JOANNE BERNADETTE C.

AGUILAR

1. Nursing Care Plan for Physical effect of Stress

NURSING CARE PLAN # 1

Assessment
Objective:
 Headache (pain scale 7/10 tension, cluster pain )
 Hypertension(BP:130/90mmHg)
 Increase heart rate (120bpm)
 Facial expression of pain ( e.g., grimace, eyes lack luster)
 Wong Baker’s face rating scale is 8

Nursing Diagnosis: Acute pain related to biological injury agent

Planning: After 3 days of nursing interventions the patient will be able to describes satisfactory
pain control at a level less than 3 to 4 on a rating scale of 0 to 10.

Nursing Interventions Rationale

INDEPENDENT

Performed a comprehensive assessment of pain. The patient experiencing pain is the most reliable source of
Determine via assessment the location, information about his or her pain, thus, assessment of pain
characteristics, onset, duration, frequency,
quality, and severity of pain.
Assessed for the location of the pain by asking
to point to the site that is discomforting.
Performed history assessment of pain
Determined the client’s perception of pain.
by conducting an interview helps the nurse in planning
optimal pain management strategies.
Alternatively, you can use the nursing mnemonic
“PQRST” to help guide your during pain assessment:
Provoking Factors: “What makes your pain better or
worse?”
Quality (characteristic): “Tell me what it’s exactly like. Is
it a sharp pain, throbbing pain, dull pain, stabbing, etc.”
Region (location): “Show me where your pain is.”
Severity: Ask your pain to rate pain by using different pain
rating methods (e.g., Pain scale of 1-10, Wong-Baker
Faces Scale).
Temporal (onset, duration, frequency): “Does it occur all
the time or does it come and go?”
Using charts or drawings of the body can both help the
patient and the nurse in determining specific pain
locations. For clients with a limited vocabulary, asking to
pinpoint the location helps in clarifying your pain
assessment – this is especially important when assessing
pain in children.
Additionally, the nurse should ask the following questions
during pain assessment to determine its history: (1)
effectiveness of previous pain treatment or management;
(2) what medications were taken and when; (3) other
medications being taken; (4) allergies or known side
effects to medications.
In taking a pain history, provide an opportunity for the
client to express in their own words how they view the

Pain should be screened every time vital signs
are evaluated.
Pain assessments must be initiated by the nurse.
Used the Wong-Baker FACES Rating Scale to
determine pain intensity.
Investigated signs and symptoms related to
pain.
Determined the patient’s anticipation for pain
relief.
Assessed the patient’s willingness or ability to
explore a range of techniques aimed at
controlling pain.
Determined factors that alleviate pain.
pain and the situation to gain an understanding of what the
pain means to the client. You can ask “What does having
this pain mean to you?”, “Can you describe specifically
how this pain is affecting you?”.
Many health facilities set pain assessment as the “fifth vital
sign” to pain assessment to routine vital signs assessment.
Pain responses are unique from each person and some
clients may be reluctant to report or voice out their pain
unless asked about it.
Some clients (e.g., children, language constraints) may not
be able to relate to numerical pain scales may need to use
the Wong-Baker Faces Rating Scale.
Bringing attention to associated signs and symptoms may
help the nurse in evaluating the pain. In some instances, the
existence of pain is disregarded by the patient.
Some patients may be satisfied when pain is no longer
massive; others will demand complete elimination of pain.
This influences the perceptions of the effectiveness of the
treatment of the treatment modality and their eagerness to
engage in further treatments.
Some patients may be hesitant to try the effectiveness of
nonpharmacological methods and may be willing to try
traditional pharmacological methods (i.e., use of
analgesics). A combination of both therapies may be more
effective and the nurse has the duty to inform the patient of
the different methods to manage pain.
Ask clients to describe anything they have done to alleviate
the pain. These may include, for example, meditation, deep

