Nursing Care Plan

Date: February 15, 2021 Student’s name: Aquino, Ma. Samantha T. Client’s name:____________________

Assessment Diagnosis Planning Intervention/Implementatio Evaluation

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Subjective: Moderate anxiety SMART GOAL:  Encourage the client to do The goals are met.
 Has not been related to abstain breathing exercises.
eating for two communication as Long term goal: *Independent Intervention  The client is
days. manifested by Rationale: able relax and
fasting After the 2 days of To promote proper breathing had relieved
nursing intervention the and relaxation of the client. feeling about the
Objective: client's anxiety shall be situation.
 BP: N/A eliminated and will be  Assess the client’s
 Temp: N/A able to eat properly. physical reaction to stress  The client’s
 RR: N/A *Independent Intervention tension is
 HR: N/A Short term goal: Rationale: eliminated.
 Refuses to talk To assess other related
to healthcare After 1 hour of nursing physical risk factors that may  The client is
provider intervention the client affect the client. able to eat
will be able to reflect to properly.
lessen the anxiety.  Manage environmental
factors such as room
temperature and lighting
*Independent Intervention
Rationale:
To lessen the client’s
stressors that can affect their
stability.
 Use of state trait anxiety
inventory to access the
client’s condition
*Collaborative Intervention
Rationale:
To assess the anxiety level of
the client that can help to
manage the coping approach
to be given.

 Assessment of vital signs

*Independent Intervention
Rationale:
To obtain objective data for
treatment.

 Listen and talk to the

client concisely in
layman’s terms
*Independent Intervention
Rationale:
To establish rapport and
explain the situation to the
client effectively.
 Instruct client about the
proper use of medications
and educate him or her to
recognize adverse
reactions.
*Independent Intervention
Rationale:
To ensure client’s safety and
well being about the drug
dosage and monitoring of
medications.

 Provide massage and

backrubs for patient to
reduce anxiety and stress
*Independent Intervention
Rationale:
To reduce tension and
anxiety feeling.