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CAPITOL UNIVERSITY COLLEGE OF NURSING Name of Student: _________________________________________________ Name of Patient: _________________________________________________ NURSING CARE PLAN ASSESSMENT DATA

(Subjective & Objective Cues) Subjective: "di na jud ko makatrabaho ani sa bukid" as verbalized by the patient NURSING DIAGNOSIS (Problem and Etiology) GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE EVALUATION Date of Assignment: _____________ Ward: ____________________ Bed No. __

Anxiety related to threat to/ or Within 8 hours of nursing interventions the change in patient will appear health status relaxed and the level of anxiety will reduced to a manageable level

Objective: -RR- 20 -restlessness -difficulty in sleeping -fatigue

After 8 hours of nursing interventions the patient appeared associated with both medical and emotional relaxed and the level of anxiety will reduced conditions 2. Use presence, touch, to a manageable level verbalization or demeanor to remind client and to encourage expressions or clarification of needs, concerns, unknowns and questions R: Being supportive 1. Monitor vital signs(e.g., rapid or irregular pulse, rapid breathing) R: To identify physical responses
and approachable encourages communication

3. Accept client's defenses, do not confront, argue and debate R: If defenses are not threatened, the client
may feel safe enough to look at the behavior

4. Allow and reinforce clients personal reaction towards the threatens to well being R: or otherwise expressing feeling
reduces

anxiety

5. Explain everything necessary regarding the disease R: To educate the


patient regarding the disease to reduce anxiety

CAPITOL UNIVERSITY COLLEGE OF NURSING

Name of Student: _________________________________________________ ____________________________________________ Name of Patient: _________________________________________________ DRUG STUDY DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) MECHANISM OF ACTION INDICATIONS

Date of Assignment: Ward: ____________________ Bed No. _____________________

CONTRAINDICATIONS

ADVERSE EFFECTS OF THE DRUG

NURSING RESPONSIBILITIES/ PRECAUTIONS