Evaluated the patient’s response to pain and
management strategies.
Evaluated what the pain suggests to the patient.
Provided measures to relieve pain before it
becomes severe.
Acknowledged and accept the client’s pain.
Provided nonpharmacologic pain management.
breathing exercises, praying, etc. Information on these
alleviating activities can be integrated in planning for an
optimal pain management.
It is essential to assist patients to express as factually as
possible (i.e., without the effect of mood, emotion, or
anxiety) the effect of pain relief measures. Inconsistencies
between behavior or appearance and what the patient says
about pain relief (or lack of it) may be more a reflection of
other methods the patient is using to cope with the pain
rather than pain relief itself.
The meaning of pain will directly determine the patient’s
response. Some patients, especially the dying, may
consider that the “act of suffering” meets a spiritual need.
It is preferable to provide an analgesic before the onset of
pain or before it becomes severe when a larger dose may
be required. An example would be preemptive analgesia
which is the administration of analgesics before surgery to
decrease or relieve pain after surgery. The preemptive
approach is also useful prior to painful procedures like
wound dressing changes, physical therapy, postural
drainage, etc.
Nurses have the duty to ask their clients about their pain
and believe their reports of pain. Challenging or
undermining their pain reports results in an unhealthy
therapeutic relationship that may hinder pain management
and deteriorate rapport.
Nonpharmacologic methods in pain management may
include physical, cognitive-behavioral strategies, and

DEPENDENT
Cognitive-behavioral therapy (CBT) for pain
management.
Cutaneous stimulation or physical interventions
Provided pharmacologic pain management as
ordered.
lifestyle pain management.
These methods are used to provide comfort by altering
psychological responses to pain.
Cognitive-behavioral interventions include:
Distraction. 
Eliciting the Relaxation Response. 
Guided imagery. 
Repatterning Unhelpful Thinking. 
Other CBT techniques include Reiki, spiritually directed
approaches, emotional counseling, hypnosis, biofeedback,
meditation, relaxation techniques.
Cutaneous stimulation provides pain relief that is effective
albeit temporary. The way it works is by distracting the
client away from painful sensations through tactile stimuli.
Cutaneous stimulation techniques include:
Massage.
Heat and cold applications. 
Acupressure.
Contralateral stimulation.
Transcutaneous Electrical Nerve Stimulation (TENS). 
Immobilization.
Other cutaneous stimulation interventions include
therapeutic exercises (tai-chi, yoga, low-intensity
exercises, ROM exercises), acupuncture.
Pain management using pharmacologic methods involves
the use of opioids (narcotics), nonopioids (NSAIDs), and
coanalgesic drugs. To relieve pain
 .

Evaluated the effectiveness of analgesics as The effectiveness of pain medications must be evaluated
ordered and observe for any signs and individually by the patient since they are absorbed and
symptoms of side effects. metabolized differently.

Evaluation: Goal met after 3 days of nursing interventions the client was able to describes
satisfactory pain control at a level less than 3 to 4 on a rating scale of 0 to 10.

NURSING CARE PLAN #2

Assessment
Objective:

 Body malaise
 Sunken eyeballs
 Poor skin turgor noted
 Fatigue
 Loose bowel movement

Nursing Diagnoses: Deficient ( isotonic )fluid volume related to active fluid volume loss
{ e.g.,diarrhea, dehydration}

Planning: After 8 hours of nursing interventions the patient will be able to maintain adequate
fluid volume as evidenced by good skin turgor

Nursing intervention Rationale

 INDEPENDENT Provides baseline for assessing and evaluating
Assessed vital signs. interventions.
Noted physical signs of dehydration. Predictors of fluid balance that should be in
client’s usual range in a healthy state.

Encouraged fluid intake and monitoring of daily
fluid intake and output.
Estimated or measure traumatic or procedural
fluid losses and note possible routes of insensible
fluid losses. Determine customary and current
weight.
Noted change in usual mentation, behavior and
functional abilities ( e.g.;confusion, falling, loss of cause poor cerebral perfusion or can reflect the
ability to carry out usual activities, lethargy ,and
dizziness.
To detect early signs of dehydration.
These factors are used to determine degree of
volume depletion and method of fluid
replacement.
These signs indicate sufficient dehydration to
effects of electrolyte imbalance. In a hypovolemic
shock state, mentation changes rapidly and client
may present in coma.

