, the
client will be able
to acknowledge
and discuss
fears,
recognizing
healthy versus
unhealthy fears.
Objectives:
After the nursing
intervention, the
clients degree of

Nursing
Intervention

Ascertain clients
perception of
what is occurring
and how this
affects life.

Rationale

Fear is a
defensive
mechanism in
protecting oneself
but, if left

Evaluation

After 8 hours of
nursing
intervention, the
client were able
to acknowledge
and discuss
fears, recognized
healthy versus
unhealthy fears,
the goal was
met.
After the nursing
intervention, the
clients degree of

fear and reality


of threat
perceived by the
client is
assessed.

After the nursing


intervention, the
client will be
assisted in
dealing with
fear/situation.

unchecked, can
become disabling
to the clients life.
Compare
verbal/nonverbal
responses.
Stay with the
client or make
arrangements to
have someone
else is there.

Discuss clients
perceptions/fearf
ul feelings.
Listen/activelisten to clients
concerns.
Provide
information in
verbal and
written form.
Speak in simple
sentences and
concrete terms.
Acknowledge
normalcy of fear,

To note
congruencies or
misperceptions of
situation.
Providing client
with
unusual/desired
support persons
can diminish
feelings of fear.
Promotes
atmosphere of
caring and
permits
explanation/correc
tion of
misperceptions.

Facilitates
understanding
and retention of
information.

fear and reality


of threat
perceived by the
client was
assessed, the
objective was
met.

After the nursing


intervention, the
client was able to
be assisted in
dealing with
fear/situation,
the objective was
met.

pain, despair,
and give
permission to
express feelings
appropriately/fre
ely.
Manage
environmental
factors such as
loud noises,
harsh lighting,
and changing
persons location
without
knowledge of
family.

Nursing
Diagnosis
Cues
Disturbed body

Analysis

Confusion [and/or

Goal
Objectives
Goal:

Nursing
Intervention

Promotes attitude
of caring, opens
door for
discussion about
feelings and/or
addressing reality
of situation.
These factors can
cause/exacerbate
stress, especially
to very young or
to older
individuals.

Rationale

Evaluation

image related to
loss or alteration
of breast
Subjective
Cues:
Objective Cues:
- The client has
undergone
removal of her
left breast tissue.

dissatisfaction] in
mental picture of
ones physical
self.

After 8 hours of
nursing
intervention, the
client will be able
to recognize and
incorporate body
image change
into self-concept
in accurate
manner without
negating selfesteem.
Objectives:
After the nursing
intervention, the
client will be able
to verbalize
understanding of
body changes.

.
Have client
describe self,
noting what is
positive and what
is negative.

Discuss meaning
of loss/change to
client.
Observe
interaction of
client with
significant
others.

To know how
client believes
others see self.

A small loss may


have big impact.
Distortions in
body image may
be unconsciously
reinforced by
family members
and/or secondary
gain issues may
interfere with
progress.

After8 hours of
nursing
intervention, the
client were able
to recognize and
incorporate body
image change
into self-concept
in accurate
manner without
negating selfesteem, the goal
was met.
After the nursing
intervention, the
client was able to
verbalize
understanding of
body changes,
the objective was
met.

After the nursing


intervention, the
clients coping
abilities and skills
is determined.

Listen to clients
comments and
responses to the
situation.

Note withdrawn
behaviour and
the use of denial.
After the nursing
intervention, the
client is assisted
in
dealing/accepting
issues of selfconcept related
to body image.

Visit client
frequently and
acknowledge the
individual as
someone who is
worthwhile.
Assist in
correcting
underlying
problems.
Provide
information at
clients level of

Different
situations are
upsetting to
different people,
depending on
individual coping
skills and past
experiences.

After the nursing


intervention, the
client coping
abilities and skills
were determines,
the objective was
met.

May be normal
response to
situation or may
be indicative of
mental illness.
Provides
opportunities for
listening to
concerns and
questions.

To promote
optimal
healing/adaptatio
n.
To allow easier
assimilation.

