ASSESSMENT NSG DX GOALS & OUTCOMES NSG INTERVENTIONS RATIONALE EVALUATION

S:
Fear and ineffective coping After 4 hours of nursing 1. Assessed patient’s 1. Provides knowledge base for Goal met

-Pt stated she feels helpless.

related to the diagnosis interventions, the client will knowledge about the the nurse to enable the
acknowledge and discuss condition, expected surgical reinforcement of needed After 4 hours of nursing
O:
concerns and will demonstrate intervention and future information, and helps identify interventions, the client
-decreased self-assurance
appropriate range of feelings.
therapies. Noted presence of patient with high anxiety, low acknowledged and discussed
-restlessness denial or extreme anxiety.
capacity for information fully her concerns and also
2. Prepared pt for diagnostic processing, and need for special demonstrated the appropriate
After 2 days of nursing tests.
attention. Note: Denial may be range of feelings.

After 2 days of nursing
2. More understanding of
control and lessens anxiety.
interventions, the client will
report fear to be reduced to a
manageable level.
interventions, the client was able
3. Implemented an ambiance of
concern, openness and
availability, as well as
privacy.
4. Encouraged questions and
provided time for expression
of fears.
useful as a coping method for a
time, but extreme anxiety needs
to be dealt with immediately.
procedures and what is to report fear to be reduced to a
happening increases feelings of manageable level.

5. Determined the support 3. Time and privacy are needed

available to the patient. Gave
information about
community resources and
encouraged a visit with a
woman who has recovered
from a mastectomy.
facilitate this process.
to provide support, discuss
feelings of anticipated loss and
other concerns. Therapeutic
communication skills, open
questions, listening, and so forth

6. Considered role of 4. Provides an opportunity to

rehabilitation after surgery. identify and clarify
misconceptions and offer
emotional support.

5. Can be a helpful resource

when patient is ready. A peer
who has experienced the same
process serves as a role model
and can provide validity to the
comments, hope for recovery
and normal future.

6. Rehabilitation is an essential
component of therapy intended
to meet physical, social,
emotional, and vocational needs
so that the patient can achieve
the best possible level of
physical and emotional
functioning.