Nursing Diagnosis (PES): Anxiety related to situational crises as evidenced by increased in blood pressure, pulse, disturbed sleep pattern

and
difficulty concentrating.

Definition: Insufficient physiologic or psychologic energy to endure or complete required or desired activities.
Assessment/ Cues Planning Interventions Rationale Evaluation
(Subjective/ Objective) (Goals and Nursing Care
Objectives) Plan
Subjective Data Short Term Goals: Independent Independent At the end of nursing
After 2 hours of care, the goal was Patient’s
o Patient verbalized “gaka nursing care:  Maintain a calm, non-  Anxiety is contagious met… Code: Elvie
balaka ko kay murag threatening manner while and may be Palmada
wala nani undang ang  The client will Short Term Goals: Age:
working with clients. transferred from staff
covid” verbalize ways 50 years old
to client or vice Sex:
o Insomia to intervene in versa. Client  The client was
 Reassure client of his or able to Female Civil
o Overthinking escalating develops feeling of
her safety and security. Status:
anxiety. security in presence verbalize ways
This can be conveyed by Married Date
of calm staff person. that intervened & Time of
 The patient will physical presence of nurse. in escalating
verbalize that Admission:
Do not leave client alone at  The client may fear anxiety. Nov. 05, 2021;
Objective Data she feels more this time. for his or her life. The
 The patient 2:05 pm
in control of his presence of a trusted Chief
o Difficulty concentrating current individual provides verbalized that
 Use simple words and brief Complaints:
situation  the client with a she feels more
messages, spoken calmly Increased
o Worries about current in control of his
 The patient’s and clearly, to explain feeling of security blood
situation of CV and assurance of current pressure,
HR will be 60- hospital experiences to situation than
o BP: 150/80 personal safety insomnia for
100 bpm, RR clients. before.
o VS: RR – 22 more than 1
12-20, and SBP week and
breaths/min  Assess the patient's  The patient’s
110-130 within  In an intensely difficulty
o HR: 135 bpm activities of daily living, as HR is now 93
24 hours. anxious situation, the concentrating
well as actual and bpm, RR
client is unable to at some point.
perceived limitations to 18, and SBP
comprehend
physical activity. Ask for 110 after of 24
Long Term Goals: anything but the most
any form of exercise that hours.
After 12 hours of elementary
nursing care: he/she used to do or wants
communication.
to try.
Long Term Goals:
 The client will  Assess client’s level of
be able to  Recognition of
anxiety. Try to determine  The client now
recognize precipitating factors
the types of situations that recognized
symptoms of is the first step in
increase anxiety and result possible
the onset of teaching the client to
in ritualistic behaviors. symptoms of
interrupt the