Actual Nursing Care Plan example from Nursing for Life Organization

1. Patient
Problem
( Actual )
Nursing diagnosis Anxiety related to (contributing factor according to the
patient’s condition)
Subjective
Data
 According to the nurse’s observation.
Objective
Data
 According to the patient description.
Objectives
Short
term
 In 2 days, the anxiety level will start to minimize.
Long
term
 In 2 weeks, anxiety symptoms will be eliminated and the patient will
resume his life normally.
Nursing
intervention
Assessment
 Assess for the presence of culture-bound anxiety states
- Rationale: The context in which anxiety is experienced, its meaning, and
responses to it are culturally mediated.
 Assess the patient’s level of anxiety. (Mild, moderate, severe and panic.)
- Rationale:
 The patient with mild anxiety will have minimal or no physiological
symptoms of anxiety. Vital signs will be within normal ranges. The patient
will appear calm but may report feelings of nervousness such as
“butterflies in the stomach.”
 The patient with moderate anxiety may appear energized, with more
animated facial expressions and tone of voice. Vital signs may be normal
or slightly elevated. The patient may report feeling tense.
 With severe anxiety, the patient will have symptoms of increased
autonomic nervous system activity, such as elevated vital signs,
diaphoresis, urinary urgency and frequency, dry mouth, and muscle
tension. At this stage, the patient may experience palpitations and chest
Nursing Care Plan Example
"Anxiety"

2. pain. The patient may be agitated and irritable and report feeling
overloaded or overwhelmed by new stimuli.
 In the panic level of anxiety, the autonomic nervous system increases to
the level of sympathetic neurotransmitter release. The patient becomes
pale and hypotensive and experiences poor muscle coordination. The
patient reports feeling completely out of control and may display
extremes of behavior from combativeness to withdrawal.
 Assess for the influence of cultural beliefs, norms, and values on the
patient’s perspective of a stressful situation.
- Rationale: What the patient considers stressful may be based on cultural
perceptions.
 Assess physical reactions to anxiety.
- Rationale: Anxiety also plays a role in somatoform disorders, which are
characterized by physical symptoms such as pain, nausea, weakness, or
dizziness that have no apparent physical cause.
 Assess how the patient uses coping techniques and defense mechanisms
to cope with anxiety.
- Rationale: Asking questions requiring informative answers helps identify
the effectiveness of coping strategies currently used by the patient. This
approach may help the patient feel like he or she is contributing to patient
care. Coping strategies may include reading, journaling, or physical activity
such as taking a walk. Defense mechanisms are used by people to preserve
the ego and manage anxiety. Some defense mechanisms are highly
adaptive in managing anxiety, such as humor, sublimation, or suppression.
Other defense mechanisms may lead to less adaptive behavior, especially
with long-term use. These defense mechanisms include displacement,
repression, denial, projection, and self-image splitting.
Interventions
 Recognize awareness of the patient’s anxiety.
- Rationale: Since a cause of anxiety cannot always be identified, the
patient may feel as though the feelings being experienced are counterfeit.
Acknowledgment of the patient’s feelings validates the feelings and
communicates acceptance of those feelings.
 Use presence, touch (with permission), verbalization, and demeanor to
remind patients that they are not alone and to encourage expression or
clarification of needs, concerns, unknowns, and questions.
- Rationale: Being supportive and approachable promotes communication.

3.  Familiarize patient with the environment and new experiences or people
as needed.
- Rationale: Awareness of the environment promotes comfort and may
decrease anxiety experienced by the patient. Anxiety may intensify to a
panic level if patient feels threatened and unable to control environmental
stimuli.
 Interact with patient in a peaceful manner.
- Rationale: The nurse or health care provider can transmit his or her own
anxiety to the hypersensitive patient. The patient’s feeling of stability
increases in a calm and non-threatening environment.
 Accept patient’s defenses; do not dare, argue, or debate.
- Rationale: If defenses are not threatened, the patient may feel secure and
protected enough to look at behavior.
 Converse using a simple language and brief statements.
- Rationale: When experiencing moderate to severe anxiety, patients may
be unable to understand anything more than simple, clear, and brief
instruction.
 Reinforce patient’s personal reaction to or expression of pain, discomfort,
or threats to well-being (e.g., talking, crying, walking, and other physical
or nonverbal expressions).
- Rationale: Talking or otherwise expressing feelings sometimes reduces
anxiety.
 Allow patient to talk about anxious feelings and examine anxiety-
provoking situations if they are identifiable.
- Rationale: Talking about anxiety-producing situations and anxious feeling
can help the patient perceive the situation realistically and recognize
factors leading to the anxious feelings.
 Provide massage and backrubs for patient to reduce anxiety.
- Rationale: This aids in reduction in anxiety.

4. Health
Teaching
 Educate patient and family about the symptoms of anxiety.
- Rationale: If patient and family can identify anxious responses, they can
intervene earlier than otherwise.
 Teach patient to visualize or fantasize about the absence of anxiety or
pain, successful experience of the situation, resolution of conflict, or
outcome of procedure.
- Rationale: Use of guided imagery has been useful for reducing anxiety.
 Teach use of appropriate community resources in emergency situations
(e.g., suicidal thoughts), such as hotlines, emergency rooms, law
enforcement, and judicial systems.
- Rationale: The method of suicide prevention found to be most effective is
a systematic, direct-screening procedure that has a high potential for
institutionalization.
Evaluation
Achieved ( ) Partially achieved ( ) Not achieved ( )
Evidence by:
Important Note
"We just recommend examples of nursing care plans. There are many references and
interventions may change according to patient condition. You should consider this, search,
and see more than one reference to reach the best quality for writing the care plan"