Assessment Nursing Goals Intervention Implementation Rational Evaluation

diagnosis
Subjective Anxiety To reduce  Remain with the  Remained with  This provides Anxiety
data: related to anxiety client at all times the client at all support to the reduced
Patient vague evidenced when level of times when client. evidenced
complains uneasy by client anxiety are high levels of anxiety  Reduced y the client
of feeling feeling of will  Move the client are high stimuli responded
of discomfort respond to to a quit area  Moved the client decreased to
discomfort. or dread relaxation with minimal or to a quit area anxiety. relaxation
accompanied techniques decreased with minimal or  It conforts the techniques
by an with a stimuli. decreased stimuli patient with a
autonomic decreassed  Remain calm in  Remained calm  Helps in decreassed
response anxiety your approach to in your approach every level of
evidenced by level. the client to the client understanding anxiety
poor impulse  Use short,  Used short,  This helps to
control simple, and clear simple, and clear reduce
Objective statements statements. anxiety and
data:  Avoid asking or  Avoided asking helps to use
Patient forcing the client or forcing the relaxation
expresses to make choices. client to make techniques
restlessness  Encourage the choices.
and client’s  Encouraged the
palpitations. participation in client’s
relaxation participation in
exercises. relaxation
 Teach the client exercises.
to use relaxation  Taught the client
techniques to use relaxation
 Help the client techniques
see mild anxiety  Help the client
see mild anxiety
Assessment Nursing Goal Intervention Implementation Rationale Evaluation
Diagnosis
Subjective data: Social isolation Patient will Convey an Conveyed an This increases The risk for self
Patient related to panic voluntarily send accepting attiude accepting attiude feelings of self- – directed
complains that anxiety, time with other by making brief, by showing word and violence is
ashamed due to evidenced by patients and staff frequent concern and faciliitates trust. reduced
his failures he withdrawal, members in contacts. Show listening to the evidenced by
met throughout. expression off group activities unconditional problems. verbalization
feelings off on the unit positive regard.
rejection
ofaloneness Offer to be with Involved the The presence of
imposed by the client during client in ward a trusted
others. group activities activities individual
that he finds provides
frightening emotional
difficult. Involve security for the
the client client
Objective data: gradually in
Patient looks different
sad. activities on the
unit.
Given positive Positive
Give recognition reinforcement to reinforcement
and positive the client enchances self-
reinforcement esteem and
for the client’s encourages
voluntary repetition of
interaction with acceptable
others. behavior.

Assessment Nursing Goal Intervention Implementation Rationale Evaluation

Diagnosis
Subjective data: Self – care Patient will Provide assistance Provided Patient safety and Patient has
Patients relative deficit related to demonstrate with self-care assistance in comfort are nursing demonstrated
complains that withdrawal, ability to meet needs as required. self-care needs priorities ability to meet
patient does not panic anxiety, self-care needs self care needs
take bath, eat or perceptual or independently independently
take care of cognitive evidenced by
hygiene impairment, Encourage client to neat and tidy
evidenced by perform Encouraged Independent appearance
difficulty in independently as client to perform accomplishment
carrying out task many activities as activities and reinforcement
associated with possible. Provide independently enhance self –
hygiene, positive esteem and
dressing reinforcement for promote repetition
grooming, eating independent of desirable
and toileting accomplishments behavior.
Objective data:
Patient looks To ensure that self-
untidy. Establish care needs are met.
Established a
structured schedule
structured
to help the client
schedule to help
fulfill these needs
patient meet his
until he is able to
needs
do so
independently.

Assessment Nursing Goal Intervention Implementation Rationale Evaluation

Diagnosis
Subjective data: Self-esteem Patient will be Be accepting of Listened to the These interventions Patient
patient disturbance able to patient and spend problems of contribute towards verbalized
complains that related to unmet verbalize time with him, patient feeling of self- positive
he have negative dependency positive aspect even though worth. aspects about
feelings, guilt, needs, lack of about self and pessimism and self and
worthlessness positive attempt new negativism may attempted new
feedback, activities seem Advised the Success and activities
unrealistic self- without fear objectionable. patient to speak independence without fear
expectations off failure about his promote feelings of evidenced by
evidenced by Focus on strengths strengths self-worth positive talk
sensitivity to and
criticism, accomplishments
negative and and minimize To facilitate
Objective data: Encouraged problem solving
pessimistic failures.
patient looks patient to
depressive and outlook.
Provide him with perform his
speak negatively simple and easily activities
achievable activity. independently
Their use can serve
Encourage the
to enhance self-
patient to perform
Encouraged esteem
his activities
patient to
without assistance.
recongnize the
Encourage patient areas of change
to recognize the
areas of change
and provide
assistance toward
this effort.