Assessment Nursing Diagnosis Planning Interventions Evaluations

SUBJECTIVE: Observe behavior After 5 hours of nursing

Anxiety related to After 5 hours of nursing indicative of the level of intervention patient appear
“Nagaalala ako, masama physiological factor: intervention patient will anxiety. relaxed, reported reduced
ang pakiramdan ko, hindi pseudo catecholamine appear relax, will report - Mild anxiety may be anxiety to a manageable
ko alam ang gagawin” as effect of thyroid hormones reduced anxiety to a displayed by irritability and level and identified healthy
verbalized by the patient as evidenced by extraneous manageable level and will insomnia. Severe anxiety ways to deal with feelings.
movement, restlessness and identify healthy ways to progressing to the panic
tremors. deal with feelings. state may produce feelings
OBJECTIVE: of impending doom, terror,
inability to speak or move,
 Palpitation shouting or swearing.
 Restlessness
 Irritability Monitor physical
 Enlargement of the responses, noting
thyroid gland palpitations, repetitive
 Tremors movements,
 Weight loss hyperventilation, insomnia.
 Rapid heartbeat - Increased number of
 Frequent bowel [beta]-adrenergic receptor
movements sites, coupled with effects
 Hyperactivity of excess thyroid
 Difficulty sleeping hormones, produce clinical
manifestations of
 Intolerance to heat
catecholamine excess even
when normal levels of
norepinephrine
or epinephrine exist.
Vital Sign:
TEMP: 38.33C Stay with the patient,
PR: 110 bspm maintaining a calm
RR: 21 cpm manner.
BP: 132/84 mmHg Acknowledge fear and
allow the patient’s
behavior to belong to the
patient.
- Affirms to patient or SO
that although patient feels
out of control, environment
is safe. Avoiding personal
responses to inappropriate
remarks or actions prevents
conflicts or overreaction to
a stressful situation.

Describe and explain

procedures, surrounding
environment, or sounds
that may be heard by the
patient.
- Provides accurate
information, which reduces
distortions
and confusion that can
contribute to anxiety and/or
fear reactions.

Speak in brief statements.

Use simple words.
- Attention span may be
shortened, concentration
reduced, limiting the
ability to assimilate
information.

Reduce external stimuli:

Place in a quiet room;
provide soft, soothing
music; reduce bright lights;
reduce the number of
persons having contact
with the patient.
- Creates a therapeutic
environment; shows
recognition that unit
activity or personnel may
increase patient’s anxiety.

Discuss with patient and/or

someone reasons for
emotional lability and/or
psychotic reaction.
- Understanding that
behavior is physically
based enhances acceptance
of the situation and
encourages different
responses and approaches.

Reinforce the expectation

that emotional control
should return as drug
therapy progresses.
- Provides information and
reassures patient that the
situation is temporary and
will improve with
treatment.

Administer antianxiety
agents or sedatives and
monitor effects.
- May be used in
conjunction with a medical
regimen to reduce effects
of hyperthyroid secretion.

Refer to support systems as

needed: counseling, social
services, pastoral care.
- Ongoing therapy support
may be desired or required
by patient/SO if crisis
precipitates lifestyle
alterations