 
DEPENDENT
Provided IVF Therapy D5 0.3 NaCl as ordered To hydrate and replace the fluid loss
Administered medications (Erceflora, To limit gastric/intestinal losses; to treat
Metronidazole, Ceftriaxone) prescribed by the bacteria.
physician

Evaluation: Goal met. After 8 hours of nursing interventions the patient was able to maintain
adequate fluid volume as evidence by good skin turgor

NURSING CARE PLAN #3

Assessment
Objective:

 Awakening earlier or later than desired

 Decreased health status

 Decreased quality of life

 Dissatisfaction with sleep pattern

  General tiredness
 Interrupted sleep
Nursing Diagnoses: Insomnia related to stressors
Planning: After 1 day of nursing interventions the patient will be able to obtain optimal amounts
of sleep as evidenced by rested appearance, verbalization of feeling rested, and improvement in
sleep pattern.
Nursing intervention
INDEPENDENT
Educated the patient on the proper food and fluid
intake such as avoiding heavy meals, alcohol,
caffeine, or smoking before bedtime.
Encouraged daytime physical activities but
instruct the patient to avoid strenuous activities
before bedtime.
Instructed the patient to follow a consistent daily
schedule for rest and sleep.
Reminded the patient to avoid taking a large
amount of fluids before bedtime.
Inhibited the patient from daytime naps unless
Rationale
Having full meals just before bedtime may
produce gastrointestinal upset and hinder sleep
onset. Coffee, tea, chocolate, and colas which
contain caffeine stimulate the nervous system.
This may interfere with the patient’s ability to
relax and fall asleep. Alcohol produces drowsiness
and may facilitate the onset of sleep but interferes
with REM sleep.
In insomnia, stress may be reduced by therapeutic
activities and may promote sleep. However,
strenuous activities may lead to fatigue and may
cause insomnia
Consistent schedules facilitate regulation of the
circadian rhythm and decrease the energy needed
for adaptation to changes.
This will refrain the patient from going to the
bathroom in between sleep.
Napping can disrupt normal sleep pattern;
needed.
Introduced relaxing activities such as warm bath,
calm music, reading a book, and relaxation
exercises before bedtime.
however, older patients do better with frequent
naps during the day to counter their shorter
nighttime sleep schedules.
These activities provide relaxation and distraction
to prepare mind and body for sleep.

DEPENDENT

Administered sedative-hypnotics, anti-

These act through general central
anxiety drugs as prescribed by the
nervous system depression and
physician
disrupt the normal stages of non-

rapid eye movement (NREM) and REM

sleep. Long-term use may cause

daytime drowsiness, rebound

insomnia, and increased dreaming

when discontinued.

Evaluation: Goal met. After 1 day of nursing interventions the patient was able to obtained
optimal amounts of sleep as evidenced by rested appearance, verbalization of feeling rested, and
improvement in sleep pattern.

2. Nursing Care Plan for Psychological effect of Stress

NURSING CARE PLAN #1

Assessment
Objective:

 Decreased affect
  Decreased judgment

 Impaired decision making

 Inability to establish goals

 Loss of interest in life

 Passivity, decreased verbalization

 Sleep disorders

 Socially repressed

 Suicidal thoughts

 Negative ruminations

Nursing Diagnoses: Hopelessness related to chronic stress

Planning: After 2 hours of nursing interventions the patient will be able to express feelings and
acceptance of life events over which he or she has no control.

Nursing intervention Rationale

INDEPENDENT
Allowed the patient to express feelings and
perceptions
Expressed hope to the patient with realistic
comments about the patient’s strengths and
The process of recognizing feelings that underlie
and drive behaviors allows patient to start taking
control of their lives.
Patients may feel hopeless, but it is helpful to hear
positive expression from others.
resources.
Assisted the patient determine aspect of life that
are under his or her control.
Allowed the patient to assume responsibility
for self-care, such as setting realistic
goals, scheduling activities, and making
independent decisions.
Aided the patient determine aspects of life events
that are not within his or her ability to control.
Discuss feelings related with this lack of control.
DEPENDENT
Administered antidepressants as indicated.
An individual’s emotional state may interfere with
problem solving. Support may be required to
identify areas that are under his or her control and
to have calrity about options for taking control.
Helping patient set realistic goals increases
feelings of control and provides satisfaction when
goals are achieved, thereby decreasing feelings of
hopelessness.
The patient needs to recognize and resolve
feelings related with inability to control certain
life situations before acceptance can be achieved
and hopefulness becomes possible.
Suicidal thinking is a symptom of depression that
is managed through proper medication.

