NURSING PROCESS

SL ASSESSMENT NURSING GOAL NURSING IMPLEMENTATION EVALUATION

NO DIAGNOSIS INTERVENTIONS
AND RATIONALE
1. SUBJECTIVE Severe anxiety Patient will Assess the level of Assess the anxiety level,
DATA related to verbalize that he anxiety, gives baseline patient becomes anxious
Patient says that he irrational gained self data for further fo unknown situations and
feels vey anxious thoughts and confidence and his evaluation. thoughts. Patient gained his
without any reason situations anxiety is reduced Provided reassurance and self confidence and
and also due to secondary to and develops a Provide reassurance and comfort by , slowly developed a
repeated undesirable absence of sense of recovery comfort, Staying with the patient. sense of recovery.
thoughts. support system. and achievement. i) Stay with Staying with the patient.
the patient. Speaking slowly and
OBJECTIVE ii) Speak calmly and
DATA slowly and Convey a sense of
Patient is having calmly. empathetic understanding.
profuse sweating, iii) Be aware of
tremors, and his your own
facial expression concern
show he is very and avoid
anxious. reciprocal
anxiety.
iv) Convey a
sense of
empathetic
understandi
ng . eg –
touch,
allowing to
cry, talk,
Gives psychological
support and minimizes
anxiety provoking
situations.
SL ASSESSMENT NURSING GOAL NURSING IMPLEMENTATION EVALUATION
NO DIAGNOSIS INTERVENTIONS AND
RATIONALE
Encourage the patient to Encourage the patient to
recall and analyze similar recall and analyze similar
instance of anxiety to instance of anxiety, patient
minimize the exposure of becomes very sad.
similar stimulations in future.
Developed behavior
Develop behavior modification strategies and
notification strategies helps reduced anger producing
to modify anxiety which situations.
provokes anger.
Interested with the person
Interest with the person when and gained more information.
he is not demanding, helps to
gain more information. Arranged for visitors and
relatives.
Arrange for visitors to
relaxes to c----- the patient.
2. SUBJECTIVE Exaggerated Patient will
DATA fear related to overcome Assess the mental status of Assured the mental status,
Patient says that he unknown anxiety as the patient, gives base line patient showed fear.
is having fear stimuli. evidenced. He data for further assessment. Oriented the patient to
without any has no environment with simple
reason. symptoms of Orient to environment using explanations.
fear. simple explanations, fear
may interfere with
orientation.

Speak slowly and calmly,

 minimizes anxiety of the
client.
SL ASSESSMENT NURSING GOAL NURSING INTERVENTIONS
NO DIAGNOSIS AND RATIONALE
Allow personal space for the
client, to help move freely.
Use simple direct statements,
helps to understand easily.
Encouraged expression of
feelings such as helplessness,
anger, to know patient coping
capacity.
Provide an emotionally non-
threatening atmosphere, helps to
minimize fear.
Set up a consistent daily
schedule. Teach relaxation
techniques.
Slow, rhythmic breathing.
Progressive relaxation of muscle
groups.
Thought stopping helps to relax
the mind.
Give divertional therapy, helps
IMPLEMENTATION EVALUATION
Oriented the patient to
environment with simple
explanations.
Spoke slowly and calmly.
Allowed personal space for
the client, helped him to move
freely. Patient had no
symptoms of fear and
Used simple direct statements. over come his anxiety.
Encouraged expression of
feelings of the patient.
Provided an emotionally no-
threatening atmosphere.
Setup daily schedule and
taught relaxation technique.
Divertional therapy given by
taking with the patient.
 to divert the mind from fearful
stimuli.

SL ASSESSMENT NURSING GOAL NURSING IMPLEMENTATION EVALUATION

NO DIAGNOSIS INTERVENTIONS AND
RATIONALE
3. SUBJECTIVE Altered thought Patient will be Approach in a calm, nurturing Approached in calm,
DATA process able to accept manner, helps to minimize nurturing manner.
Patient says that he is reoccupation reality, anxiety.
treated bad by his related to identify his Avoided making
relatives and friends intense fear. relationship Avoid making promises that promises.
at workplace because and evaluate cannot be fulfilled.
of his disease his behavior. Verify the interpretation
condition and they Verify your interpretation of of what patient was
show hatred towards what person is experiencing, experiencing.
him. helps to understand things
correctly. Observe for verbal and
OBJECTIVE DATA non-verbal hallucinations
Patient looks sad and Observe for verbal and non- and patient frequently
he is a case of verbal hallucinations, twisted his arm.
anxiety. inappropriate laughter,
delayed, verbal response, eye Directed the focus from
movements, move lips without delusion expression to
sound, increased motor discussion of reality
movements, helps to know centered situations.
whether the patient is in real
world or in hallucination.

