NURSING CARE PLAN

Patient’s Initials: K.C Chief Complaint: Fatigue associated with the Name of Student Nurse:
Age & Gender: 40yrs. Old/Female past disaster event.

Birthdate: May 23, 1982 Admitting Diagnosis: Risk for Post-Trauma Level/Block/Group:
Syndrome r/t Exposure to disaster AEB Emotional
reactions
Address: Malabago, Mangaldan, Hospital/Area:
Pangasinan, Philippines The Medical City / Gen. Ward
Date of Confinement: Clinical Instructor:
Date: 08/20/2022

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

ANALYSIS INTERVENTIONS

Subjective Data: Post-Trauma After nursing - Provide a calm, safe  Helps client deal Goals met.
“Ayoko na! sana Syndrome is a interventions, environment. with the After nursing
hindi na ulet mental health the patient is disruption in interventions
mangyare yung condition that expected to: - Determine personal life. , the patient
dati!” - as verbalized develops following involvement in event, can:
by the patient. a traumatic event - Express own such as the survivor,  All those
characterized by feelings and SO, and family, concerned with a - Express own
Objective Data: intrusive thoughts reactions rescue or aid worker, traumatic event feelings and
 Fatigue about the incident, openly, healthcare provider, or are at risk for reactions
 Confused recurrent avoiding family member of emotional trauma openly,
 Fearfulness distress/anxiety, projection. responder. and have needs avoiding
 Flashbacks flashback and related to them projection.
 Exhausted avoidance of - Demonstrate - Evaluate life factors situation and
similar situations. ability to deal and stressors currently involvement in - Demonstrate
Vital Signs taken: These are most with emotional or recently the event ability to deal
common in reactions in an occurring such as with emotional
 BP- 140/90
females individually displacement from  Affects client’s reactions in an
mmHg
  HR- 72 bpm appropriate home due to reaction to individually
 RR- 20 cpm manner catastrophic event— current event and appropriate
 Temp- 37.5 illness, injury, natural is basis for manner
degrees - Maintain disaster, or planning care and
Celsius appropriate terrorist attack. Identify identifying
mental and how client’s past appropriate - Maintain
NURSING physical experiences may supports and appropriate
DIAGNOSIS functioning as affect current situation resources. mental and
long as physical
Risk for Post- possible. - Determine availability  Family and others functioning as
Trauma Syndrome and usefulness of close to the client long as
r/t Exposure to - Demonstrate client’s support may also be at possible.
disaster AEB active systems— family, risk and require
Emotional reactions participation in social, and community. assistance to - Demonstrate
necessary and cope with the active
desired - Identify and discuss trauma participation in
activities in client’s strengths as necessary and
activity levels. well as vulnerabilities  Provides desired
information to activities in
- Provide emotional and build on for activity levels.
physical presence by coping with
sitting with traumatic
client and SO and experience
offering solace
 Strengthens
- Note presence of coping abilities.
nightmares, reliving the
incident, loss of  These responses
appetite, irritability, are normal in the
numbness and crying, early post
and family or incident time
relationship disruption frame. If
prolonged and
- Encourage and assist per sis tent, they
client in learning stress
management may indicate
techniques. need for more
intensive therapy
 Promotes
relaxation and
helps individual
exercise control