POTENTIAL

Date/Time Cues Objectives of Care Interventions Evaluation

Nursing
Diagnosis
Subjective: Anxiety related 1. Be free from 1. Maintain a calm, GOAL UNMET
April 11, to uncertainty, injury. non-threatening
2019 “I don’t want to die”. fear of the 2. Discuss manner while After 24 hours of nursing
As verbalized by the unknown, and feelings of working with the intervention. The patient
patient. disruption of dread, anxiety, client. Rationale: was not able to attain the
normal routine. and so forth Anxiety is following:
3. Respond to contagious and may
relaxation be transferred from 1. Be free from
techniques health care provider injury.
with a to client or vice 2. Discuss feelings of
decreased versa. Client dread, anxiety, and so
anxiety level. develops feeling of forth
4. Reduce own security in presence 3. Respond to
anxiety level. of calm staff relaxation techniques with
5. Be free from person. a decreased anxiety level.
anxiety attacks. 2. Establish and 4. Reduce own
maintain a trusting anxiety level.
relationship by 5. Be free from
listening to the anxiety attacks.
client; displaying
warmth, answering
questions directly,
offering
unconditional
acceptance; being
available and
 respecting the
client’s use of
personal space.
Rationale:
Therapeutic skills
need to be directed
toward putting the
client at ease,
because the nurse
who is a stranger
may pose a threat to
the highly anxious
client.
3. Remain with the
client at all times
when levels of
anxiety are high
(severe or panic);
reassure client of
his or her safety and
security. Rationale:
The client’s safety
is utmost priority. A
highly anxious
client should not be
left alone as his
anxiety will
escalate.
4. Move the client to a
quiet area with
minimal stimuli
such as a small
room or seclusion
 area (dim lighting,
few people, and so
on.) Anxious
behavior escalates
by external stimuli.
Rationale: A
smaller or secluded
area enhances a
sense of security as
compared to a large
area which can
make the client feel
lost and panicked.
5. Maintain calmness
in your approach to
the client. The
client will feel more
secure if you are
calm and inf the
client feels you are
in control of the
situation.
Rationale: Provide
reassurance and
comfort measures.

6. Educate the patient

and/or SO that
anxiety disorders
are treatable.
Rationale:
Pharmacological
therapy is an
 effective treatment
for anxiety
disorders; treatment
regimen may
include
antidepressants and
anxiolytics.
7. Support the client’s
defenses initially.
Rationale: The
client uses defenses
in an attempt to
deal with an
unconscious
conflict, and giving
up these defenses
prematurely may
cause increased
anxiety.
8. Maintain awareness
of your own
feelings and level of
discomfort.
Rationale: Anxiety
is communicated
interpersonally.
Being with an
anxious client can
raise your own
anxiety level.
Discussion of these
feelings can provide
a role model for the
 client and show a
different way of
dealing with them.
9. Stay with the
patient during panic
attacks. Use short,
simple directions.
Rationale: During
a panic attack, the
patient needs
reassurance that he
is not dying, and the
symptoms will
resolve
spontaneously. In
anxiety, the client’s
ability to deal with
abstractions or
complexity is
impaired.