Direct the focus from delusion

expression to discussion of
reality centered situations,
helps to divert to mind.
Set limits for discussing

SL ASSESSMENT
NO
SUBJECTIVE DATA
4. Patient says that he is
separated from his parents
because of illness and feels
depressed. He says that
his relatives make fun of
him and feels shame to
stay in the hospital. He
says that he needs others
help.
repetitive delusion material,
prevent the reality of unreal
ideas.
NURSING GOAL NURSING
DIAGNOSIS INTERVENTIONS AND
RATIONALE
Direct the focus from
delusion expression to
discussion of reality
centered situation, helps to
divert the mind.
Set limits for discussing
repetitive delusion
material, prevent the
reality of unreal ideas.
Help correct false beliefs
with increased level of
anxiety, to prevent further
attack.
Ask for meaning of what is
said, do not understand,
helps to understand
Self esteem Patient correctly.
disturbance will
related to identify Avoid negative criticism,
intense fear. positive provide privacy and safe
attention environment, to maintain
about good rapport and to
himself. promote social interaction
with others.
Avoid over protection
IMPLEMENTATION EVALUATION
Direct the focus from Patient accepted
delusion expression to his reality and
discussion of reality identified his
centered situations. relationship.
Set limits for discussing
repetitive delusion
material.
Helps to correct false
beliefs with increased
levels of anxiety.
Asked for meaning of what
is said.
Avoided over protection
while still ----- the demand
made on the individual.
Explored strength and
resources with the patient.
Provided a positive
reinforcement that he will
be cured and can come up
in life.
 while still limiting the
demand made on the

SL ASSESSMENT NURSING GOAL NURSING IMPLEMENTATION EVALUATION

NO DIAGNOSIS INTERVENTIONS
AND RATIONALE
Individual to promote
social interaction with
others.

Explore strength and

resources with the
person, to maintain and
promote social
interaction.
5. OBJECTIVE
DATA Alteration in Provide a positive
Patient is restless psychomotor Patient will reinforcement that he
and he is having activity, attain normal will be cured and can
increased restlessness activity as come up in life, Assessed the mental status,
psychomotor related to evidenced by he promotes self- patient has increased Patient attained
activity. He is a anxiety. is able to find confidence. psychomotor activity. normal activity to
case of anxiety the relationship same extent and able
neurosis. between anxiety Assess the mental status Observed the increased to find relationship
and increased of the patient, gives activity of the client. between anxiety and
activity. baseline data for further increased activity.
assessment. Encouraged the client to
verbalize relationship
Observe the increased between the visit of a
activity of the client, relative and increased
indicates patients activity and restlessness.
anxiousness.
Encourage the client to
verbalize
SL ASSESSMENT NURSING GOAL NURSING IMPLEMENTATION EVALUATION
NO DIAGNOSIS INTERVENTIONS AND
RATIONALE
between visit of a relative Provided calm and quiet
and increased activity and environment.
restlessness helps to know
the source of anxiety. Encouraged to take rest.

Provide calm and quiet Encouraged to have naps

environment, minimizes
anxiety.
Encourage to take rest,
gives physical rest.
Encourage to have naps in
the day time, minimizes
increased psychomotor
activity.
in the day time.
Give divertional therapy
by talking with the
patient according to his
likes.
Administered anti-anxiety
drug Tab. Amitriphylle as
per doctor’s order.

Give divertional therapy

by talking with the patient
according to his likes,
helps to divert the mind
from anxious stimuli.

Administer anti-anxiety
Altered drug as per doctor’s order,
6. SUBJECTIVE perception Patient’s perception helps to suppress the
DATA auditory will be improved as central nervous system
Patient says that he hallucination evidenced by patient activity.
is having some related to mental communicates his
discomforting voice illness. problem effectively.
when he is alone.
SL ASSESSMENT NURSING GOAL NURSING
NO DIAGNOSIS INTERVENTIONS AND
RATIONALE
Assess the perception status of
the patient, gives baseline data,
for further evaluation.
Observe for verbal and non-
verbal hallucination helps to
know whether the patient is
having hallucination or not.
Explain the relatives and the
patient that once he recovers
symptoms will disappear, helps
to cope up with the situation.
Don’t leave the patient alone,
prevents harm to himself and
others.
Help to connect false
perception with increased
levels of anxiety, to know the
cause for anxiety.
Ask for meaning of what is
said, do not assure that you
understand, helps to know the
correct meaning.
IMPLEMENTATION EVALUATION
Assess the perception status,
patient leaves auditory voices
telling him that he is impotent. Patients perception
improved and he
Observe for verbal and non- communicated his
verbal hallucination. Patient problem effectively.
learned verbal hallucination.
Explain the relatives and the
patient that once he recovers
symptoms will disappear, helps to
cope up with the situation.
Patient was not left alone.
Helped to connect false
perception with increased levels
of anxiety.
Ask for meaning of what is said,
patient understood correct
meaning.
SL ASSESSMENT NURSING GOAL NURSING IMPLEMENTATION EVALUATION
NO DIAGNOSIS INTERVENTIONS AND
RATIONALE
7. SUBJECTIVE Sleep pattern Patient develops Assess the normal sleeping Assessed the sleeping
DATA disturbance regular sleeping pattern of the patients, pattern, patient had
Patient says that he related to pattern as gives baseline data for disturbed sleep.
is sleeping late night emotional evidenced by he further assessment.
and unable to sleep disturbances. slept Limited the amount and
as before since 2 comfortably for Limit amount and length of length of day time sleeping.
months. about 8 hours. day time sleeping, if
excessive interferes with Limited intake of
OBJECTIVE right end sleeping. caffeinated drinks.
DATA
Patient looks vey Limit intake of caffeinated Had person limit night time
tired and drowsy. drinks, it stimulates the fluids.
central nervous system.

