COLLEGE OF NURSING
Silliman University
CUES/EVIDENCES
SUBJECTIVE:
“Murag hapit nako mabuang
ani akong anxiety”
“Sige rakog ka anxious most
of the time”
“Nagsugod akong anxiety
mga 1 month pagsugod sa
online class, feel nako di ko
ka cope tungod pressured
kayko sa acads ug sa family.”
“Feel nako gi control nakos
anxiety”
“Di kayko ka decide ug
tarong kay mabalaka ko if
sakto ba or sayop akong
gihimo”
“Dili napod tarong akong pag
tulog karon, mga 3-4 hours
nalang ako tulog kada gabii”
OBJECTIVE:
- Shaky & sweaty
hands
- Feet constantly
tapping the floor
- Restless
- Diaphoresis
- Dry skin, and patchy
Dumaguete City
NURSING CARE PLAN
NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
INDEPENDENT:
Ineffective coping r/t After 2 weeks of our 1. Establish a trusting A trusting relationship
situational crisis as care, the patient will be relationship with allows the client to
evidenced by disturbed able to: the client. freely express his/her
thought processes feelings and does not
1. Demonstrate see the student nurse
ways and ability as a threat.
to cope
effectively. 2. Maintain the To enhance therapeutic
2. Report a decrease trusting relationship and to
in restlessness. relationship with provide for meeting
3. Verbalize a return the client by being psychological needs.
to normal number available to her;
hours of sleep (6- answer her
8 hours) questions and
4. Verbalize signs queries, and
and symptoms of respecting her
increasing decisions/
anxiety and 3. Discuss with the This is the first step in
intervene to client the teaching the client to
maintain anxiety situations that interrupt the escalation
at manageable trigger anxiety. of anxiety.
level.
5. Maintain eye 4. Provide a quiet Anxiety might be
contact when environment as increased by noisy
talking to student much as possible. surroundings and
nurses and family cause panic to the
members. client.
 lips 5. Teach relaxation Anxiety is minimized
- Unable to maintain exercises such as when the patient is
eye contact deep breathing relaxed and these are
- Easily distracted techniques, music effective non-
- therapy, or guided pharmacological ways
imagery. to decrease anxiety.

6. Encourage To assist client in

verbalization of dealing with anxiety.
fears and anxieties
and expression of
feelings of
depression and
anger. Let the
client know that
these are normal
reactions.
7. Remain with the Safety of the client is a
client when priority. A highly
anxiety attacks are anxious client should
severe. not be left alone.

DEPENDENT:
1. Administer Stimulate serotonin and
anxiolytics as dopamine receptors on
prescribed by the nerves, thereby altering
physician the chemical messages
that nerves receive.

2. Administer SSRIs Increases levels of

as prescribed by serotonin in the brain.
the physician SSRIs block the
reabsorption of
serotonin into neurons.