ASSESSMENT NURSING SCIENTIFIC GOAL INTERVENTION RATIONALE EVALUATION

DIAGNOSIS RATIONALE
Subjective Cue: Anxiety r/t threat or Anxiety is associated After 30 minutes of Independent: After 30 minutes of
change in health and with circumstances in nursing care, the 1. Identify and 1. Ongoing anxiety nursing care, the
“Nababaraka gad ako socioeconomic status which a person client will be able to: acknowledge client’s related to concerns client was able to:
nga maospital ako as evidenced by perceives a stimulus as perception of threat about impact of
utro kahuman hini uncertainty and a threat, irrespective 1. Demonstrate or situation. Diabetes Mellitus on 1. Demonstrate
nga akon pagka- expressions of of whether it may problem Encourage future lifestyle, problem
admit. Damo paman concern about future actually be solving and expressions of, and matters left solving and
gud tak irintindihon events. threatening or not. avoid denying unattended or
effectiveness effectiveness
nga iba asya karuyag The stimulus evokes a feelings of anger unresolved, and
of resources of resources
ko na umuli.” as patterned reaction grief, sadness and effects of illness on
verbalized by the involving cognitive, fear. family may be
patient. 2. Verbalize present in varying 2. Verbalize
emotional, behavioral,
appropriate degrees some time appropriate
motor and visceral
range of and may be range of
responses. The
Objective Cues: response include
feelings manifested by feelings
 Trouble sympathetic nervous symptoms of
concentrating system activation, 3. Appear depression. 3. Appear
or thinking alterations in relaxed and relaxed and
about attention and report of 2. Observe verbal and 2. Client may not report of
anything other concentration, sleep anxiety is nonverbal signs of express concern anxiety is
than the reduced to a anxiety, and stay with directly, but words or reduced to a
disturbances,
present worry. manageable client. Intervene if actions may convey manageable
ritualized behavior
 Feeling weak level client displays sense of agitation, level
and changes in motor
and tired. destructive behavior. aggression and
responsiveness.
hostility.
 Face appears
worried. 3. Maintain confident 3. Client and SO may
manner, without false be affected by
Source: Principles of
assurance. anxiety or uneasiness
Pathophysiology –
displayed by health
Bullokc, Shane (SRG )
team members.
 Honest explanations
may alleviate anxiety.

4. Encourage 4. Increase
independence, self- independence from
care and decision staff promotes self-
making within confidence and
accepted treatment reduces feelings of
plan. abandonment that
can accompany in
going home for the
patient.

5. Orient client and 5. Predictability and

SO to routine information can
procedures and decrease anxiety for
expected activities. client.
Promote participation
when possible.

6. Answer all
questions factually. 6. Accurate
Provide consistent information about
information. situation reduces
fear.

7. Encourage client
and SO to 7. Sharing
communicate to one information elicits
another, sharing support and comfort
questions and and can relieve
concerns.
 tension of
unexpressed worries.
8. Provide privacy to
client and SO.
8. Allow needed time
for personal
expression of
feelings; may
enhance mutual
support and promote
more adaptive
9. Provide rest behaviors.
periods and
uninterrupted sleep 9. Conserves energy
time and quiet and enhances coping
surroundings with abilities.
client controlling type
and amount of
external stimuli.

Source: Nursing care

plans: Guidelines for
individualizing client
care across the life
span by Marilyn
Doenges; Mary
Frances Moorhouse;
Alice C. Murr