If voiding during the night

time is disruptive have ----
limit night time fluids and
void before retiring,
prevents awakening during
sleep.
Explained the pe---- and
Explain the person and significant others the causes
significant others the of sleep disturbances and
causes of sleep disturbance ways to avoid it.
and possible ways to avoid
it, to avoid disturbing Provided calm and quiet
factors. environment.
SL ASSESSMENT NURSING GOAL NURSING IMPLEMENTATION EVALUATION
NO DIAGNOSIS INTERVENTIONS
AND RATIONALE
Provide calm and quiet Encouraged to have warm Patient sleeping
environment , noise will bath before going to bed. pattern improved
interfere with falling and he slept
asleep. Administer sedative comfortably.
tab.diazepam as per
Encourage to have warm doctor’s order.
bath before going to bed,
causes vasodialation.

Administer sedatives as
per doctor’s order, it will
depress the central
nervous system.

SUBJECTIVE Assess the pre-morbid Assess the pre-morbid

8. DATA Impaired social social interaction and social interaction and
Patient says that he interaction related Patient will relation of the patient, relation of the patient.
is not able to to effects of develop self- gives baseline data for
interact easily with behavior and confidence as further evaluation. Discuss feeling with the
others well because action on forming evidenced by he patient. Patient developed
of his anxious and maintaining learnt the Provide an individual self confidence and
behavior. relationship. importance of supportive relationship, Used questions and learnt importance
socialization. helps to have good social observations to of socialization.
OBJECTIVE interaction with others. encouraged patient with
DATA Discuss feelings, to have limited interaction skills.
Now patient is good relationship.
having only limited
friends and he is
easily irritated and
 shows his anxiety
and fear.

SL ASSESSMENT NURSING GOAL NURSING IMPLEMENTATION EVALUATION

NO DIAGNOSIS INTERVENTIONS AND
RATIONALE
Use questions and Out ---- activities of the
observations to encourage day.
persons with limited
interaction skills, increases Taught the patient how to
socialization. approach and
communicate with others.
Outline activities of the day
and focus on accomplishing
them, helps to resemble
things.

Teach how to approach

others to communicate and
teach to identify which
9. SUBJECTIVE DATA interaction and rapport
Patient says that he increases communication
don’t know anything Altered spiritual Patient will skills and interest to speak
about his disease distress, be expressing with others. Assessed the causative
condition and whether deviation, pain his feelings and contributing factors.
lit is curable or not. He related to related to Assess the causative and
also says God is not inability to deal change in contributing factors, to Allowed the patient to
loving him. with anxiety. belief. provide appropriate care. express the anger towards
God.
OBJECTIVE DATA Allow the patient to express
Patient talks to me the anger towards God to Allowed client to solve
about God and he will reduce the distress. problem and find ways
not be cured.
Allow client to solve
 problem and find ways to
express and

SL ASSESSMENT NURSING GOAL NURSING IMPLEMENTATION EVALUATION

NO DIAGNOSIS INTERVENTIONS AND
RATIONALE
relieve anger.
Suggest suicidal imaginary
and medication to
reinforce the fails.
Provide uninterrupted
quiet time for prayer, to
reduce the distress.
to express and relieve Spiritual distress
anger. relieved and patient
developed good
Suggested suicidal changes in religious
imaginary and medications belief.
to reinforce the fails.
Provided interrupted quiet
time for prayer.

Introduce spiritual leader Introduced spiritual

to reinforce the faith and leaders and ideas
reduce the distress. reinforced the faith and
reduced distress.

Assess the literacy level of

10. SUBJECTIVE the patient, to plan Assess the literacy level,
DATA Knowledge Patient will accordingly. patient is uneducated.
Patient says that he deficit regarding gain
didn’t know psychiatric knowledge as Assess the understanding Assessed the
anything about his illness and evidenced by ability and interest of the understanding ability,
disease condition treatment. patient copes patient in learning, helps to patient showed interest.
and treatment. to prevent. teach the patient at his
level of understanding. Explained about the
OBJECTIVE disease condition at the
DATA Explain about the disease level of client.
Patient is not able to condition at a level the
answer even simple client can understand, Explained in simple
 questions regarding helps to gain knowledge sentences.
his disease condition about disease condition.
and treatment.

SL ASSESSMENT NURSING GOAL NURSING INTERVENTIONS IMPLEMENTATION EVALUATION

NO DIAGNOSIS AND RATIONALE
Explain a simple sentence, for easy Written instruction are not Patient gained
understanding. given. knowledge to some
extent and copes to
Give written instruction to patient, Encouraged the patient not to prevent the
act as a reminder. stop medication abruptly and reoccurrence.
come for regular follow-up.
Encourage patient to come for
regular check up and also not to
stop medication abruptly without
physician advise to prevent relapse
of disease.