Example of Nursing Care Plan: Dr. Evelyn M Del Mundo

EXAMPLE OF
NURSING CARE
PLAN
DR. EVELYN M DEL MUNDO
Sample situation of GAD
◦ A 28 year-old female presents to the clinic with complaints of joint pain
(arthralgia) and intermittent low back pain. Patient cannot recall any
mechanism of injury. She reports she has trouble falling asleep at night
and is unable to get a good night’s rest. She often feels "restless" or "on
edge", which she associates with not sleeping. She states she
constantly worries about her performance in school, her family, and her
mother’s health, who has recently been diagnosed with Stage IV Small
Cell Carcinoma. Patient also states she wakes up at night with
throbbing headaches that last for a couple hours. She feels tense the
majority of the day, causing her to feel stiff. She also has difficulty
paying attention in class and finishing her homework.
◦ Subjective:
◦ Joint pain, low back pain, headache, muscle stiffness, difficulty sleeping and paying
attention for approximately a year. Previously diagnosed with PTSD and treated with
CBT.
Demographic Information: Second Year Graduate Student, female, 28
Medical diagnosis if applicable: Diagnosed with PTSD in February of 2000.
◦ Co-morbidities:
◦ Hypertension, drinks 10+ alcoholic beverages per week (possible substance abuse),
Depression
Previous care or treatment: PTSD treated with Cognitive Behavioral Therapy by
Clinical Psychologist following car crash in 2000.
◦ Self-Report Outcome Measures:

◦ Objective:
◦ Vitals: HR= 98 bpm (tachycardia), BP: 146/92 mmHg (hypertension), RR= 24 bpm.
Palpable muscle tightness in upper trapezius, forward flexed head along with
increased kyphosis. Patient appears to be profusely sweating and hands are cold and
clammy to touch.
◦
• Cervical AROM= limited extension and bilateral rotation
• Shoulder AROM= bilateral shoulder flexion decreased.
• Myotomes= C1/C2, C2/C3 and C3/C4 weakness
• UE sensation intact
• LE AROM= limited trunk flexion/extension, along with knee flexion and ankle
dorsiflexion deficits.
• Myotomes= L4/L5, L5/S1 weakness
• LE sensation intact
◦ Clinical Impression:
¬ Hypertension
¬ Tachycardia
¬ Increased respiratory rate
¬ Red Flags:
Patient used phrases such as “restless and on edge” to describe her
current state.
Patient has a significant medical history and suffered from PTSD and
possible substance abuse, along with the stress of school and her
mother’s health.
¬ Outcome Measures: Patient scored significantly high on the GAD-7,
Worry Questionnaire & the McGill Pain Questionnaire.
Nursing Care Plans for GAD
◦ Nurses encounter anxious clients and families in a variety of
situations.
◦ The nurse must first assess the person’s anxiety level because
this determines what interventions are likely to be effective.
◦ Treatment of anxiety disorders usually involves medication and
therapy.
◦ A combination of both produces better results than either one
alone.
◦ When working with an anxious person, the nurse must be aware of her own anxiety
level. It is easy for the nurse to become easily anxious – remaining calm and in
control is essential if the nurse is going to work effectively with the client.
◦ The following are seven (7) nursing care plans (NCP) and nursing
diagnosis (NDx) for patients with anxiety and panic disorders:
◦ Anxiety
◦ Fear
◦ Ineffective Coping
◦ Powerlessness
◦ Social Isolation
◦ Self-Care Deficit
◦ Deficient Knowledge
Anxiety
◦ Nursing Diagnosis
◦ Anxiety
◦ May be related to:
◦ lack of knowledge regarding symptoms, progression of condition, and
treatment regimen.
◦ actual or perceived threat to biologic integrity.
◦ unconscious conflict about essential values and goals of life.
◦ Situational and maturational crises.
Possibly evidenced by
◦ Decreased attention span
◦ Restlessness
◦ Poor impulse control
◦ Hyperactivity, pacing
◦ Feelings of discomfort, apprehension or helplessness
◦ Delusions
◦ Disorganized thought process
◦ Inability to discriminate harmful stimuli or situations
Desired Outcomes
◦ Be free from injury

◦ Discuss feelings of dread, anxiety, and so forth
◦ Respond to relaxation techniques with a decreased anxiety
level.
◦ Reduce own anxiety level.
◦ Be free from anxiety attacks.
Planning/Implementation Rationale
Nursing Interventions Rationale

Anxiety is contagious and may be
Maintain a calm, non threatening transferred from health care provider to
manner while working with the client or vice versa. Client develops
client. feeling of security in presence of calm
staff person.
Establish and maintain a trusting
relationship by listening to the client;
Therapeutic skills need to be directed
displaying warmth, answering
toward putting the client at ease, because
questions directly, offering
the nurse who is a stranger may pose a
unconditional acceptance; being
threat to the highly anxious client.
available and respecting the client’s
use of personal space.
Remain with the client at all times
The client’s safety is utmost priority. A
when levels of anxiety are high
highly anxious client should not be left
(severe or panic); reassure client of
alone as his anxiety will escalate.
his or her safety and security.
Anxious behavior escalates by
Move the client to a quiet area with external stimuli. A smaller or
minimal stimuli such as a small room secluded area enhances a sense of
or seclusion area (dim lighting, few security as compared to a large area
people, and so on.) which can make the client feel lost
and panicked.
The client will feel more secure if you
Maintain calmness in your approach
are calm and inf the client feels you
to the client.
are in control of the situation.
Provide reassurance and comfort