Evaluation: Goal met. After 2 hours of nursing interventions the patient was able to expressed
feelings and acceptance of life events over which he or she has no control.

NURSING CARE PLAN #2

Assessment
Objective:
 Tachycardia (120bpm)
 Mental Confusion noted
 Avoid looking at equipment or keeps vigilant watch over equipment
 Increased questioning
 Increased awareness
 Verbalized anxiety
  Uncooperative behavior

Nursing Diagnosis: Anxiety related to stressors

Planning: After 2 days of nursing interventions the patient will be able to use effective coping
mechanisms

Nursing Intervention Rationale

INDEPENDENT

Assessed previous coping mechanism used.
Anxiety and ways of decreasing perceived anxiety are
highly individualized. Interventions are most effective
when they are consistent with the client’s established
coping pattern. However, in the acute care setting these
techniques may no longer be feasible.

Assessed the client’s level of anxiety. Shock can result in an acute life-threatening situation that
will produce high levels of anxiety in the client as well as
in significant others.

Explained all procedures as appropriate, Information helps reduce anxiety. Anxious clients unable to
keeping explanations basic. understand anything more than simple, clear, brief
instructions.

Encouraged the client to verbalized his or her Talking about anxiety-producing situations and anxious
feelings. feelings can help the client perceive the situation in a less
threatening manner.

Acknowledged an awareness of the client’s Acknowledgement of the client’s feelings validates the
anxiety. client’s feelings and communicates acceptance of those
feelings.

Reduced unnecessary external stimuli by maintaining a Anxiety may escalate with excessive conversation, noise,
quite environment. If medical equipment is a source and equipment around the client.
of anxiety, consider providing sedation to the client.

Maintained a confident, assured manner while The staff’s anxiety may be easily perceived by the client.
interacting with the client. Assure the client The client’s feeling of stability increases in a calm and
and significant others of close, continuous non-threatening atmosphere. The presence of a trusted
monitoring that will ensure prompt person may help the client feel less threatened.
intervention.

DEPENDENT
Administered anxiolytic medication as To relieve anxiety
prescribed by the physician.

Evaluation: Goal met after 2 days of nursing intervention the client was able to use effective
coping mechanisms.

NURSING CARE PLAN #3

Assessment
Objective:
 Alteration in interpretation or response to stimuli
 Progressive alteration in cognitive function
 Impaired Social functioning
 Alteration in short-term/long term memory
 Alteration in personality

Nursing Diagnosis: Chronic confusion related to brain injury

Planning: After 3 days of nursing interventions the patient will be able to functions at a maximal
cognitive level
 Nursing Intervention
INDEPENDENT
Provided a calm environment.
Promoted reality-oriented relationships and
environment (e.g., display clocks,
calendars, personal items, seasonal
decorations).
Encouraged the patient to check the
calendar and clock often to orient himself
or herself.
Talked to the patient using simple, concrete
nouns in positive terms.
Allowed family members to orient the
patient about current news and family
events.
Kept the environment quiet and
nonstimulating; avoid using buzzers and
alarms if possible. Reduce sights and
sounds that have a high potential for
misinterpretation such as buzzers, alarms,
and overhead paging systems.
DEPENDENT
Referred family to social services or other
supportive services.
Encouraged family to make use of support
groups or other service programs.
Rationale
Any
extraneous noise and stimuli can be misinterpreted by the
confused patient. Images on walls may be threatening for the
patient.
Orientation to one’s environment increases one’s ability to
trust others.
Familiar personal possessions increase the patient’s comfort
level.
This method can reduce anxiety. Saying “stay sitting on the
chair” is more positive than saying “Don’t get up.”
A confused patient may not completely understand what is
happening. Increased orientation promotes a greater degree of
safety for the patient.
Sensory overload can result in agitated behavior in a patient
with chronic confusion. Misinterpretation of the environment
can also contribute to agitation.
To assist with meeting the demands of caregiving for older
patients.
Community resources provide support, assist with problem-
solving, and reduce the demands associated with caregiving.
Evaluation: Goal met after 3 days of nursing intervention the client was able to functions at a
maximal cognitive level

