ASSESSMENT/CUES/ NURSING OBJECTIVES INTERVENTIONS RATIONALE

EVIDENCES DIAGNOSIS
SUBJECTIVE: Anxiety After 3 weeks of 1. Maintain a calm, non- - Anxiety is contagious and
“I don’t like nursing of nursing threatening manner while may be transferred from health
remembering” as interventions, the working with the client. care provider to client or vice
verbalized by the client will be able to: versa. Client develops feeling
patient. 1. Discuss feelings of of security in presence of calm
dread, anxiety and staff person.
suppressed emotions 2. Establish and maintain a - Therapeutic skills need to be
OBJECTIVE: towards the accident. trusting relationship by directed toward putting the
1. Decreased attention 2. Verbalize signs and listening to the client, client at ease, because the
span symptoms of displaying warmth, answering nurse who is a stranger may
2. Restlessness once increasing anxiety and questions directly, offering pose a threat to the anxious
triggered on the intervene to maintain unconditional acceptance, client.
memories of the anxiety at manageable being available and respecting
accident or about level. the client’s use of personal
family. space.
3. Shows feeling of
discomfort, 3. Remain with the client at all - The client’s safety is utmost
apprehension or times when levels of anxiety priority. A highly anxious
helplessness are high, reassure client of his client should not be left alone
4. Disorganized thought safety and security. as his anxiety will escalate.
process
4. Move the client to a quiet - Anxious behaviour escalates
area with minimal stimuli such by external stimuli. A smaller
as a small room or seclusion or secluded area enhances a
area (dim lighting, few people). sense of security as compared
to a large area which can make

5. Maintain calmness in your
approach to the client.
6. Provide assurance and
comfort measures.
the client feel lost and
panicked.
- The client will feel more
secure if you are calm and if
the client feels you are in
control of the situation.
- To help relieve anxiety.

7. Support the client’s defenses - The client uses defences in an

initially. attempt to deal with an
unconscious conflict, and
giving up these defences
prematurely may cause
increased anxiety.
8. Maintain awareness of your - Anxiety is communicated
own feelings and level of interpersonally. Being with an
discomfort. anxious client can raise your
own anxiety level. Discussion
of these feelings can provide a
role model for the client and
show a different way of
dealing with them.
9. Stay with the patient during - During a panic attack, the
panic attacks. Use short, simple patient needs reassurance that
directions. he is not dying and the
symptoms will resolve
spontaneously. In anxiety, the
client’s ability to deal with

10. Avoid asking or forcing the
client to make choices.
11. Observe for increasing
anxiety. Assume a calm
manner, decrease
environmental stimulation, and
provide temporary isolation as
indicated.
12. Encourage the client’s
participation in relaxation
exercises such as deep
breathing, progressive muscle
relaxation, and guided
imagery.
13. Teach signs and symptoms
of escalating anxiety, and ways
to interrupt its progression such
as relaxation techniques, deep
breathing exercises, brisk
walks and jogging.
14. When level of anxiety has
been reduced, explore with the
abstractions or complexity is
impaired.
- The client may not make
sound and appropriate
decisions or may unable to
make decisions at all.
- Early detection and
intervention facilitate
modifying client’s behaviour
by changing the environment
and client’s interaction with it,
to minimize the spread of
anxiety.
- Relaxation exercises are
effective nonchemical ways to
reduce anxiety.
- So the client can start using
relaxation techniques; gives the
client confidence in having
control over his anxiety.
- Recognition of precipitating
factors is the first step in
client the possible reasons for teaching client to interrupt
occurrences. escalation of anxiety.

15. Encourage client to talk - Verbalization of feelings in a

about traumatic experience nonthreatening environment
under nonthreatening may help client come to terms
conditions. Help client work with unresolved issues.
through feelings of guilt related
to the traumatic event. Help
client understand that this was
an event to which most people
would have responded in like
manner. Support client during
flashbacks of the experience.
ASSESSMENT/CUES/ NURSING OBJECTIVES INTERVENTIONS RATIONALE
EVIDENCES DIAGNOSIS
SUBJECTIVE: Ineffective After 3 weeks of 1. Assess client’s level of - Helping the client recognize
“I don’t like coping nursing interventions, anxiety. Investigate the types the precipitating factors is the
remembering” as the client will be able of situations that increase first step in teaching the client
verbalized by the client. to: anxiety and result in ritualistic to interrupt the escalating
1. Demonstrate ability behaviors. anxiety.
to cope effectively.
OBJECTIVE: 2. Demonstrate ability 2. Encourage independence - Positive reinforcement
1. Inability to meet role to interrupt obsessive and give positive enhances self-esteem and
expectations. thoughts and refrain reinforcement for independent encourages repetition of
2. Self-isolation from ritualistic behaviors. desired behaviors.
3. In denial of the behaviors.
situation 3. During the beginning of - To deny client this activity
4. Inability to treatment, allow plenty of time can precipitate panic level of
participate in the for rituals. Do not be anxiety.
problem-solving of own judgmental or verbalize
situation disapproval of the behaviour.
5. Dependent to
Johnson 4. Support and encourage - Client may be unaware of the
client’s efforts to explore the relationship between emotional
meaning and purpose of the problems and compulsive
behavior. behaviors. Recognition and
acceptance of problems is
important before change can
occur.
5. Gradually limit the amount - Anxiety is minimized when
of time allotted for ritualistic client is able to replace
behaviour as client becomes
more involved in unit ritualistic behaviors with more
activities. adaptive ones.

6. Encourage the recognition of - Recognition of precipitating

situations that provoke factors is the first step in
obsessive thoughts or ritualistic teaching client to interrupt
behaviors. escalation of anxiety.

7. Provide positive - Positive reinforcement

reinforcement for non- enhances self-esteem and
ritualistic behaviors. encourages repetition of
desired behaviors.
ASSESSMENT/CUES/ NURSING OBJECTIVES INTERVENTIONS RATIONALE
EVIDENCES DIAGNOSIS
SUBJECTIVE: Powerlessness After 3 weeks of 1. Have client take as much - Providing client with choices
“I don’t have any nursing intervention, responsibility for own self-care and responsibility will increase
friends other than you, the client will be practices. his feeling of control.
Johnson” as verbalized able to:
by the client. 1. Participate in 2. Help client set realistic - Unrealistic goals set the client
decision making goals. up for failure and reinforce
OBJECTIVE: regarding own care. feelings of powerlessness.
1. Dependence on 2. Effectively 3. Help identify areas of life - Client’s emotional condition
Johnson. problem-solve ways situation that client can control. prevents his ability to solve
2. Reluctant to express to take control of his problems. Support is required
true feelings. life situation. to perceive the benefits and
3. Nonparticipation in consequences of available
care or decision making alternatives.
when opportunities are 4. Help the client identify areas - To deal with unresolved
provided (On the first of life situation that are not issues and accept what cannot
half of the movie). with his ability to control; be changed.
encourage verbalization of
these feelings.

5. Identify ways and instances - Positive reinforcement

in which the client can achieve
and encourage participation in
these activities; provide
positive reinforcement for
participation.
enhances self-esteem and
encourages repetition of
positive behaviors.