REPUBLIC of the PHILIPPINES

City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
INSTITUTE OF NURSING

NURSING CARE PLAN

Assessment Nursing Diagnosis Inference Planning Intervention Rationale Evaluation
Generalized Anxiety Independent: After 1 hour of nursing
Disorder (GAD) is a Short Term: 1. Assess the patient’s vital Determine a baseline for the interventions, the client was be
Subjective Cues: mental health signs effectiveness of interventions and able to report lessened or
disorder ● Within 1 hour of rule out other medical conditions resolved her anxiety
● “Nurse nag-aalala characterized by intervention, the patient such as hypertension or fever. Goal Met
excessive,
po ako, at wala pa will state that her anxiety 2. Provide proper ventilation of Ventilation of the environment
● Anxiety persistent, and promote comfort of the patient
po ang asawa ko will lessen or resolve, and the environment.
related to unrealistic worry
paano nato” she will describe effective 3. Loosen up clothes
unfamiliar about everyday Loose clothes will provide comfort
verbalized by the coping mechanisms.
surroundings, things. Anxiety ● Within 1 hour of for better feeling of the client After 1 hour of nursing
patient
processes, and produces fear, worry, intervention, patient’s Vital Sign
intervention, patient’s vital
procedures and and a constant bring back to Normal Level
● The patient worries sign will bring back to 4. Encourage the client to
hospitalization feeling of being Goal Met
about the course of Normal Level. drink ampule fluid This will minimize risk of
labour and delivery overwhelmed.
dehydration and panic attack. And
People with anxiety
aid in worsening the situation
disorder find these
feelings hard to
control, cause
This will aid the anxiety of the client
severe disruption to 5. Stay with the client
Objective Cues: they will fill secured and safe. For
their life, and
them to calm down

NAME OF PATIENT: Patima Frias AGE: 26 years old

CLINICAL IMPRESSION/DIAGNOSIS: ANXIETY
 REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
experience anxiety Long Term: INSTITUTE OF NURSING
6. Engage the patient and Birth is often the first time a woman
regularly. family in discussions is hospitalized. Assessing previous After 24-48 hours of nursing
● Increased Heart ● Within 24-48 hours regarding their previous experiences and acknowledging interventions, the client was be
Rate People experiencing Patient will improve experiences being hospitalized concerns show respect and able to Improved coping skills and
● Breathing rapidly generalized anxiety coping skills and and their expectations and provide explored other coping mechanisms
● Sweating disorder describe exploring other coping methods for successful coping the nurse with helpful information. Goal Met
● Feeling weak and feelings of fear, mechanisms. during stressful events in Reflecting on methods used to
tired worry, the past. cope in the past during stressful
● Trouble apprehensiveness, situations allows the patient to call
Concentrating and irritability. They on her own strengths. After 24 - 48 hours of nursing
may also report ● Within 24–48 hours, the 7. Assess for verbal and intervention, the client was able to
physical symptoms patient will understand Verbal as well as nonverbal cues achieved understanding her
nonverbal cues regarding
such as fatigue, her anxiety and worries, can provide the nurse with insights anxiety and worries decreased
the patient’s anxiety
Vital Signs: restlessness, and their fears level. into how the patient is coping with Goal Met
● Blood Pressure: muscular tension, decrease. the hospitalization and the labor
130/85 mmHg and difficulty
sleeping. process. Examples of nonverbal
● Pulse Rate: 104bpm cues that might indicate anxiety are
● Temperature: 36.5 °C
not making eye contact, fidgeting,
being distracted, or ignoring
teaching. Anxiety decreases the
patient’s ability to focus and relax.
Relaxation is important in labor to
provide adequate oxygenation and
promote optimal labor progress.

NAME OF STUDENT: MARK JASON DIAZ YEAR/GROUP: II-A BSN CONCEPT: MCN: MOTHER AREA: DUTY ROTATION PROF: ROCHEL KLATH DATE: 11 / 09 / 2022

NAME OF PATIENT: Patima Frias AGE: 26 years old

CLINICAL IMPRESSION/DIAGNOSIS: ANXIETY
 REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
INSTITUTE OF NURSING

References: 8. Explain the purpose of any

Explanation or demonstration of
equipment or procedure
procedures or equipment and their use
https://nursing.com/ (monitoring fetal
lesson/nursing-care- status, IV, sterile vaginal exam) or purpose will provide information and
plan-for-generalized- to the patient along with decrease anxiety. Patients
anxiety-disorder rationales
often are fearful or concerned that a
and options for care.
procedure will hurt or ask,
“Why is this being done?” Informed
consent and explanations of
treatment options are necessary to
provide the opportunity for
shared decision making and facilitate
cooperation and trust of the
patient.
9. Review the stages of labor
as they occur, reassuring
The patient may become fearful if she
the woman and
does not understand what is
family of normal expectations
happening to her body during labor or
and behaviors, while
feels something is abnormal.
providing
coaching and support. Explaining in lay terms the labor process,
normal progress, and what
to expect while providing encouragement
and support enhances the
patient’s and family’s coping skills and
well-being and decreases
anxiety..
Dependent:
10. Have a discussion with your
It is essential for a nurse to make effective
primary care physician to
NAME OF PATIENT: Patima Frias AGE: 26 years old
CLINICAL IMPRESSION/DIAGNOSIS: ANXIETY
 REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
INSTITUTE OF NURSINGdetermine whether or not use of the resources available to them.
you require a referral to a
specialist.
Collaborative:
The continuous support of the doula in
11. Encourage doula
labor has been shown to
(professional or lay-
increase satisfaction with the birth
support person) support of
experience and provide the
the laboring woman when
woman with additional support that
available.
reassures her as labor
progresses. Women report a greater
satisfaction with their labors
when they have continuous labor support
(Burke, 2014).

NAME OF PATIENT: Patima Frias AGE: 26 years old

CLINICAL IMPRESSION/DIAGNOSIS: ANXIETY