NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objectives: ANXIETY 1. Limit Independent: Client Will:
(severe to aggressive • Maintain open • Provides for
• Suicidal panic) as behavior; communication accurate • Verbalize
behaviour evidenced by promote and provide information awareness of
abuse of socially consistency of and reduces feelings of
• Fear of alcohol/other acceptable care. anxiety. anxiety and
being alone drugs and responses. • Underlying healthy ways to
transient • Assess feelings of deal with them.
psychotic 2. Encourage escalating worthlessne
symptoms. assertive anxiety and ss, • Recognize
behaviors to observe client powerlessne warning signs of
attain sense contact ss can lead increasing
• depression of control. inadequacy to anxiety and
and anxiety with reality increasing validate
anxiety. perceptions
• self- • Need for before drawing
destructive 3. Assist client to • Note rapid immediate conclusions.
feelings learn healthy changes in gratification
ways of behavior (e.g., can lead to • Develop and
controlling from frustration implement
anxiety/develo cooperative to and changes effective
• paranoia ping positive angry, in behavior, methods for
self-concept. demanding, which may decreasing
and loss of
contact with argumentative). indicate loss anxiety.
4. Promote of touch
reality development with reality • Report anxiety
of effective • May cloud reduced to
coping skills. symptomato manageable
• Monitor for logy, level.
substance use; potentiate • Use resources
note physical erratic effectively.
5. Help client
learn alternate, symptoms of behavior,
constructive abuse (e.g., and
methods of slurred speech, interfere
interacting with mood swings, with
others. dilated/ progress
requiring therapeutic
constricted intervention
pupils,
abnormal vital
signs, needle
marks). • Specific
instructions
• Provide and
information in expectations
brief, clear, about what
calm manner is happening
help client
maintain
contact with
reality.

• Auditory and
• Maintain calm, visual
quiet, stimulation
nonstimulating may
environment. increase
labile affect
and
potential for
• Correct acting-out
misinterpretatio • Confronting
ns of mispercepti
environment as ons
expressed by honestly,
 the client with a
caring and
accepting
attitude,
provides a
therapeutic
orientation
to reality
and
preserves
client’s
• Encourage feelings of
client to dignity and
identify events self-worth.
that precipitate
stress/anxious • Helps to
feelings establish a
cause-effect
relationship,
enhancing
• Explore how awareness
client has dealt and
with these promoting
feelings, change.
including times • Provides an
when understandi
substances ng of the
were taken to relationship
relive tension, between
anxiety. anxiety and
drug use.
• Have client
keep an “anger
journal” • When
 describing reviewed
when anger periodically
occurs, how it is with primary
handled, and nurse/
outcome insight therapist,
of situation. therapeutic
writing can
provide into
developmen
t of feelings,
effectivenes
s of
response
and create
opportunity
to develop
• Assist in new coping
learning to strategies
identify early • Promotes
warning signs developmen
that anxiety is t of internal
escalating and control.
request
intervention
before it
becomes
overwhelming.

• Provides
• Ask client to knowledge
describe for adapting
events/feelings new
preceding, effective
cutting or coping skills
 hurting self. and
Explore ways to breaking the
relieve anxiety pattern of
without self- self-
damaging acts. destructive
acts.
• Discuss fears
involving • Knowledge
interactions of specific
with parents, fear may
spouse, provide
children, or insight into
significant problem
other(s). areas.

Collaborative:

• Administer
medications as • May help
indicated: reduce
Antipsychotics, anxiety,
e.g., hostility,
haloperidol ideas of
(Haldol), to thiothixine
other (Navane),
therapeutic thioridazine
approaches. (Mellaril);
reference,
illusions,
increasing
• antidepressants receptivenes
 s
• A number of
agents have
been used
with varying
success to
help
alleviate
symptoms
of severe
depression