NURSING CARE PLAN

Name of Patient: ___Patient P__________________________ Age: __32_____ Civil Status: ________M__Sex: _____F____Religion: _____________________
Address: ________________________________________Informant: ______________________ Relationship: _________________________________________
Chief Complaint: ________________________________ _________ Medical Diagnosis: ___________________________________________________________
Date PROBLE ASSESSME NURSING PLANNING IMPLEMENTATION
M LIST NT (cues & DIAGNOS (Objectives- EVALUATION
(According evidences/ IS long & short Rationale/ Justifications
to priority) Objective & term) (Nursing Theories of Care,
Nursing Interventions Reference
Maslow’s subjective) Developmental stage, s
Hierarchy tasks, Principles, EBP,
of Needs Standards of Nursing
Practice)

1.Anxiety Subjective: Risk for Long Term: Independent: N Goal Met. After 7
2. “I don’t want Post- A days of rendering
Nonrespons to go through Trauma After 7 days of  Establish rapport. N nursing intervention,
 To gain patient’s trust.
ive that again” as Syndrome nursing  Observe for and D the patient was able
 To note the factors
3. the patient caused by intervention, the elicit information A to demonstrate ability
that aggravate possible
Mystificati verbalize. non- patient will be about physical or to deal with
sever anxiety.
on conductivit able to psychological injury. 15TH emotional reactions
y of demonstrate Edition in an individually
Octo Objective: Environme ability to deal Doenges appropriate manner
 Listen for  To prevent rumination
ber 1, nt to needs with emotional et. al, 2019 and verbalize the
and Comments of guilt, about lack of absence of severe
2022 1. Non- reactions in an humiliation, shame, Pages 676-
insufficient individually responsible that leads 684 anxiety, or reduced
cooperative psychologi or taking on to anxiety and PTSD. anxiety, or fear.
2. Mystified appropriate responsibility.
cal support manner and
during
Interview report absence
of severe  Provide safe, and
3.Unexplaine clean environment.  To promote trust and
d Discomfort anxiety, or safety of the client.
reduced anxiety
or fear.

Dependent:

 Administer
medication such as  To prevent
antidepressants as sleeplessness of the
necessary and as the client.
doctor ordered.

Collaborative:

 Provide daily therapy

or therapeutic  Assess the condition
conversation. of the mental state of
the client and help
alleviate severe
factors.
Name of Student Nurse & Signature: ______________________________ Year and Section: __BSN 2-A______Date/Duration of Patient Care: ___________________
Name of Clinical Instructor: ___Rejoice G. Liberato _RN, MN______________________Rating: _______________________ Remarks: _______________________