3. Nursing Care Plan for Behavioral effect of Stress

NURSING CARE PLAN #1

Assessment
Objective:
 Hyperactivity: most important predictor of imminent violence (e.g., pacing, restlessness)
 Increasing anxiety and tension: clenched jaw or fist, rigid posture, fixed or tense facial
expression, mumbling to self, shortness of breath, sweating, rapid pulse
 Verbal abuse (e.g., uses profanity, is argumentative, makes intrusive demands)
 Loud voice, change of pitch, or very soft voice, forcing others to strain to hear
 Changes in level of consciousness (e.g., confusion, disorientation, memory impairment)
 Intense eye contact or avoidance of eye contact
  Recent acts of violence, including property violence
 Stony silence
 Alcohol or drug intoxication
 Carrying a weapon or object that might be used as a weapon (e.g., fork, knife, rock)

Nursing Diagnoses: Ineffective coping related to inadequate opportunity to prepare for stressor

Planning: After 1 hour of nursing interventions the patient will be able to verbalize awareness of
own coping abilities

Nursing intervention Rationale

INDEPENDENT

Assisted patient set realistic goals and identify
personal skills and knowledge.
Provided chances to express concerns, fears,
feeling, and expectations.
Used empathetic communication.
Conveyed feelings of acceptance and
understanding. Avoid false reassurances.
Encouraged patient to make choices and
participate in planning of care and scheduled
activities.
Involving patients in decision making helps them
move toward independence.
Verbalization of actual or perceived threats can
help reduce anxiety and open doors for ongoing
communication.
Acknowledging and empathizing creates a
supportive environment that enhances coping.
An honest relationship facilitates problem-solving
and successful coping. False reassurances are
never helpful to the patient and only may serve to
relieve the discomfort of the care provider.
Participation gives a feeling of control and
increases self-esteem.

Encouraged the patient to recognize his or her During crises, patients may not be able to
own strengths and abilities. recognize their strengths. Fostering awareness can
expedite use of these strengths.
Considered mental and physical activities within
the patient’s ability (e.g., reading, television,
outings, movies, radio, crafts, exercise, sports,
games, dinners out, and social gatherings).
Assisted patients with accurately evaluating the
situation and their own accomplishments.
If the patient is physically capable, encouraged
moderate aerobic exercise.
Provided information the patient wants and needs. Patients who are coping ineffectively have
Do not give more than the patient can handle.
Provided touch therapy with permission. Give
patient a back massage using slow, rhythmic
stroking with hands. Use a rate of 60 strokes a
minute for 3 minutes on 2-inch wide areas on both pressure, and increased skin temperature at
sides of the spinous process from the crown to the significant levels. The conclusion is that
sacral area.
Assisted the patient with problem-solving in a
constructive manner.
Provided information and explanation regarding
care before care is given.
Eliminated stimuli in an environment that could
be misinterpreted as threatening.
Interventions that improve body awareness such
as exercise, proper nutrition, and muscular
relaxation may be helpful for treating anxiety and
depression.
It can be helpful for the patient to recognize that
he or she has the skills and reserves of strength to
effectively manage the situation. The patient may
need help coming to a realistic perspective of the
situation.
Aerobic exercise improves one’s ability to cope
with acute stress.
reduced ability to absorb information and may
need more guidance initially.
A soothing touch can reveal acceptance and
empathy. Slow stroke back massage decreased
heart rate, decreased systolic and diastolic blood
relaxation is induced by slow stroke back
massage.
Constructive problem solving can promote
independence and sense of autonomy.
In traumatic situations, families have a need for
information and explanations. Providing
information prepares the patient and family for
understanding the situation and possible
outcomes.
The presence of noise associated with medical
equipment can increase anxiety and make coping
more challenging.
Discussed changes with patient before making Communication with the medical staff provides
them. patients and families with understanding of the
medical condition.
Provided outlets that foster feelings of personal Opportunities to role-play or rehearse appropriate
achievement and self-esteem. actions can increase confidence for behavior in
actual situations.
Pointed out signs of positive progress or change. Patients who are coping ineffectively may not be
able to assess their progress toward effective
coping.
Encouraged use of cognitive behavioral relaxation Relaxation techniques, desensitization, and guided
(e.g., music therapy, guided imagery). imagery can help patients cope, increase their
sense of control, and allay anxiety.
Supported of coping behaviors; give patient time A supportive presence creates a supportive
to relax. environment to enhance coping.
Discussed with patient about his or her previous Describing previous experiences strengthens
stressors and the coping mechanisms used. effective coping and helps eliminate ineffective
coping mechanisms.
Used distraction techniques during procedures that Distraction is used to direct attention toward a
cause patient to be fearful. pleasurable experience and block the attention of
the feared procedure.
Applied systematic desensitization when Fear of new things diminishes with repeated
introducing new people, places, or procedures that exposure.
may cause fear and altered coping.
DEPENDENT
Referred for counseling as necessary. Arranging for referral assists the patient in working
with the system, and resource use helps to develop
problem-solving and coping skills.
Referred to medical social services for evaluation This will promote adequate coping as part of the
and counseling. medical plan of care.
If the patient is associated with the mental health Based on knowledge of the home and family, home
system, actively engage in mental health team care nurses can often advocate for patients. These
 planning. nurses are often requested to monitor medications
and therefore need to know the plan of care.

