NURSING CARE PLAN

Moderate Anxiety related to unfamiliarity with the surgical procedure as evidenced by increased blood
pressure level

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: “gi Moderate After 4 hours Provide Can provide After 4 hours
kulbaan ko Anxiety of nursing preoperative reassurance that of nursing
dong oi related to intervention education, client safety intervention
natural man unfamiliarity the patient including precautions are the patient
tingali gyud with the will be able to intentional constantly was able to
na” as surgical report repetitive ongoing, alleviate report
verbalized by procedure as decreased verification of client’s anxiety, as decrease fear
the pt. evidenced by fear and client well as provide and anxiety
increased anxiety identifiers, information for reduced to a
Objective: blood reduced to a procedure, formulating manageable
T- 35.8 C pressure manageable marked site intraoperativev level as
P- 102 bpm level step and acre. evidenced by
R- 22 cpm surgical “time- Acknowledges that lowered
BP- 160/90 out” process. foreign blood
mm/hg Discuss routine environment may pressure level
procedures and be frightening, (130/70)
processes that alleviates
may frighten or associated fear.
concern client Decreased anxiety
level reduces
elevation of
glucocorticosteroid
levels, which can
interfere with
healing
Inform client or
SO of nurse’s Develops trust or
intraoperative rapport,
advocate role decreasing fear of
loss of control in a
foreign
environment.
Provides patient or
SO with contact
person

Assure client
anticipating
anesthesia that Reduces concerns
drowsiness or that client may
sleep occurs, “see” the
that more procedure
sedation may
be requested
and will be
given if needed,
and that
surgical drapes
will block view
of the operative
field

Collaborative:

Refer to Further evaluation

surgeon, may be desired or
anesthesiologist required for client
and the other to deal with fear,
members of the especially
surgical team concerning life
threatening
conditions, serious
and or high-risk
procedures

Administer
medication as
indicated:

Sedatives, Used to promote

hypnotics sleep the evening
before surgery;
may enhance
coping abilities