Helps relieve anxiety.
measures.
Pharmacological therapy is an effective treatment for
Educate the patient and/or SO that anxiety
anxiety disorders; treatment regimen may
disorders are treatable.
include antidepressants and anxiolytics.
The client uses defenses in an attempt to deal with an
Support the client’s defenses initially. unconscious conflict, and giving up these defenses
prematurely may cause increased anxiety.
Anxiety is communicated interpersonally. Being with an
anxious client can raise your own anxiety
Maintain awareness of your own
level. Discussion of these feelings can provide a role
feelings and level of discomfort.
model for the client and show a different way of dealing
with them.
During a panic attack, the patient needs reassurance
Stay with the patient during panic attacks. that he is not dying and the symptoms will resolve
Use short, simple directions. spontaneously. In anxiety, the client’s ability to deal with
abstractions or complexity is impaired.
The client may not make sound and
Avoid asking or forcing the client to make
appropriate decisions or may unable to make
choices.
decisions at all.
Early detection and intervention facilitate
Observe for increasing anxiety. Assume a calm
modifying client’s behavior by changing the
manner, decrease environmental stimulation,
environment and the client’s interaction with it,
and provide temporary isolation as indicated.
to minimize the spread of anxiety.
PRN medications may be indicated for high Medication may be necessary to decrease
levels of anxiety. Watch out for adverse side anxiety to a level at which the client can feel
effects. safe.
Encourage the client’s participation

in relaxation exercises such as deep breathing, Relaxation exercises are effective nonchemical
progressive muscle relaxation, guided imagery, ways to reduce anxiety.
meditation and so forth.
Teach signs and symptoms of escalating anxiety,

and ways to interrupt its progression (e.g., So the client can start using relaxation
relaxation techniques, deep- breathing techniques; gives the client confidence in having
exercises, physical exercises, brisk walks, control over his anxiety.
jogging, meditation).
Panic attacks are caused by neuropsychiatric

Administer SSRIs as ordered.
disorder that responds to SSRI antidepressants.
Help the client see that mild anxiety can be a

The client may feel that all anxiety is bad and not
positive catalyst for change and does not need
useful.
to be avoided.
Cognitive-behavioral therapy
Positive reframing Turning negative messages into positive ones.
It involves the therapist’s use of questions to more realistically

appraise the situation. It is also called the “what if” technique
Decatastrophizing
because the worst case scenario is confronted by asking a
“what if” question.
Helps the person take more control over life situations. These
Assertiveness training techniques help the person negotiate interpersonal situations
and foster self-assurance.
When level of anxiety has been

Recognition of precipitating factors is the first step in teaching
reduced, explore with the client the
client to interrupt escalation of anxiety.
possible reasons for occurrence.
Encourage client to talk about
traumatic experience under
nonthreatening conditions. Help
client work through feelings of guilt
related to the traumatic event. Help Verbalization of feelings in a nonthreatening environment
client understand that this was an may help client come to terms with unresolved issues.
event to which most people would
have responded in like manner.
Support client during flashbacks of
the experience.
Outcomes:
After being diagnosed with GAD from her primary care physician,
patient was referred back to PT for treatment of the musculoskeletal
deficits secondary to GAD. Her primary care prescribed her Paxil to
increase her levels of serotonin, which greatly improved her motivation
for therapy. Within 2-3 weeks her AROM improved and the scores on
her outcome measures decreased significantly.
DISCUSSION/ EVALUATION
◦ There is limited research on physical therapy interventions to directly treat GAD. However,
physical therapy can be very effective when treating musculoskeletal impairments that are
secondary to GAD. An important role physical therapists can take is patient education.
◦ By educating patients about sticking to an adherent medical regimen (medication schedule)
that can help improve patient compliance and can educate the patient on the complexity of
their condition.
◦ Also, teaching the patient relaxation techniques, such as deep breathing exercises and
massage techniques can help to decrease muscle tension. Exercise is another way that
physical therapists can aid in reducing anxiety and significantly improve cardiovascular
health.
◦ Physical therapy when combined with other interventions such as cognitive behavioral
therapy and holistic approaches can significantly improve the overall quality of life in patients
suffering from GAD.
◦
References:
◦ 1. Goodman CC and Snyder TK. Differential Diagnosis for Physical Therapists: Screening for
Referral. 4th edition. St. Louis, Missouri: Saunders Elsevier, 2007.
2. Katzman M. Current Considerations in the Treatment of Generalized Anxiety Disorder. CNS
Drugs. 2009; 23: 103-120. Available from: ProQuest Medical Library. Accessed March 23,
2017, Document ID: 1658393961.
3. Kavan M., Elsasser G., Barone E. Generalized Anxiety Disorder: Practical Assessment and
Management. American Family Physician. 2009; 79:785-791, 9-10.
4. Medical Foundation for Medical Education and Research. Mayo Clinic: Depression and
anxiety: Exercise eases symptoms. http://www.mayoclinic.com/health/depression-and-
exercise/MH00043. Updated October 10, 2014. Accessed March 27, 2017.
5. Medical Foundation for Medical Education and Research. Mayo Clinic: Serotonin and
Norepinephrine Reuptake Inhibitors
(SNRIs). http://www.mayoclinic.com/health/antidepressants/MH00067. Updated December 10,
2008. Accessed March 24, 2017.
◦ http://www.physio-pedia.com/Generalized_Anxiety_Disorder

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EXAMPLE OF

◦ Self-Report Outcome Measures:

◦ Be free from injury

Nursing Interventions Rationale

Provide reassurance and comfort

Encourage the client’s participation

Teach signs and symptoms of escalating anxiety,

Panic attacks are caused by neuropsychiatric

Help the client see that mild anxiety can be a

It involves the therapist’s use of questions to more realistically

When level of anxiety has been

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