Evaluation: Goal met. After 1 hours of nursing interventions the patient was able verbalized
awareness of own coping abilities

NURSING CARE PLAN #2

Assessment
Objective:

 Dry skin and mucous membranes, decreased skin turgor

 Increased pulse rate(117bpm)
 Output greater than input (diuretic use); concentrated urine/decreased urine
output (dehydration)
 Weakness
 Change in mental state
 Hemoconcentration, altered electrolyte balance

Nursing Diagnosis: Risk for Deficient Fluid Volume related to inadequate intake of food and
liquids

Planning: After 3 days of nursing interventions the patient will be able to verbalize
understanding of causative factors and behaviors necessary to correct the fluid deficit

Nursing Intervention Rationale

INDEPENDENT
Monitored and recorded vital signs, Indicators of the adequacy of circulating volume.

capillary refill, status of mucous Orthostatic hypotension may occur with the risk of falls and injury following
sudden changes in position.
membranes, skin turgor.

Noted amount and types of fluid intake. Patient may abstain from all intake, with resulting dehydration; or substitute
Measure urine output accurately. fluids for caloric intake, disturbing electrolyte balance.

Discussed strategies to stop vomiting Helping patients deal with the feelings that lead to vomiting and
and laxative and diuretic use. laxative or diuretic use will prevent continued fluid loss. Note:
Patient with bulimia has learned that vomiting provides a release
of anxiety.

Identified actions necessary to regain Involving the patient in the planning to correct fluid imbalances
or maintained optimal fluid improves chances for success.
balance (specific fluid intake schedule).

Reviewed electrolyte and renal Fluid, electrolyte shifts, decreased renal function can adversely
function test results. affect a patient’s recovery or prognosis and may require additional
intervention.

DEPENDENT

Administered and monitored IV, TPN; Used as an emergency measure to correct fluid and electrolyte
electrolyte supplements, as indicated. imbalance and prevent cardiac dysrhythmias.

Evaluation: Goal met after 3 days of nursing intervention the client was able to verbalized
understanding of causative factors and behaviors necessary to correct the fluid deficit
 NURSING CARE PLAN #3

Objective:
 Weight loss
 Weakness
 Decreased appetite
 Poor muscle tone

Nursing Diagnosis: Imbalanced nutrition: Less than body requirements related to psychological
disorder
Planning: After 1 day of nursing intervention the patient will be able to improve appetite from
poor to fair

Nursing Intervention Rationale

( Independent )
INDEPENDENT Suggest severity of effect in fluid and
Used flavoring agents to determine enhance electrolyte balance and nutritional status.
food satisfaction and stimulate appetite.
Encouraged clients to choose foods, have To promote comfort and enhance intake.
family members to bring food that seen
appealing( which are not contraindicated)
Promoted pleasant relaxing environment To reduce gastric acidity and improve nutrient
including socialization when possible to intake.
enhance food intake.
Prevented unpleasant odors. To reduce the occurrence of vomiting
Auscultated bowel sounds. Hyperactive bowel sounds due to GI
disturbance.

Dependent
Referred to dietician from modification of diet To gradually stimulate appetite for fast
( General liquids ) recovery.

Evaluation: Goal met. After 8 hours of rendering nursing intervention the patient was able to
improved appetite from poor to fair.