Patient/Client Nursing Assessment:
Objective Data:
- Patient’s mood anxious.
- Irritable
- Agitated
- Restless.
- Shaking legs, pacing
- Worried facial expression
- Startle response
- Fragmented sleep pattern
- Sweating palms
- Rapid speech
- Altered vital signs
- Crying, absent insight
- Aggressive behaviour
- Panic
- Fearful
- Hypervegalance
- Indegestion, heart burn
- appetite,nausea vomiting,dirrhea.
Subjective Data:
- Patients Verbalize: increased muscle tension
- Feel difficulty concentrating
- Frequent sensation of tingling.
- Feeling of gabrahut, fear.
- Others:
Nursing Diagnosis
Anxiety related to:
- Hallucinations
- Fear of open,
- public places and
- crowd
- Fear of close space
- Multiple life stress
- PTSD
- Threat to self
- Others:
Goal/Expected Outcome
S.T.G.(Short Term Goal)
- Able to express anxiety by 1-2 days and its cause
- Learning skills to control anxiety by 3-4 days
- Express feelings of relaxation by the help of meds & utilization of learned skills by one week
L.T.G.(Long Term Goal)
- By the time of discharge patient will be able to free or control his anxiety by using effective coping skills at his/her
- Anxiety will be at the scale of ______
- Other:
Nursing Intervention Statements
- Assess patient anxiety level.As Per Scale
- Approach the patient in calm manner.
- Help the patient to identify factors those make him tense anxious.
- Encourage him to share his stressors and acknowledge feelings
- Teach deep breathing exercises,muscle relaxation, guided imagery
- Reduce environmental stimulation.
- Help the patient identify support person at home, safe place.
- Arrange small group activities
- Teach diversonal activities e.g.drawing, painting, arts & craft Involve family in patients care
- Administer anti-anxiety drugs as PRN & regular basis as per order