After the nursing


intervention, the
client was
assisted in
dealing/accepting
issues of selfconcept related
to body image,
the objective was
met.

acceptance and
in small pieces.

Nursing
Diagnosis
Cues
Decisional
conflict related to
treatment
options.
Subjective
Cues:
Objective Cues:
- The client
reported that she
is confused
regarding her
treatment
options.

Analysis

Uncertainty
about course of
action to be
taken when
choice among
competing
actions involves
risk, loss, or
challenge to
values and
beliefs.

Goal
Objectives
Goal:
After 8 hours of
nursing
intervention, the
client will be able
to verbalize
awareness of
positive and
negative aspects
of
choices/alternativ
e actions.
Objectives:
After the nursing
intervention, the
client will be
assisted in

Nursing
Intervention

Rationale

Activelisten/identify
reason for
indecisiveness.

Helps client to
clarify problem
and work toward
a solution.

Review
information client

Accurate and
clearly

Evaluation

After 8 hours of
nursing
intervention, the
client were able
to verbalize
awareness of
positive and
negative aspects
of
choices/alternativ
e actions, the
goal was met.
After the nursing
intervention, the
client was
assisted in

knowing the
causative/contrib
uting factors.

After the nursing


intervention, the
client will be
assisted to
develop/effectivel
y use problemsolving skills.

has about the


healthcare
decision.

Clarify and
prioritize
individual goals,
noting where the
subject of the
conflict falls on
this scale.

Identify positive
aspects of this
experience and
assist client to
view it as a
learning
opportunity.
Correct
misperceptions

understood
information
about situation
will help the
client make the
best decision for
self.
Choices may
have risky,
uncertain
outcomes; may
reflect a need to
make value
judgments or
may generate
anticipated
regret over
having to reject
positive choice
and accept
negative
consequences.
To develop new
and creative
solutions.

knowing the
causative/contrib
uting factors, the
objective was
met.

After the nursing


intervention, the
client was
assisted in
developing/effecti
vely using
problem-solving
skills, the
objective was
met.

client may have


and provide
factual
information.

Nursing
Diagnosis
Cues
Impaired Skin
Integrity related
to left breast
wound secondary
to breast cancer.

Analysis

Goal
Objectives

Altered
epidermis and/ or
dermis.

Goal:
After 8 hours of
nursing
intervention, the
client will be able
to show no signs

Nursing
Intervention

Provides for
better decision
making.

Rationale

Evaluation

After 8 hours of
nursing
intervention. The
client was able to
show no sign of

Subjective
Cues:

of infection of her
left breast.

Objective Cues:

Objectives:
After the nursing
intervention, the
clients
causative/contrib
uting factors will
be assessed.

- During the
physical
examination, the
client has a scar on
her left breast due
to her surgery.

After the nursing


intervention, the
client will be able
to participate in
prevention
measures and
treatment
program.

infection on her
left breast, the
goal was met.
Assess skin, note
for color, turgor,
and sensation.

Demonstrate
good skin
hygiene.

Instruct family to
maintain clean
clothes
preferably cotton
fabric.
Emphasize the
importance of
proper nutrition
and fluid intake.
Provide and
apply wound
dressing.

Encourage early

Establishes
comparative
baseline
providing
opportunity for
timing
intervention.
Maintaining clean
dry skin provide
barrier to
infection.
Stiff or rough
clothes causes
skin friction and
increases risk of
infection.
Improve nutrition
and hydration
will improve skin
condition.
Wound dressing
serves as barrier
to surrounding
tissue.

After the nursing


intervention, the
clients
causative/contrib
uting factors was
assessed, the
objective was
met.
After the nursing
intervention, the
client was able to
participate in the
prevention and
treatment
program, the
objective was
met.

ambulation.
Assist client in
understanding
and following
medical regimen.
Encourage to
verbalize
feelings.

Promotes
circulation.

Enhances
commitment to
plans, optimizing
outcomes.
To promote
proper
intervention to
the problem.