Lyceum of the Philippines
University College of Nursing
ASSESSMENT
Subjective Data`
“Client verbalizes distress
about occasional pain in the
chest and abdomen”.
Objective Data:
-Restlessness
-Trouble with thinking and
concentrating
-Denies facial grimacing
-Denies abdominal guarding
-Abdominal examination
shows none rebound
tenderness upon palpation
-Failure to do activities of
daily living.
-Normal ECG reading.
NURSING CARE PLAN
DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Ineffective coping Short term goal: Independent: 1. Develop a trusting Short term goal:
related to extreme After 30 minutes of 1. Recognize and relationship with the After 30 minutes of
anxiety secondary nursing interventions: accept that the client. nursing interventions:
to somatoform physical
disorder. The client will complaint is real 2. Encourage client to The client was able to
demonstrate use of to client. verbalize any demonstrate the use of
relaxation techniques negative thoughts, relaxation techniques to
to mitigate anxiety. 2. Ask questions to feelings, and mitigate anxiety.
determine if the behaviors in order
Long term goal: patient has for the nurse and
After 3 days of suicidal healthcare team to Long term goal:
nursing intervention: ideations, or provide holistic care After 3 days of nursing
possible and keep client safe. intervention:
The client will be able substance
to cope with current abuse. 3. Despite not having The client was able to
condition by re- any medical reason cope with current
establishing normal 3. Allow the patient for the pain, condition and establish
ADLs to express healthcare normal ADLs.
feelings and providers should
thoughts about provide a caring
pain. environment to the
patient and allow
4. Promote expression of
behavior feelings and
modification by thoughts about it.
acknowledging
 the patient’s
Vital signs: efforts too 4. To encourage client
T: 36.5c positively cope to shift her focus
PR: 69bpm with current and energy to
RR: 18bpm condition. positive thinking and
BP: 120/80 behavior while
O2: 98% keeping track of
5. Encourage the realistic goals and
patient to perform activities towards
relaxation healthy coping.
techniques, such
as deep breathing
exercises, guided 5. To help the patient
imagery. become relaxed
and feel
6. Discuss possible comfortable.
alternative
coping strategies 6. To facilitate
client may use in adoptive coping.
response to
stress. 7. To provide client
with the appropriate
Dependent: medications for
their clinical needs.
7. Administer
medications as
prescribed.