Assessment Diagnosis Planning Intervention Rationale Evaluation

Anxiety related to the Goal: INDEPENDENT; Goal met;

Subjective data: threat of health status After 1-2 hrs of nursing After 2 hrs of nursing
 Monitor vital signs - It obtain baseline data and to
“Parang na trauma ako alteration secondary to interventions, the patient will interventions, the patient
frequently. monitor possible physical
sa nangyari sa akin kasi gestational hypertension. be able to identify healthy will be able to identify
response associated with both
first time na nangyari sa ways to deal with anxiety as healthy ways to deal with
medical and emotional
akin yung magkaroon evidenced by, the patient anxiety.
conditions.
ng highblood habang will; Outcomes;
nagbubuntis”, and  Verbalize awareness - to provide ongoing/timely The patient;
 List helpful resources and
“madali akong  Verbalize own anxiety support.  Appeared more
people or crisis managers.
mapagod” as verbalized and coping relaxed
by the patient. mechanism/patterns.  Reported decrease of
 Effectively use coping being anxious
 Establish a therapeutic
Objective data: mechanisms to deal with  Showed stable and
relationship, conveying - to avoid the contagious effect
 Vital signs as anxiety normal vital signs
empathy and unconditional or transmission of anxiety
follows;  Demonstrate problem-  used support systems
BP: 130/80 mmHg solving skills positive regard. effectively
Temp: 36.6 0C
PR: 70 bpm
RR: 17 cpm  Assist the client in -becoming aware helps client
developing self-awareness to control behaviors and begin
- Restless of verbal and nonverbal to deal with issues that are
- skin color - pale behaviors causing anxiety
- color of nailbed – pale
 Acknowledge the feeling of -validates reality of feelings.
False reassurances may be
 anxiety/fear. Do not deny or interpreted as lack of
reassure the patient that understanding or dishonesty,
everything will be alright. further isolating client.

 Encourage the patient and - the ability to recognize

anxiety aids clarifying
family to recognize
information, rectifying
symptoms of anxiety.
misconseptions, and gaining
perspective to help in the
problem solving process.

- establishes rapport, promotes

 Be available to the client for expression of feelings, and
listening and talking. helps client/ significant others
tto deal with issues that are
causing anxiety

- to reduce anxiety and

 Provide accurate distinguish what is based on
information about the reality
situation.

-moderate anxiety heightens

 Assist the client to use awareness and permits the
anxiety for coping with the client to focus on dealing with
problems
 situations. - to aid in the maintenance of
emotional control in the
 Maintain a calm,
response to shifting
compassionate, and helpful physiological status. Helps in
approach. minimizing the transmission of
interpersonal feelings.

- to get rid of negative thoughts

and promote mental health
 Encourage awareness of
negative thoughts and
replace with positive - to promote mental wellness
thoughts.

 Review happenings,
thought, and feelings
-it is useful for being prepared
preceding anxiety.
for/dealing with anxiety-
 Review strategies, such provoking situations.
as role playing, use of
visualizations to practice
anticipated events, and
prayer/meditation.